Scope and Target Population:
Adult patients age 18 and over in primary care who have symptoms of low back pain or radiculopathy. The focus is on acute and chronic management, including indications for medical, non-surgical or surgical referral. For workers' compensation patients, check with state guidelines where the patient resides and where the injury took place: http://www.workerscompensation.com/workers_comp_by_state.php.

The pregnant population is excluded from this guideline; however, the following considerations are noted.

Low back pain (LBP), alone or in combination with pelvic pain, is a common problem suffered by women during pregnancy. Studies estimate 50%-80% of women will suffer from LBP during pregnancy, and one study found that approximately 62% of women rated the pain as moderately severe. Despite the significance of this problem, only one third of pregnant women reported LBP to their prenatal care providers.

The typical course of LBP during pregnancy is that it generally begins in the mid-late 2nd trimester and resolves during the post-partum course and, unfortunately, is likely to return in subsequent pregnancies. As mentioned most cases resolve in the post-partum period, although Norén reported that 20% of women with LBP during pregnancy were found to have LBP three years following delivery.

The clinical history and physical examination should include elements that focus on the mother and the fetus, and the medical care provider should consider a broad differential. The physical examination is similar to non-pregnant patients with LBP, although lumbar flexion will be limited as the pregnancy progresses and the gravid abdominal examination can be challenging.
Lumbar radiographs are routinely avoided during pregnancy due to concern for fetal health. Magnetic resonance imaging is the test of choice for severe pregnancy-related LBP.

According to a Cochrane review, effective treatment of pregnancy-related LBP, as measured by pain reduction and back-pain related sick leave, included strengthening exercises, sitting pelvic tilt exercises and water gymnastics.

Aims:

1. Improve the assessment and reassessment of patients age 18 and older with low back pain diagnosis.
   
2. Reduce unnecessary imaging for low back pain patients age 18 and older in the absence of "red flag" indicators or progressive symptoms.
   
3. Increase the use of recommended conservative approach as first-line treatment, such as activity, self-care and analgesics for patients age 18 and older with low back pain diagnosis.
   

Clinical Highlights:

• Back pain assessment should include a subjective pain rating, functional status, patient history including notation of presence or absence of "red flags" (Cauda Equina Syndrome or other conditions noted in Annotation #1) and psychosocial indicators, assessment of prior treatment and response, employment status, and clinician's objective assessment.
  
• Reduce unnecessary imaging unless "red flag" indicators exist.
  
• A conservative approach should be first-line treatment. Emphasize patient education and conservative home self-care, which includes early ambulation, postural advice, resumption of activities, use of ice and heat, anti-inflammatory and analgesic over-the-counter medications, and early return to work or activities.
  
• Patients with acute low back pain should be advised to stay active and continue ordinary daily activity. For chronic back pain, there is evidence that exercise therapy is effective.
  
• Consult or refer to spine specialist if conservative treatment fails.