---
title: Low Back Pain Clinical Approach
description: A comprehensive guide to the clinical assessment and management of low back pain.
keywords: 
  - low back pain
  - radiculopathy
  - sciatica
  - spinal stenosis
  - discogenic pain
category: clinical
---

## Introduction

Low back pain is an extremely common condition, affecting up to 80% of individuals at some point in their lifetime. It is a leading cause of disability and lost productivity worldwide. The clinical approach to low back pain requires a thorough history, physical examination, and judicious use of diagnostic imaging and laboratory testing to establish the underlying etiology and guide appropriate management.

## History and Physical Examination

The initial clinical evaluation should focus on eliciting the key features of the patient's low back pain presentation. Important historical elements include:
- Onset, duration, and character of the pain (e.g. sharp, dull, radiating)
- Aggravating and alleviating factors 
- Associated symptoms such as radiculopathy, weakness, numbness, or bowel/bladder dysfunction
- Past medical history, including prior episodes of low back pain, trauma, or spinal surgeries
- Medication use, including analgesics, anti-inflammatory drugs, or muscle relaxants

The physical examination should assess:
- Inspection for spinal deformities, muscle atrophy, or skin changes
- Palpation for tenderness, muscle spasm, or trigger points
- Range of motion in all planes, noting any pain, stiffness, or limitations
- Neurologic examination, including motor, sensory, and reflex testing of the lower extremities
- Provocative maneuvers such as straight leg raise, crossed straight leg raise, or Patrick's test

## Diagnostic Evaluation

Initial diagnostic workup for low back pain may include:
- Plain radiographs of the lumbosacral spine to evaluate for bony abnormalities, fractures, or degenerative changes
- MRI of the lumbar spine, which can assess disc pathology, spinal stenosis, and nerve root compression
- Electrodiagnostic studies (EMG/NCS) to evaluate for radiculopathy or neuropathy

Additional testing may be warranted in certain clinical scenarios:
- CT imaging for suspected spinal instability or bony pathology
- Bone scan to evaluate for occult fracture or malignancy
- Laboratory tests (e.g. ESR, CRP, HLA-B27) if inflammatory or infectious etiologies are suspected

## Differential Diagnosis

The differential diagnosis for low back pain is broad and includes:
- Mechanical/degenerative: Disc herniation, spinal stenosis, spondylolisthesis, facet arthropathy
- Inflammatory: Ankylosing spondylitis, psoriatic arthritis, reactive arthritis
- Infectious: Vertebral osteomyelitis, discitis, epidural abscess
- Neoplastic: Metastatic disease, primary spinal tumors
- Referred pain: Abdominal, pelvic, or retroperitoneal pathology
- Neuropathic: Radiculopathy, peripheral neuropathy, complex regional pain syndrome

A focused history and physical examination, combined with appropriate diagnostic testing, is crucial to differentiate these etiologies and guide management.

## Treatment Approach

The treatment of low back pain is multimodal and tailored to the underlying cause. Initial management typically involves:
- Activity modification and physical therapy to improve strength, flexibility, and function
- Oral analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or muscle relaxants
- Topical creams or ointments containing NSAIDs or capsaicin

For radicular pain or neurogenic claudication, additional interventions may be considered:
- Epidural steroid injections to reduce inflammation and provide symptomatic relief
- Gabapentin (300-1200 mg daily) or pregabalin (75-300 mg daily) for neuropathic pain
- Surgical decompression (e.g. laminectomy, discectomy) for severe, refractory cases

In patients with suspected inflammatory or infectious etiologies, the following treatments may be indicated:
- Oral corticosteroids (e.g. prednisone 20-40 mg daily) for inflammatory conditions
- Antibiotic therapy (e.g. cefazolin, vancomycin) for suspected spinal infections

Multidisciplinary pain management, including physical therapy, behavioral therapy, and interventional procedures, may be beneficial for patients with chronic, refractory low back pain.

## Monitoring and Follow-Up

Patients with low back pain should be monitored for improvement in pain, function, and quality of life. Objective measures, such as the Oswestry Disability Index or the Roland-Morris Disability Questionnaire, can be used to track patient progress.

Red flags that warrant more urgent evaluation or escalation of care include:
- Severe or progressive neurologic deficits (e.g. bowel/bladder dysfunction, lower extremity weakness)
- Fever, chills, or other signs of infection
- History of cancer or unexplained weight loss
- Failure to improve with appropriate conservative management

Patients should be followed closely, with consideration for referral to a spine specialist if conservative treatments are ineffective or if there are concerning features on the initial evaluation.

## Conclusion

Low back pain is a common and complex clinical presentation that requires a comprehensive approach to history, physical examination, and diagnostic testing to determine the underlying etiology. Multimodal treatment, including activity modification, pharmacotherapy, and interventional procedures, should be tailored to the specific diagnosis. Ongoing monitoring and follow-up are essential to ensure optimal patient outcomes.