Cleveland Clinic Journal of MedicinePursuing the Diagnosis of Low Back Pain

The diagnostic approach to low back pain must balance the need for conservative management with vigilance for serious underlying conditions, highlighting the importance of clinical judgment in identifying and treating both common and less obvious causes.

Low back pain is a prevalent concern among patients, with up to 80% experiencing it at some point in their lives. Current guidelines recommend a conservative approach initially, often avoiding diagnostic imaging to reduce costs and unnecessary interventions. However, clinicians must remain alert to red flags indicating serious conditions that require prompt diagnosis and treatment. This article examines the nuances of managing acute, subacute, and chronic low back pain, emphasizing the importance of clinical assessment and the judicious use of imaging to identify conditions like spondylitis and other significant pathologies.

Key Points:

• Low back pain is common, affecting approximately 80% of individuals at some point.
• Guidelines recommend conservative management for acute and subacute low back pain, including avoiding initial diagnostic imaging.
• Most patients experience nonspecific low back pain without a clear structural cause, often resolving with lifestyle and physiotherapeutic interventions.
• Clinicians must be vigilant for red flags suggesting serious conditions such as skeletal malignancy, infections, cauda equina syndrome, and vertebral fractures.
• Red flags include documented fevers, weight loss, severe nocturnal pain, trauma, corticosteroid use, and a history of cancer.
• Evidence supporting the use of individual red flags is weak, but they remain important in clinical evaluation.
• Diagnostic imaging is discouraged initially to reduce costs and avoid unnecessary procedures and radiation exposure.
• Incidental findings from imaging can lead to further tests and increased healthcare costs without improving outcomes.
• Chronic back pain requires a tempered diagnostic strategy, with consideration of mechanical or anatomic causes like hip disease and spinal stenosis.
• Inflammatory spine diseases, such as spondylitis, may require imaging for diagnosis, particularly if clinical suspicion is strong.
• Spondylitis symptoms include constant pain, morning stiffness, nocturnal pain disrupting sleep, and a history of inflammatory conditions.
• Direct-to-consumer advertising has raised awareness of spondylitis, affecting both men and women, and often associated with psoriasis or inflammatory bowel disease.
• Sacroiliac joint radiography and, if necessary, MRI should be pursued in suspected spondylitis cases.
• Even without imaging evidence, patients with a compelling history and clinical findings may respond to anti-inflammatory therapies and biologics.
• Differential diagnosis for sacroiliac joint abnormalities is crucial to avoid misdiagnosis and ensure appropriate treatment.

Low back pain (LBP) is the leading cause of disability globally. In 2020, approximately 1 in 13 people, equating to 619 million people, experienced LBP, a 60% increase from 1990. Cases of LBP are expected to rise to an estimated 843 million by 2050, with the greatest growth anticipated in Africa and Asia, where populations are getting larger and people are living longer. (WHO)

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