Perils and pointers in the evaluation and management of back pain

This article examines the current treatment of low back pain in light of the recent Agency for Health Care Practice and Research (AHCPR) guidelines on the acute management of low back pain (the AHCPR is an agency of the federal government). The article describes the most important history questions, the most helpful physical signs, and the most practical examination techniques. Considerable emphasis is placed on ruling out the "red flag" diagnoses that require immediate treatment. The article agrees with the AHCPR that if the red flags of cancer, infection, fracture, and neurologic deficit are ruled out, most of the remaining causes of acute back pain are largely self-healing over 4-8 weeks. Emphasis is placed on using the history and physical examination rather than expensive studies to rule out the red flag cases, so that cost-effective management of low back pain is possible. The author also reviews the ten top causes of low back pain and their evaluation and treatment.