Best Practice Case Studies-Case 156 Asset 2 Chronic Low Back Pain in Adults

Pdf Summary

The article reviews the evaluation, treatment, and prevention of chronic low back pain, defined as lumbar pain lasting 12 weeks or more. Chronic low back pain affects about 13% of U.S. adults and is often nonspecific/idiopathic, though clinicians must still consider mechanical, radicular, inflammatory, infectious, neoplastic, and other causes.<br /><br />Assessment should begin with a careful history and physical exam to identify red flags requiring urgent workup, such as cancer, infection, fracture, or cauda equina syndrome, and yellow flags that increase disability risk, including depression, anxiety, poor coping, and social stressors. The exam should include a focused neurologic evaluation and testing for radicular symptoms. Routine imaging and lab testing are not recommended unless red flags, neurologic deficits, or failure to improve with conservative care are present.<br /><br />First-line treatment is nonpharmacologic. Patients should remain active and avoid bed rest. Helpful options include exercise therapy, physical therapy, behavioral counseling such as cognitive behavioral therapy or mindfulness-based stress reduction, spinal manipulation, massage, acupuncture, dry needling, and transcutaneous electrical nerve stimulation. Among these, exercise and early physical therapy can improve pain and function and reduce unnecessary imaging and opioid use.<br /><br />Medications are second-line. NSAIDs are the preferred initial drug therapy. Duloxetine may provide modest benefit. Evidence does not support routine use of acetaminophen, muscle relaxants, benzodiazepines, anticonvulsants, oral corticosteroids, or long-term opioids. Epidural steroid injections may offer only short-term relief for radicular pain.<br /><br />Most patients do not need surgery. Referral may be considered for progressive neurologic deficits, worsening spinal stenosis, worsening spondylolisthesis, or persistent herniated disk symptoms. Prevention is important: identifying patients at risk for transition from acute to chronic pain and using stratified, targeted early treatment may reduce chronicity, disability, and health care use.

Meta Tag

Edition 4th Edition

Related Case 4th Edition, Case 156

Topic Spine

Keywords

chronic low back pain

lumbar pain

red flags

yellow flags

nonpharmacologic treatment

exercise therapy

physical therapy

NSAIDs

duloxetine

spinal manipulation

4th Edition

4th Edition, Case 156

Spine