Acute Lower Back Problems in Adults - Organization

Organization and Clinical Categories

Chapter 2 <http://text.nlm.nih.gov> of this guideline focuses on the initial assessment of the patient with activity limitations due to acute low back symptoms, and Chapter 3 <http://text.nlm.nih.gov> addresses initial treatment methods for these patients. The assessment and treatment methods considered in these chapters can typically be managed by the primary care clinician. Up to 90 percent of patients with acute low back problems recover within 1 month from activity limitations due to symptoms. [6] <http://text.nlm.nih.gov>, [14] <http://text.nlm.nih.gov>, [15] <http://text.nlm.nih.gov> Chapter 4 <http://text.nlm.nih.gov>addresses diagnostic and treatment considerations for the small percentage of patients who still have substantial symptoms or limitations after 1 month. Many of these diagnostic and therapeutic methods can be managed by the primary care clinician; others will require consultation with a specialist.

The panel recognized that different clinical disciplines use a variety of diagnostic labels that implicitly suggest a cause for low back symptoms. However, these labels are often unreliable for categorizing causes of acute low back problems. Even after an extensive workup, only about 15 percent of patients can be given a definitive diagnosis. [16] <http://text.nlm.nih.gov>

Since the many diagnostic labels currently used to describe low back problems may confuse patients and clinicians, the panel considered it more useful to classify a patient's acute low back problem into one of three descriptive clinical categories based on medical history and physical examination findings:

• Potentially serious spinal condition: spinal tumor, infection, fracture, or cauda equina syndrome suggested by findings from medical history or physical examination ("red flags").
  
• Sciatica: back–related lower limb symptoms suggesting nerve root compromise.
  
• Nonspecific back symptoms: symptoms occurring primarily in the back that suggest neither nerve root compromise nor a serious underlying condition.
  

In the panel's opinion, clinicians would have enough information to make appropriate decisions about initial assessment and treatment, as well as some hints about prognosis, after correctly classifying patients with low back problems into one of the above three categories. The panel used this classification scheme in making guideline recommendations about assessment and treatment methods.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.