← Diagnosis and Management Guides
Low Back Pain
Key considerations: Cauda equina syndrome, Spinal epidural abscess, Vertebral fracture
Cannot miss
- Cauda equina syndrome
- Spinal epidural abscess
- Vertebral fracture
- Aortic aneurysm
- Malignancy
Likely diagnoses
- Mechanical/musculoskeletal LBP
- Disc herniation
- Spinal stenosis
- Sacroiliac joint dysfunction
Red flags
- Saddle anesthesia
- Urinary retention
- Progressive bilateral leg weakness
- Fever with back pain
- Cancer history with new back pain
- IV drug use
Workup
- history: Duration, radiation, bowel/bladder function, red flag symptoms; exam: Straight leg raise, neurologic exam (L4-S1 myotomes), rectal tone if cauda equina concern; labs: ESR/CRP if infection or malignancy suspected; imaging: MRI if red flags present (EMERGENT for cauda equina); Plain films only for trauma or suspected fracture; bedside: Post-void residual if urinary retention concern
Management
- immediate: Cauda equina: EMERGENT MRI and neurosurgery consult; general: NSAIDs first-line, muscle relaxants short-term; Physical therapy is the most effective long-term treatment; Avoid opioids and imaging for uncomplicated LBP; Return to activity as tolerated
Disposition
- admit: Cauda equina syndrome, epidural abscess, progressive neurologic deficit; discharge: Non-specific LBP with activity modification, NSAID, PT referral; consults: Neurosurgery/spine surgery for cauda equina, abscess
Clinical pearls
- Imaging within 6 weeks of onset for non-specific LBP does not improve outcomes and may increase unnecessary interventions
- Cauda equina: time-critical — surgical decompression within 48 hours improves outcomes
Source and review
- ACP LBP Guidelines 2017. Last reviewed: 2024-11-01