On any given day, primary care physicians (PCPs) evaluate and recommend treatment for at least several patients who present with low back pain (LBP). In fact, the lifetime incidence of LBP is estimated to be between 51% and 84%.1 A recent review directed at primary care, “Evaluation and Treatment of Low Back Pain: A Clinically focused Review for Primary care Specialists,” published in the Mayo Clinic Proceedings, is a well-informed guide on the topic.2
Here I offer brief answers to 3 essential questions that must be addressed during a primary care work up for LBP.
1. After history and physical, what are “red flag” symptoms/signs?
When interviewing, ask about important risk factors for the more dangerous etiologies for LBP. For example, vertebral compression fractures are associated with female sex, age greater than 70 years, trauma, and corticosteroid use. Has there been recent significant trauma? Is there a history of malignancy? On examination, is there a contusion? When examining the patient, a finding of radiculopathy and bowel/bladder complaints are disturbing accompaniments. Another red flag is any sign that LBP may be a result of cauda equina syndrome. This is a surgical emergency and is associated with sudden onset of axial or radicular pain, leg weakness, bowel and/or bladder dysfunction, and loss of perineal sensation, which may manifest in saddle anesthesia.
1. Murray CJ, Atkinson C, Bhalla K, et al. US burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013; 310:591-608.
2. Hooten WM, Cohen SP. Evaluation and treatment of low back pain: a clinically focused review for primary care specialists. Mayo Clin. Proc. 2015; 90:1699-1718.
3. Chou R, Qaseem A, Owens DK, et al Clinical Guidelines Committee of the American College of Physicians. Diagnostic Imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011; 154:181-189.