Guideline from National Guideline Clearinghouse

Acute low back problems in adults.

Initial Assessment Methods

Information about the: patient's age duration and description of symptoms impact of symptoms on activity response to previous therapy

	Past history: red flags for possible cancer or infection, especially important in patients over age 50 cancer, unexplained weight loss immunosuppression intravenous drug use history of urinary infection pain increased by rest presence of fever
	signs and symptoms of cauda equina syndrome: red flags for severe neurologic risk to the patient bladder dysfunction saddle anesthesia major limb motor weakness
	Inquiries about history of significant trauma relative to age a fall from height or motor vehicle accident in a young adult a minor fall or heavy lift in a potentially osteoporotic or older patient

	Attention to psychological and socioeconomic problems in the individual's life
	Use of instruments such as a pain drawing or visual analog scale is an option to augment the history.
	Recording the results of straight leg raising (SLR) is recommended in the assessment of sciatica in young adults. In older patients with spinal stenosis, SLR may be normal.
	A neurologic examination emphasizing ankle and knee reflexes ankle and great toe dorsiflexion strength distribution of sensory complaints

Clinical Care Methods

     Patient Information
     Patient Education About Low Back Symptoms

     Patients with acute low back problems should be given accurate information about the following (Strength of Evidence = B):

	Expectations for both rapid recovery and recurrence of symptoms based on natural history of low back symptoms.
	Safe and effective methods of symptom control.
	Safe and reasonable activity modifications.
	Best means of limiting recurrent low back problems.
	The lack of need for special investigations unless red flags are present.
	Effectiveness and risks of commonly available diagnostic and further treatment measures to be considered should symptoms persist.

     Structured Patient Education: Back School

	In the workplace, back schools with worksite-specific education may be effective adjuncts to individual education efforts by the clinician in the treatment of patients with acute low back problems. (Strength of Evidence = C.)
	The efficacy of back schools in nonoccupational settings has yet to be demonstrated. (Strength of Evidence = C.)

     Symptom Control: Medications
     Acetaminophen and NSAIDs

Acetaminophen,  Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are acceptable for treating patients with acute low back problems.

	NSAIDs potential side effects. The most frequent complication is gastrointestinal irritation.
	Phenylbutazone is not recommended, based on an increased risk for bone marrow suppression.

     Muscle Relaxants

	Muscle relaxants are an option in the treatment of patients with acute low back problems. While probably more effective than placebo, muscle relaxants have not been shown to be more effective than NSAIDs.
	No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone.
	Muscle relaxants have potential side effects, including drowsiness in up to 30 percent of patients.

     Opioid Analgesics

	When used only for a time-limited course, opioid analgesics are an option in the management of patients with acute low back problems.
	Opioids appear to be no more effective in relieving low back symptoms than safer analgesics, such as acetaminophen or aspirin or other NSAIDs.
	Clinicians should be aware of the side effects of opioids, such as decreased reaction time, clouded judgment, and drowsiness, which lead to early discontinuation by as many as 35 percent of patients.
	potential physical dependence and the danger associated with the use of opioids while operating heavy equipment or driving.

     Oral Steroids

	Oral steroids are not recommended for the treatment of acute low back problems.
	A potential for severe side effects is associated with the extended use of oral steroids or the short-term use of steroids in high doses.

     Colchicine

Based on conflicting evidence of effectiveness as well as the potential for serious side effects, colchicine is not recommended for treating patients with acute low back problems.

     Antidepressant Medications

Antidepressant medications are not recommended for the treatment of acute low back problems.

     Symptom Control: Physical Treatments
     Spinal Manipulation

	Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms.
	When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated before beginning manipulation therapy.
	There is insufficient evidence to recommend manipulation for patients with radiculopathy.
	A trial of manipulation in patients without radiculopathy with symptoms longer than a month is probably safe, but efficacy is unproven.
	If manipulation has not resulted in symptomatic improvement that allows increased function after 1 month of treatment, manipulation therapy should be stopped and the patient reevaluated.

     Physical Agents and Modalities

The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost. As an option, patients may be taught self- application of heat or cold to the back at home.

     Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) is not recommended in the treatment of patients with acute low back problems.

     Shoe Insoles and Shoe Lifts

	Shoe insoles may be effective for patients with acute low back problems who stand for prolonged periods of time. Given the low cost and low potential for harms, shoe insoles are a treatment option.
	Shoe lifts are not recommended for treatment of acute low back problems when lower limb length difference is <=2 cm.

     Lumbar Corsets and Back Belts

	Lumbar corsets and support belts have not been proven beneficial for treating patients with acute low back problems.
	Lumbar corsets, used preventively, may reduce time lost from work due to low back problems in individuals required to do frequent lifting at work.

     Traction

Spinal traction is not recommended in the treatment of patients with acute low back problems.

     Biofeedback

Biofeedback is not recommended for treatment of patients with acute low back problems.

     Symptom Control: Injection Therapy
     Trigger Point and Ligamentous Injections

	Trigger point injections are invasive and not recommended in the treatment of patients with acute low back problems.
	Ligamentous and sclerosant injections are invasive and not recommended in the treatment of patients with acute low back problems.

     Facet Joint Injections

Facet joint injections are invasive and not recommended for use in the treatment of patients with acute low back problems.

     Epidural Injections (Steroids, Lidocaine, Opioids)

	There is no evidence to support the use of invasive epidural injections of steroids, local anesthetics, and/or opioids as a treatment for acute low back pain without radiculopathy.
	Epidural steroid injections are an option for short-term relief of radicular pain after failure of conservative treatment and as a means of avoiding surgery.

     Acupuncture

Invasive needle acupuncture and other dry needling techniques are not recommended for treating patients with acute low back problems.

     Activity Modification
     Activity Recommendations:

	Patients with acute low back problems may be more comfortable if they temporarily limit or avoid specific activities known to increase mechanical stress on the spine, especially prolonged unsupported sitting, heavy lifting, and bending or twisting the back while lifting. (Strength of Evidence = D.)
	Activity recommendations for the employed patient with acute low back symptoms need to consider the patient's age and general health, and the physical demands of required job tasks. (Strength of Evidence = D.)

     Bed Rest

	A gradual return to normal activities is more effective than prolonged bed rest for treating acute low back problems. (Strength of Evidence = B.)
	Prolonged bed rest for more than 4 days may lead to debilitation and is not recommended for treating acute low back problems. (Strength of Evidence = B.)
	The majority of low back patients will not require bed rest. Bed rest for 2 to 4 days may be an option for patients with severe initial symptoms of primarily leg pain. (Strength of Evidence = D.)

     Exercise

	Low-stress aerobic exercise can prevent debilitation due to inactivity during the first month of symptoms and thereafter may help to return patients to the highest level of functioning appropriate to their circumstances. (Strength of Evidence = C.)
	Aerobic (endurance) exercise programs, which minimally stress the back (walking, biking, or swimming), can be started during the first 2 weeks for most patients with acute low back problems. (Strength of Evidence = D.)
	Conditioning exercises for trunk muscles (especially back extensors), gradually increased, are helpful for patients with acute low back problems, especially if symptoms persist. During the first 2 weeks, these exercises may aggravate symptoms since they mechanically stress the back more than endurance exercises. (Strength of Evidence = C.)
	Back-specific exercise machines provide no apparent benefit over traditional exercise in the treatment of patients with acute low back problems. (Strength of Evidence = D.)
	Evidence does not support stretching of the back muscles in the treatment of patients with acute low back problems. (Strength of Evidence = D.)
	Recommended exercise quotas that are gradually increased result in better outcomes than telling patients to stop exercising if pain occurs. (Strength of Evidence = C.)

Special Studies and Diagnostic Considerations

     Electrophysiologic Tests (EMG and SEP)

	Needle EMG and H-reflex tests of the lower limb may be useful in assessing questionable nerve root dysfunction in patients with leg symptoms lasting longer than 4 weeks (regardless of whether patients also have back pain). (Strength of Evidence = C.)
	If the diagnosis of radiculopathy is obvious and specific on clinical examination, electrophysiologic testing is not recommended. (Strength of Evidence = D.)
	Surface EMG and F-wave tests are not recommended for assessing patients with acute low back symptoms. (Strength of Evidence = C.)
	SEPs may be useful in assessing suspected spinal stenosis and spinal cord myelopathy. (Strength of Evidence = C.)

     Bone Scan

A bone scan is recommended to evaluate acute low back problems when spinal tumor, infection, or occult fracture is suspected from red flags on medical history, physical examination, or collaborative lab test or plain x-ray findings. Bone scans are contraindicated during pregnancy. (Strength of Evidence = C.)

     Thermography

Thermography is not recommended for assessing patients with acute low back problems. (Strength of Evidence = C.)

     Plain X-Rays

	Plain x-rays are not recommended for routine evaluation of patients with acute low back problems within the first month of symptoms unless a red flag is noted on clinical examination (such as specified below). (Strength of Evidence = B.)
	Plain x-rays of the lumbar spine are recommended for ruling out fractures in patients with acute low back problems when any of the following red flags are present: recent significant trauma (any age), recent mild trauma (patient over age 50), history of prolonged steroid use, osteoporosis, patient over age 70. (Strength of Evidence = C.)
	Plain x-rays in combination with CBC and ESR may be useful for ruling out tumor or infection in patients with acute low back problems when any of the following red flags are present: prior cancer or recent infection, fever over 100 degrees F, IV drug abuse, prolonged steroid use, low back pain worse with rest, unexplained weight loss. (Strength of Evidence = C.)
	In the presence of red flags, especially for tumor or infection, the use of other imaging studies such as bone scan, CT, or MRI may be clinically indicated even if plain x-rays are negative. (Strength of Evidence = C.)
	The routine use of oblique views on plain lumbar x-rays is not recommended for adults in light of the increased radiation exposure. (Strength of Evidence = B.)

     CT, MRI, Myelography, and CT-Myelography

	In the presence of red flags suggesting cauda equina syndrome or progressive major motor weakness, the prompt use of CT, MRI, myelography, or CT-myelography is recommended. Because these serious problems may require prompt surgical intervention, planning for use of such imaging studies is best done in consultation with a surgeon. (Strength of Evidence = C.)
	CT, MRI, myelography, or CT-myelography and/or consultation with an appropriate specialist is recommended when clinical findings strongly suggesting tumor, infection, fracture, or other space-occupying lesions of the spine. (Strength of Evidence = C.)
	Routine spinal imaging tests are not generally recommended in the first month of symptoms except in the presence of red flags for serious conditions. After 1 month of symptoms, an imaging test is acceptable when surgery is being considered (or to rule out a suspected serious condition). (Strength of Evidence = B.)
	For patients with acute low back problems who have had prior back surgery, MRI with contrast appears to be the imaging test of choice to distinguish disc herniation from scar tissue associated with prior surgery. (Strength of Evidence = D.)
	CT-myelography and myelography are invasive and have an increased risk of complications. These test are indicated only in special situations for preoperative planning. (Strength of Evidence = D.)
	The following are minimal quality criteria for imaging studies of the lumbar spine (Strength of Evidence = B): CT and MRI cuts to be made no wider than 0.5 cm and parallel to the vertebral endplates. MRI scanners to have a magnetic field strength no less than 0.5 T (tesla) and to allow a scanning time adequate for optimal image acquisition. Myelography and CT-myelography to use water-based contrast media. The technical protocols for these imaging tests to be described on radiologist reports.

     Discography

	Discography is invasive, and its use is not recommended for assessing patients with acute low back pain. Interpretation is equivocal, and complications can be avoided with other noninvasive techniques. (Strength of Evidence = C.)
	Due to increased potential risks, CT-discography is not recommended over other imaging studies (MRI, CT) for assessing patients with suspected nerve root compression due to lumbar disc hernia. (Strength of Evidence = C.)

     Surgery for Herniated Disc

	It is recommended that the treating clinician discuss further treatment options, with the patient with sciatica after approximately 1 month of conservative therapy. The clinician should consider referral to a specialist when all of the following conditions are met: (1) sciatica is both severe and disabling, (2) symptoms of sciatica persist without improvement or with progression, and (3) there is clinical evidence of nerve root compromise. (Strength of Evidence = B.)
	Standard discectomy and microdiscectomy are of similar efficacy and appropriate for selected patients with herniated discs and nerve root dysfunction. (Strength of Evidence = B.)
	Chymopapain is an acceptable treatment for such patients, but less efficacious than standard or microdiscectomy. If chymopapain is being considered, testing patients for allergic sensitivity to this substance can reduce incidence of anaphylaxis. (Strength of Evidence = C.)
	Percutaneous discectomy is significantly less efficacious than chymopapain in treating patients with lumbar disc herniation. This and other new methods of lumbar disc surgery are not recommended until they can be proven efficacious in controlled trials. (Strength of Evidence = C.)
	Patients with acute low back pain alone, who have neither suspicious findings for a significant nerve root compression nor any positive red flags, do not need surgical consultation for possible herniated lumbar disc. (Strength of Evidence = D.)

     Surgery for Spinal Stenosis

	Elderly patients with spinal stenosis who can adequately function in the activities of daily life can be managed with conservative treatments. Surgery for spinal stenosis should not usually be considered in the first 3 months of symptoms. Decisions on treatment should take into account the patient's lifestyle, preference, other medical problems, and risks of surgery. (Strength of Evidence = D.)
	Surgical decisions for patients with spinal stenosis should not be based solely on imaging tests, but should also consider the degree of persistent neurogenic claudication symptoms, associated limitations, and detectable neurologic compromise. (Strength of Evidence = D.)

     Spinal Fusion

	In the absence of fracture, dislocation, or complications of tumor or infection, the use of spinal fusion is not recommended for the treatment of low back problems during the first 3 months of symptoms. (Strength of Evidence = C.)
	Spinal fusion should be considered following decompression at a level of increased motion due to degenerative spondylolisthesis. (Strength of Evidence = C.)
	Social, economic, and psychological factors can significantly alter a patient's response to back symptoms and to the treatment of those symptoms. (Strength of Evidence = D.)

     Assessment of Psychosocial Factors

In a patient with acute low back symptoms and no evidence of serious underlying spinal pathology, the inability to regain tolerance of required activities may indicate that unrealistic expectations or psychosocial factors need to be explored before considering referral for a more extensive evaluation or treatment program.

DEVELOPER(S):
Agency for Health Care Policy and Research (AHCPR) - Federal Government Agency (U.S.)

COMMITTEE:
The Panel on Acute Lower Back Problems in Adults

GROUP COMPOSITION:
From 200 nominations solicited through a Federal Register announcement and from professional and consumer organizations interested in the care of patients with low back problems, AHCPR selected 23 individuals representing the fields of biomechanical and spine research, chiropractic care, emergency medicine, family medicine, internal medicine, neurology, neurosurgery, occupational health nursing, occupational medicine, occupational therapy, orthopedics, osteopathic medicine, physical and rehabilitation medicine, physical therapy, psychology, rheumatology, and radiology. The panel also included a consumer representative who had experience low back problems, but did not work in the health care field.

Names of Panel Members: Stanley J. Bigos, MD (Chair) ; Reverend O. Richard Bowyer ; G. Richard Braen, MD ; Kathleen Brown, PhD, RN ; Richard Deyo, MD, MPH ; Scott Haldeman, DC, MD, PhD; John L. Hart, DO ; Ernest W. Johnson, MD ; Robert Keller, MD; Daniel Kido, MD, FACR; Matthew H. Liang, MD, MPH; Roger M. Nelson, PT, PhD; Margareta Nordin, RPT, DrSci; Bernice D. Owen, PhD, RN Sc, PhD; Richard K. Schwartz, MS, OTR, FSR; Donald H. Stewart, Jr., MD; John J. Triano, MA, DC; Lucius C. Tripp, MD, MPH, FACPM; Dennis C. Turk, PhD; Clark Watts, MD, JD; James N. Weinstein, DO

ENDORSER(S):
Not stated

GUIDELINE STATUS:
This is the original release of the guideline.

Print copies: Available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; (800) 358-9295.

COMPANION DOCUMENTS:
The following documents are available:

1. Acute low back problems in adults: assessment and treatment. Rockville, MD: AHCPR, 1994. (Quick reference guide for clinicians; no.14). AHCPR Publication No. 95-0643.
2. Understanding acute low back problems. Rockville, MD: AHCPR, 1994 Dec. (Consumer guide; no. 14). AHCPR Publication No. 95-0644.
3. Los problemas de la espalda. Rockville, MD: AHCPR, 1995 April. (Consumer guide, Spanish; no.14). AHCPR Publication No. 95-0645.
4. Bigos SJ, Bowyer OR, Braen GR, Brown K, et al. Acutre low back problems in adults. Rockville, MD: AHCPR, 1997 Feb. (Guideline technical report; no. 14). AHCPR Publication No. 97-N012.

Electronic copies: Items 1 through 3 are availabe from the National Library of Medicine's HSTAT database.

Print copies: Items 1 through 4 are available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907: (800) 358-9295.

NGC STATUS:
This summary was completed by ECRI on August 1, 1998. The information was verified by the guideline developer as of December 1, 1998.

COPYRIGHT STATEMENT:
No copyright restrictions apply.