Low Back Pain Essentials: Red Flags, Imaging Guidelines & Stepwise Treatment

Below is a **concise but complete NEET PG–level single-place reference** on:
**Low Back Pain Essentials: Red Flags, Imaging Guidelines & Stepwise Treatment**

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# **LOW BACK PAIN – COMPLETE GUIDE**

## **1. Definition**

Low back pain (LBP) = Pain between lower rib margins and gluteal folds, with or without leg radiation.
Most cases are **mechanical**, **self-limiting**, and improve within 4–6 weeks.

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# **2. Pathophysiology (Essential Points)**

* **Muscle/ligament strain** → micro-tears → inflammation.
* **Disc degeneration** → reduced hydration, annular tears → bulge/herniation → nerve root compression (radiculopathy).
* **Facet arthropathy** → synovial inflammation.
* **Spinal stenosis** → narrowing of canal/foramina → neurogenic claudication.
* **Sacroiliac dysfunction** → inflammatory or mechanical load.

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# **3. Causes of Low Back Pain**

### **A. Mechanical (90%)**

* Lumbar strain/sprain
* Degenerative disc disease (DDD)
* Facet joint osteoarthritis
* Disc herniation
* Spondylolisthesis/spondylolysis
* Spinal stenosis

### **B. Non-Mechanical**

* **Infection:** Vertebral osteomyelitis, discitis, epidural abscess
* **Inflammatory:** Ankylosing spondylitis, spondyloarthropathies
* **Neoplastic:** Primary/mets
* **Visceral causes:** Renal colic, pancreatitis, AAA

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# **4. Red Flags (NEET PG Favourites)**

Red flags prompt **urgent evaluation + imaging**:

### **Trauma / Structural**

* Recent significant trauma
* Minor trauma in elderly/osteoporosis → compression fracture

### **Cancer red flags**

* Age >50 or <20
* History of cancer
* Unexplained weight loss
* Night pain, unrelenting pain
* Failure to improve after 4–6 weeks

### **Infection red flags**

* Fever, chills
* Recent bacterial infection
* IV drug use
* Immunosuppression (HIV, steroids, DM)

### **Neurologic red flags**

* **Cauda equina symptoms:**

* Saddle anesthesia
* New urinary retention or overflow incontinence
* Fecal incontinence
* Severe/progressive bilateral neurological deficit

### **Other**

* Pain worse at rest
* Unexplained systemic symptoms

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# **5. Imaging Guidelines (Based on ACR & Evidence-Based Practice)**

### **A. NO Immediate Imaging If:**

* Age <50
* No red flags
* Pain <6 weeks
* Neurologic exam normal

**Reason:** Most cases resolve; imaging won’t change outcomes.

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### **B. When to Image Immediately?**

| Condition | Preferred Imaging |
| ---------------------------------------- | -------------------------------- |
| **Neurologic deficit / Cauda equina** | **MRI Lumbar Spine – urgent** |
| **Suspected cancer** | MRI with contrast |
| **Suspected infection** | MRI with contrast |
| **Fracture after trauma / osteoporosis** | **X-ray** first; CT if unclear |
| **Spondylolysis** | X-ray oblique; MRI/CT to confirm |

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### **C. Persistent Pain (>6 weeks)**

* If conservative therapy fails → MRI (best for disc, nerve roots, stenosis).

### **D. What Each Imaging Shows**

* **X-ray:** alignment, fractures, spondylolisthesis, facet OA.
* **MRI:** disc herniation, stenosis, infection, tumor, nerve root compression.
* **CT:** fracture detail, bony abnormalities.

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# **6. Clinical Features**

### **Mechanical LBP**

* Worse with activity, better with rest
* Localized pain
* No neurological deficit

### **Radiculopathy**

* Shooting leg pain in dermatomal pattern
* Positive straight leg raise (SLR)
* Weakness, numbness, diminished reflexes

### **Spinal Stenosis**

* Neurogenic claudication
* Worse in extension, better when sitting/leaning forward

### **Spondyloarthropathy**

* Morning stiffness >30 min
* Pain improves with exercise
* Alternating buttock pain

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# **7. Stepwise Management of Low Back Pain**

## **A. FIRST-LINE (0–6 Weeks)**

### **Non-Pharmacologic**

* **Stay active** (avoid bed rest)
* Heat therapy
* Physiotherapy:

* Core strengthening
* McKenzie exercises
* Ergonomic correction
* Weight loss

### **Pharmacologic**

* **NSAIDs** (Ibuprofen, Naproxen, Diclofenac)
* **Muscle relaxants** (short-term): Tizanidine, Cyclobenzaprine
* Avoid opioids unless severe, refractory pain.

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## **B. SECOND-LINE (Persistent pain or radiculopathy)**

* **Oral corticosteroids** (short tapers for acute radiculopathy)

* **Neuropathic agents:**

* Gabapentin/Pregabalin
* Duloxetine

* Consider **Spinal manipulation therapy**

* Traction is NOT recommended routinely.

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## **C. THIRD-LINE (6–12 weeks & MRI–confirmed pathology)**

### **Interventions**

* **Epidural steroid injections** (disc herniation, radiculopathy)
* **Facet joint injections / Medial branch blocks**
* **Radiofrequency ablation** (facet arthropathy)

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## **D. SURGERY**

### **Indications**

* Cauda equina syndrome (emergency)
* Progressive motor deficit
* Severe refractory radiculopathy >6–12 weeks
* Structural pathology:

* Herniated disc
* Spinal stenosis
* Spondylolisthesis with instability
* Tumor/infection requiring decompression

### **Common surgeries**

* Microdiscectomy
* Laminectomy
* Spinal fusion (instability)

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# **8. Differential Diagnosis (Quick List)**

* Ankylosing spondylitis
* Hip pathology (radiates to thigh)
* Piriformis syndrome
* Pyelonephritis
* Renal/ureteric stone
* Pancreatitis
* AAA

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# **9. Patient Education Points**

* Most episodes resolve within weeks.
* Avoid prolonged rest.
* Maintain exercise routine even after improvement.
* Warning signs requiring urgent care:

* Urinary issues
* Saddle anesthesia
* Progressive weakness
* Fever/weight loss

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