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Joaquim AF
188 Rev Assoc M ed Bras 2016; 62(2):188-191
REVIEW ARTICLE
Initial approach to patients with acute lower back pain
Andrei Fernandes Joaquim1*
1PhD – Neurosurgeon, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
Summary
Study conducted at Universidade
Estadual de Campinas (Unicamp),
Neurology Department,
Campinas,SP, Brazil
Article received: 6/10/2014
Accepted for publication: 10/21/2014
*Correspondence:
Address: Depto. de Neurologia
Cidade Universitária Zeferino Vaz
Barão Geraldo
Campinas, SP – Brazil
Postal code: 13083-887
Low back pain is in one of the most common reasons for seeking medical care
in emergency care units, and also the second most common cause of work ab-
senteeism. The recognition of red flags for serious diseases such as tumors and
fractures, through proper history-taking and clinical examination, is essential
for proper treatment and to rule out differential diagnoses. In the absence of
suspected severe underlying disease, subsidiary radiological examinations are
unnecessary. Analgesic and anti-inflammatory drugs are the treatment of choice
and can be cautiously associated with muscle relaxants and opioids in more se-
vere cases. Most patients will have complete improvement of symptoms after a
few months, but a minority can develop chronic low back pain or present with
recurrent episodes. The proper understanding of all of the above can optimize
results and avoid diagnostic and therapeutic errors.
Keywords: Low back pain, emergency treatment, diagnosis.
Introduction
Acute low back pain is defined as low back pain of less than
6 weeks, experienced between the rib cage and buttocks
and which may or may not radiate into the legs. Usually, it
starts after waking or after a specific movement, such as
carrying weight, leaning, or sitting or standing up sudden-
ly.1 The pain generally worsens with movement of the mus-
cles in the lower back. Low back pain is also known as non-
specific when it cannot be assigned to known causes; that
is, defined conditions such as infection, osteoporosis, tu-
mors, ankylosing spondylitis, fractures, inflammation or
nerve compression.1 Non-specific pain possibly results from
an exaggerated and sustained muscle spasm.
Epidemiologically, acute low back pain is one of the
most common reasons for seeking medical care in emer-
gency units, and is the second leading cause of work ab-
sence.2,3 It is estimated that about 40% of low back pain
are work-related, with probable variations by region, lev-
el of economic development of the country, and the oc-
cupation of workers.4 Approximately 30% of patients with
acute back pain will not be fully recovered in 6 months
and may develop chronic pain or recurrent episodes of
low back pain (LBP), which emphasizes the importance
of diagnosis.3
Although the causal relationship is questionable, some
risk factors should be pointed out such as the work de-
pendent on vigorous physical activity, repetitive move-
ments and which demand paraspinal muscles (getting up
and down, bending, etc.), exposure to vibration, prolonged
static postures, and more. Psychosocial risk factors can
also often be found in these patients, such as job dissat-
isfaction, depression, anxiety, excessive stress, cognitive
dysfunction.5
Given its economic and social importance, the prop-
er management of these patients in emergency care units
or offices is of fundamental importance. Treatment of
acute low back pain aims to reduce pain, improve func-
tion and prevent the progression to recurrent or chronic
pain.
Key points in the initial approach
1. Identify severe causes of low back pain that require
specific treatment – identify the “red flags” or signs
of severe underlying disease, such as fractures, tu-
mors or infections.
2. Rule out differential diagnoses – urological or gas-
trointestinal disease, etc.
3. Identify potential root compression and neurologic
deficits.
Red flags
The basic principles of proper history-taking followed by
comprehensive physical examination are crucial for initial
management of any disease. Although uncommon, severe