Low Back Pain

Management of Low Back Pain in Primary health care

Step 1. Screen for Red Flags

• Cancer history, unexplained weight loss, fever, night sweats
• Trauma, Age >50 years, osteoporosis, long-term steroids
• Neurologic deficits (foot drop, saddle anesthesia, incontinence)

If any → immediate x-ray + urgent referral if serious cause is found or still suspected.

Step 2. Categorize

• Acute (<4 wks)            Subacute (4–12 wks)            Chronic (>12 wks)

Step 3. Initial Conservative Care (If No Red Flags)

• Stay active (avoid bed rest), avoid aggravating movements or heavy lifting.
• NSAID first-line: Ibuprofen 400-600 mg TID or Naproxen 250–500 mg BID
• Education: reassure, ergonomics, educate that natural recovery is common.
• Review after 4–6 weeks

Note: Paracetamol is not effective, topical diclofenac may help mild acute cases, and muscle relaxants should be reserved for short-term use only when other measures fail.

Step 4. When to Order Imaging

• Do NOT order imaging at first visit for non-specific pain without red flags.
• Order x-ray before deciding referralif:
  • Pain persists >6 weeks despite optimal conservative therapy
  • Pain is progressive during the conservative management period
  • Pain chronic (>12 wks)
  • Symptoms suggest possible structural cause (radicular pain, worsening stiffness, atypical features)

Step 5. Referral Rules

• If acute/subacute, improved within 4–6 wks → No referral, give proper education.
• If persistent >6 wks → Do imaging first, then:
  • If normal → Routine referral to physiotherapy
  • If abnormal (disc disease, stenosis, fracture, etc.) → Specialist referral

Author: Dr. Fahad Saad Almutairi , Reviewer: Dr. Bader Thuwaini Alanazi