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triage

A Practical Guide to Managing Low Back Pain in the Primary Care Setting: Epidemiology, Pathoanatomy, Clinical Evaluation and Triage—Part 1

Teaser: 

Conner Joseph Clay1, José M. Orenday-Barraza, MD2, María José Cavagnaro MD2, Leah Hillier MD CCFP (SEM)3, Leeann Qubain1, Eric John Crawford MD MSc(c) FRCSC4, Brandon Hirsch MD5, Ali A. Baaj MD2, Robert A. Ravinsky MDCM MPH FRCSC5

1 University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
2Department of Neurosurgery, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
3Department of Family Medicine & Community Medicine, Banner University Medical Center Phoenix, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
4Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
5Department of Orthopaedic Surgery, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.

CLINICAL TOOLS

Abstract: Low back pain (LBP) is one of the most common presenting complaints in the primary care setting, with significant economic implications and impairment of quality of life. Effective treatment of low back pain can frequently be delivered in the primary care setting. Knowledge of common pain generators, and recognition of pain patterns based on the history and physical exam helps guide the treatment of LBP without the need for excessive resource utilization. The majority of patients presenting with LBP can be confidently treated with targeted conservative management, frequently obviating the need for advanced imaging and diagnostic investigations.
Key Words: low back pain, mechanical low back pain, lumbar pain, degenerative disease, clinical evaluation, triage.

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Pre-test CME Quiz Post-test CME Quiz
The lumbar spine is designed to be both strong and flexible, but disruption or degeneration of the supporting structures of the spine can result in low back pain without major pathology.
Low back pain can be characterized into one of four pain patterns using a focused history supported by a relevant physical exam.
Lumbar spine MRI is indicated if accompanying Red Flag symptoms, such as recent systemic illness, high suspicion for tumour, or progressive/severe neurological symptoms/signs are present with the back pain.
The presence of "red flag" signs and symptoms must be carefully interpreted as a group and not individually.
Most adults will experience LBP sometime during their life.
Knowledge of common pain generators, and recognition of pain patterns based on the history and physical exam help guide treatment without the need for excessive resource utilization.
The goal of triaging LBP is to determine which cases arise from sinister pathology, and which cases can be safely managed conservatively.
Diagnostic investigations and specialist referral are warranted only when there is suspicion of a specific disease process that would be managed differently than mechanical LBP.
When clearly identified, the four LBP pain patterns should be treated in the primary care setting before undergoing advanced imaging.
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Related Terms: Back Health, low back pain, mechanical low back pain, lumbar pain, degenerative disease, clinical evaluation, triage
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