Urgent Care Management of Acute Low Back Pain: A Review of Current Evidence

Table of Contents

 

About This Issue

Low back pain is a common and painful condition for many people for various reasons. This issue of Evidence-Based Urgent Care explores the complexities of evaluating and managing low back pain (LBP) in the urgent care setting. The importance of a systematic, evidence-based approach for accurate diagnosis and effective treatment aims to distinguish between benign and potentially serious or life-threatening causes. Key red-flag signs and symptoms, current recommendations for diagnostic imaging, and effective management strategies are reviewed. In this issue, you will learn:

The etiology and pathophysiology of low back pain;

How a red-flag features from a detailed history and thorough physical examination can help determine if a referral for more advanced imaging or specialty care is needed;

The most current treatment and pain management recommendations, including effective nonpharmacologic pain relief strategies; and

About current evidence that addresses best practices for disposition, patient education, and shared decision-making.

CODING & CHARTING: Accurate documentation of the elements of medical decision making for a presentation of low back pain in supports full reimbursement and quality care. Learn more in our monthly coding column.

1. About This Issue
2. Acknowledgement
3. Abstract
4. Case Presentations
5. Introduction
6. Etiology and Pathophysiology
   1. Mechanical
      1. Intervertebral Disc Herniation
      2. Fracture
      3. Compression Syndromes
      4. Spinal Epidural Hematoma
      5. Sciatica
      6. Spondylosis
   2. Infectious
      1. Spondylodiscitis
      2. Spinal Epidural Abscess
   3. Inflammatory
   4. Referred Pain
7. Differential Diagnosis
8. Urgent Care Evaluation
   1. History
      1. Compression and Mechanical Causes
         1. Conus Medullaris Syndrome
         2. Cauda Equina Syndrome
         3. Malignancy
         4. Fracture
         5. Spinal Stenosis and Herniation
      2. Infectious Causes
      3. Referred Pain Causes
   2. Physical Examination
9. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging Studies
      1. X-ray
      2. Computed Tomography
      3. Magnetic Resonance Imaging
10. Treatment
    1. Treatment of Emergent Causes of Back Pain
    2. Treatment for Nonspecific Back Pain
       1. Topical Preparations
       2. Nonsteroidal Anti-inflammatory Drugs
       3. Acetaminophen
       4. Skeletal Muscle Relaxants
       5. Opioids
       6. Tramadol
       7. Corticosteroids
       8. Diazepam
       9. Gabapentin
       10. Trigger Point Injections
       11. Nonpharmacologic Management
    3. Patient Education
11. Controversies and Cutting Edge
12. Disposition
13. Case Conclusions
14. Risk Management Pitfalls in the Urgent Care Management of Acute Low Back Pain
15. 5 Things That Will Change Your Practice
16. Summary
17. Time- and Cost-Effective Strategies
18. Critical Appraisal of the Literature
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
    2. Problems Addressed
    3. Complexity of Data
    4. Risk of Patient Management
    5. Documentation Tips
20. Coding Challenge: Managing Acute Low Back Pain in Urgent Care
21. Clinical Pathway for Acute Low Back Pain in Urgent Care Patients
22. References

Acknowledgement

Portions of this content were previously published in: Molyneux K, Vaswani S. Emergency Department Management of Patients With Low Back Pain: A Review of Current Evidence. Emerg Med Pract. 2024; 26(11):1-24. Used with permission of EB Medicine.

Abstract

Low back pain is a common presentation in the urgent care setting, and determining whether the cause is benign, serious, or even life-threatening can be challenging. A systematic strategy for the history and physical examination can help reduce unnecessary imaging, and an evidence-based approach will inform safe and effective pain management recommendations. This issue reviews the evidence on red-flag signs and symptoms for low back pain, current diagnostic studies recommendations, and best-practice treatment and disposition strategies.

Case Presentations

A 57-year-old woman with no significant past medical history presents to the urgent care center with left-sided low back pain radiating to the left leg...

• She arrives clutching her back and limps to the examination room.
• She said she has had low back pain before, but it is more severe today.
• On examination, you elicit pain with palpation of her left lower back and elevation of her leg. Vital signs are normal.
• You wonder whether this presentation warrants imaging and how best to treat her pain...

A 41-year-old man with a history of psoriatic arthritis presents to the urgent care with back pain and new-onset urinary incontinence...

• For 4 days, he has had difficulty controlling his urination.
• Yesterday he developed low back pain, and his legs gave out when he got out of bed.
• His vital signs are: temperature, 37.8°C; heart rate, 104 beats/min; blood pressure, 142/87 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, normal.
• On examination, the patient is warm to touch, but he is not in distress. He has midline tenderness to palpation of his lower thoracic spine, and bilateral lower extremity weakness.
• You wonder how emergent the diagnostic testing needs to be, and how best to expedite management...

An 81-year-old man is brought into the urgent care by his daughter due to sudden-onset left-sided low back pain...

• He has a history of low back pain, but it intensified suddenly in a different location than his usual pain.
• He says he has been a lifelong cigarette smoker.
• His vital signs are normal with the exception of heart rate, 124 beats/min and blood pressure, 92/52 mm Hg.
• He appears cool, clammy, and diaphoretic, and he is in distress.
• He has no focal weakness or neurologic findings on examination.
• This seems different than a muscle strain, and you wonder what the best test would be to evaluate the cause of his back pain…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Acute Low Back Pain in Urgent Care Patients

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60(10):3072-3080. (Cohort; 1172 patients) DOI: 10.1002/art.24853

5. * Han CS, Hancock MJ, Downie A, et al. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev. 2023;8(8):CD014461. (Cochrane review; 14 studies) DOI: 10.1002/14651858.CD014461.pub2

9. * Anderson SW, Bhattacharjee S, Patanwala AE. Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States. Am J Emerg Med. 2020;38(9):1802-1806. (Comparative study; 8.6 million visits) DOI: 10.1016/j.ajem.2020.06.002

17. * Galliker G, Scherer DE, Trippolini MA, et al. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. Am J Med. 2020;133(1):60-72. (Systematic review; 22 studies, 41,320 patients) DOI: 10.1016/j.amjmed.2019.06.005

24. * Shaw B, Kinsella R, Henschke N, et al. Back pain “red flags”: which are most predictive of serious pathology in the emergency department? Eur Spine J. 2020;29(8):1870-1878. (Retrospective observational study; 1000 patients) DOI: 10.1007/s00586-020-06452-1

25. * Expert Panel on Neurological Imaging and Musculoskeletal Imaging, Beckmann NM, West OC, et al. ACR Appropriateness Criteria® suspected spine trauma. J Am Coll Radiol. 2019;16(5S):S264-S285. (Practice guideline) DOI: 10.1016/j.jacr.2019.02.002

36. * Ropper AH, Zafonte RD. Sciatica. N Engl J Med. 2015;372(13):1240-1248. (Review) DOI: 10.1056/NEJMra1410151

38. * Macedo F, Annaswamy T, Coller R, et al. Diagnosis and treatment of low back pain: ynopsis of the 2021 US Department of Veterans Affairs and US Department of Defense clinical practice guideline. Am J Phys Med Rehabil. 2024;103(4):350-355. (Practice guideline) DOI: 10.1097/PHM.0000000000002356

39. * Chiarotto A, Koes BW. Nonspecific low back pain. N Engl J Med. 2022;386(18):1732-1740. (Review) DOI: 10.1056/NEJMcp2032396

43. * Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472. (Meta-analysis; 7 studies) DOI: 10.1016/S0140-6736(09)60172-0

47. * Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-597. (Review) DOI: 10.7326/0003-4819-137-7-200210010-00010

49. * Hutchins TA, Peckham M, Shah LM, et al. ACR Appropriateness Criteria® low back pain: 2021 update. J Am Coll Radiol. 2021;18(11s):S361-S379. (Practice guideline) DOI: 10.1016/j.jacr.2021.08.002

50. * Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria® low back pain. J Am Coll Radiol. 2016;13(9):1069-1078. (Practice guideline) DOI: 10.1016/j.jacr.2016.06.008

53. * Cashin AG, Wand BM, O’Connell NE, et al. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2023;4(4):CD013815. (Cochrane review; 103 studies) DOI: 10.1002/14651858.CD013815.pub2

55. * Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. (Practice guideline) DOI: 10.7326/M16-2367

60. * van der Gaag WH, Roelofs PD, Enthoven WT, et al. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database Syst Rev. 2020;4(4):CD013581. (Cochrane review; 32 trials, 5356 participants) DOI: 10.1002/14651858.CD013581

65. * Cashin AG, Folly T, Bagg MK, et al. Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis. BMJ. 2021;374:n1446. (Systematic review/meta-analysis; 49 trials) DOI: 10.1136/bmj.n1446

66. * Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-1580. (Randomized controlled trial; 323 patients) DOI: 10.1001/jama.2015.13043

84. * Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. (Systematic review; 11 guidelines) DOI: 10.1136/bjsports-2018-099878

89. * Dahm KT, Brurberg KG, Jamtvedt G, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010(6):CD007612. (Cochrane review/meta-analysis; 10 randomized controlled trials) DOI: 10.1002/14651858.CD007612.pub2

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Keywords: low back pain, cauda equina syndrome, spinal epidural abscess, spinal stenosis, pseudoclaudication, disk herniation, sciatica, straight leg raise test, crossed leg raise test, lumbar, spinal cord compression, spinal cord, lumbar stress fractures, spinal epidural hematoma, spondylosis, spondylodiscitis, transverse myelitis, conus medullaris syndrome, topical NSAIDs, topical diclofenac, topical menthol, skeletal muscle relaxants