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Practice Guidelines
ACP Guidelines for the Diagnosis and Treatment of Low Back Pain

Table 1
Diagnostic Work-up for Initial Evaluation of Low Back Pain

POSSIBLE KEY FEATURES ON HISTORY OR PHYSICAL ADDITIONAL

IMAGING*
CAUSE EXAMINATION STUDIES*

Ankylosing Morning stiffness; improvement with exercise; alternating Anteroposterior ESR and/or
spondylitis buttock pain; awakening because of back pain during the pelvis plain CRP, HLA-
second part of the night; younger age radiography B27

Cancer History of cancer with new onset of low back pain MRI ESR

Unexplained weight loss; failure to improve after one Lumbosacral ESR

month; age older than 50 years plain
radiography

Multiple risk factors present Plain ESR

radiography or
MRI

Cauda equina Urinary retention; motor deficits at multiple levels; fecal MRI None
syndrome incontinence; saddle anesthesia

Herniated Back pain with leg pain in an L4, L5, or S1 nerve root None None
disc distribution; positive straight-leg-raise test or crossed
straight-leg-raise test

Symptoms present longer than one month MRI Consider

EMG/NCV

Severe or Progressive motor weakness MRI Consider

progressive EMG/NCV
neurologic
deficits

Spinal Radiating leg pain; older age; pseudoclaudication is a None None

stenosis weak predictor

Symptoms present longer than one month MRI Consider

EMG/NCV

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POSSIBLE KEY FEATURES ON HISTORY OR PHYSICAL ADDITIONAL

IMAGING*
CAUSE EXAMINATION STUDIES*

Vertebral History of osteoporosis; use of corticosteroids; older age Lumbosacral None

compression plain
fracture radiography

Vertebral Fever; intravenous drug use; recent infection MRI ESR and/or
infection CRP

CRP = C-reactive protein; EMG = electromyography; ESR = erythrocyte sedimentation rate; HLA = human leukocyte
antigen; MRI = magnetic resonance imaging; NCV = nerve conduction velocity.

*— Level of evidence for diagnostic evaluation is variable.

Adapted with permission from Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society [published correction appears in
Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):481.

Copyright © 2008 by the American Academy of Family Physicians.

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