Acute and chronic low back pain: a practical approach for the primary care physician

Low back pain is one of the leading causes of seeking for medical help worldwide and represents a significant burden for healthcare systems. In primary care settings, low back pain can be characterized according to a functional classification, rather than anatomical, and most patients present with nonspecific low back pain without features of severity. Still, many patients undergo unnecessary imaging studies, while current evidence demonstrates that their routine use in patients with nonspecific low back pain does not improve clinical outcomes and may increase costs and unnecessary interventions. A targeted approach focused on the identification of red flags is essential. Magnetic resonance imaging is primarily indicated in the presence of severe or progressive neurological deficits, suspected cauda equina syndrome, infection, fracture, malignancy, or inflammatory back pain. In acute low back pain cases, treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 inhibitors such as celecoxib, and in selected cases opioids. Those patients with low back pain persisting for more than six weeks, a multimodal strategy is suggested, including the use of anticonvulsants such as pregabalin or antidepressants such as amitriptyline and physical therapy and encouraging the return to routine activities. In refractory cases, referral to a specialist is suggested, particularly when surgical intervention or invasive procedures are being considered.