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

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Below is a **concise but complete NEET PG–level single-place reference** on: **Low Back Pain Essentials: Red Flags, Imaging Guidelines & Stepwise Treatment** --- # **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. --- # **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. --- # **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 --- # **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 --- # **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. --- ### **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 | --- ### **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. --- # **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 --- # **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. --- ## **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. --- ## **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) --- ## **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) --- # **8. Differential Diagnosis (Quick List)** * Ankylosing spondylitis * Hip pathology (radiates to thigh) * Piriformis syndrome * Pyelonephritis * Renal/ureteric stone * Pancreatitis * AAA --- # **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 --- If you want, I can also generate: ✅ **20–30 NEET PG–level case-based MCQs (HTML-CSS-JS in one file)** ✅ SEO tags & long-tail keywords ✅ An infographic-style image for LBP Just tell me — **“Give MCQs” / “Give tags” / “Generate image.”**