Summary
Definition
History and exam
Key diagnostic factors
- obesity, stress, and psychiatric comorbidities
- history of prior lower back pain
- pain radiation does not extend beyond the knee
- absence of red-flag symptoms
- absence of fever, fluctuance, exquisite tenderness to palpation
- sensory, motor, and deep-tendon reflex exams within normal limits
- negative straight- or crossed straight-leg raise test
Other diagnostic factors
- dull, gnawing, tearing, burning, or electric pain associated with muscle spasms
- lack of pain on flexion or relief on extension
- scoliosis or kyphosis
- negative FABER, Gaenslen, or Schober testing
Risk factors
- obesity
- family history of degenerative disk disease
- poor musculotendinous flexibility and abnormal posture
- stress and psychiatric comorbidities
- increasing age
- female sex
- heavy physical and occupational activities
- tobacco use
- prolonged standing
- vitamin D levels
Diagnostic tests
1st tests to order
- clinical diagnosis
Tests to consider
- lumbar spine MRI
- lumbar spine x-ray
- lumbar spine CT
- myelography
- CBC
- erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- urinalysis and culture
- blood cultures
- radionuclide bone scan
- electromyogram (EMG)
Treatment algorithm
acute and subacute lower back pain (≤12 weeks)
chronic lower back pain (>12 weeks)
recurrent lower back pain
Contributors
Authors
Andrew Sherman, MD, MS
Professor and Vice Chair
Department of Physical Medicine & Rehabilitation
University of Miami Miller School of Medicine
Miami
FL
Disclosures
AS declares that he has no competing interests.
Acknowledgements
Dr Andrew Sherman would like to gratefully acknowledge Dr Robert W. Irwin, Dr Louise Thwaites, Dr Karen Walker-Bone, Dr Joanne Borg-Stein, and Dr Philip Chiou, previous contributors to this topic.
Disclosures
RWI, LT, KWB, JBS, and PC declare that they have no competing interests.
Peer reviewers
Jennifer Baima, MD
Staff Physiatrist
Orthopedic and Arthritis Center
Brigham and Women's Hospital
Chestnut Hill
MA
Disclosures
JB declares that she has no competing interests.
Alexios G. Carayannopoulos, DO, MPH
Interventional Spine Physiatrist
Pain Medicine Specialist
Medical Director
Spine Center
Lahey Clinic
Burlington
MA
Disclosures
AGC declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
American College of Radiology. ACR appropriateness criteria: low back pain. 2021 [internet publication].Full text
National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Dec 2020 [internet publication].Full text
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 Apr 4;166(7):514-30.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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