Low Back Pain
The Problem: Back pain with radicular symptoms can be referred to the clinic unless there are signs of a potentially dangerous underlying condition such as the following: fracture (suggested by trauma especially if patient osteoporotic),  tumour  (especially if age <20 or >50; previous history of cancer; unexplained recent weight loss; or pain that is worse at night or lying down),  infection (consider if recent fevers or chills; patient immunosuppressed; intravenous drug user or recent bacterial infection), cauda equina syndrome (suggested by recent onset of bladder or bowel dysfunction and a severe neurological deficit in the lower extremity), or rapidly progressive radicular deficits (including a foot drop)1.  For cauda equina patients be sure to check their anal tone, perianal sensation and get a post void urinary residual. You need plain films of the spine to start with. You can get a CT of the lumbar spine at night. If you really suspect cauda equina or conus medularis compression you need to get a CT-myelogram or MRI within hours rather than days. This can be a challenge so just contact the radiology resident on call and discuss it.	What We Do: If there is not an emergency requiring surgical treatment, patients can choose to use or not use many different strategies or treatments because there is no evidence-supported golden road to comfort for them. (Please see the reference "Guideline from National Guideline Clearinghouse: Acute low back problems in adults".) They can: rest in bed or not 2 ; undergo acupuncture or not 3 ; carry out special exercises or not 4 ; use a back brace or not 5 ; use massage therapy or not 6 ; see a surgeon or not 7, 8 ;  You can prescribe any NSAID you choose with good evidence that it will help for short-term symptom relief 9.  Behavioural treatment seems to be an effective treatment for chronic low back pain patients. Psychosocial risk factors play an important role in the development of chronic back pain and disability 10 .  Therefore, referral to a centre specialized in such treatment can be justified. Links: Scales and scores pertinent to low back pain include the Oswestry and the Roland Morris. Guideline from National Guideline Clearinghouse: Acute low back problems in adults" Evidence Footnotes:
Authorship: Dr Valerie Taylor	Last Revised: 31 May 2002

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