Acute lower back by definition is self-limited, lasting less than 4 weeks. While acute lower back pain may last up to 4 weeks, in fact it often only lasts less than 1 or 2 weeks. Because of its short duration and relative benign nature, acute lower back pain has received much less attention in the medical literature than chronic lower back pain. There are two very good reasons for this. First, it is very difficult to study something that is only going to last four weeks at most. To measure the effectiveness of any particular intervention would require massive amounts of patients in a study in order to detect whether that intervention was effective. Second, because of its limited duration, testing and treatments are of limited value. Diagnostic testing is rarely performed [1]. Treatments are used to take away symptoms and ideally speed recovery, but invasive treatments tend to be avoided because, again, the pain is going to go away anyway [2].

So understanding that the research is sparse in this arena, what is a physician to do when treating a patient who presents with acute lower back pain?

The first thing to do with a patient with acute lower back pain is to make sure there are no red flag signs or symptoms. Red flag signs or symptoms may indicate a more serious underlying problem such as infection, fracture, spinal cord compression, or underlying cancer. See Table 3.1 for red flag signs and symptoms. Assuming no red flags, how does one approach a patient with acute lower back pain?

Doctors are often asked in training and in board examinations: What is the first diagnostic thing you do when a patient comes in presenting with lower back pain? The answer is uniformly to take a comprehensive history and perform a thorough physical examination. After that, in a patient with simple acute lower back pain, no neurologic signs or symptoms and no red flag signs or symptoms, there is no need for diagnostic imaging studies.

When considering treatment for acute lower back pain, the first thing to gauge is the severity. If the severity is mild to moderate, then recommendations generally include:

Advice to stay active and continue to move but not to do activities that directly increases pain.

Ice the lower back in the first 48 h after an injury (20 min on, 20 min off) for a few times per day. Heat or ice, or a combination of both for symptom relief after that, with an emphasis on explaining to the patient that it really doesn’t “matter” which they use—heat or ice—as neither will affect the long-term duration of the pain and problem and so the patient should use whichever she feels helps her symptoms most.