Conference Coverage

Case-Based Evaluation and Multimodal Management of Acute, Chronic Low Back Pain in Primary Care

Edited by:
Anthony Calabro, MA

Key Highlights

  • Low back pain (LBP) has multifactorial etiologies (degenerative, non-degenerative, and visceral) and requires recognition of red flags that warrant urgent evaluation.
  • Clinical assessment should link history and physical findings to underlying pathophysiology, including dermatomal, myotomal, and sclerotomal patterns.
  • First-line management emphasizes nonpharmacologic therapies, particularly for chronic LBP.
  • Pharmacologic options include NSAIDs, SNRIs, muscle relaxants, and opioids, with evolving evidence guiding appropriate use.
  • Interventional procedures, such as epidural injections and spinal cord stimulation, may be appropriate for selected patients with persistent or refractory symptoms.

Low back pain (LBP) remains one of the most prevalent and disabling conditions worldwide, with a lifetime prevalence of up to 80% and a substantial impact on quality of life and health care utilization. In this Practical Updates in Primary Care session, Brett Snodgrass, DNP, FNP-C, and Steven Stanos, DO, presented a case-based, guideline-driven framework to support primary care clinicians in evaluating and managing both acute and chronic LBP.

The session objectives focused on developing competency in case-based assessment and treatment, understanding the epidemiology and burden of LBP, and performing a structured clinical evaluation through history and physical examination. The presenters emphasized categorizing LBP into axial, radicular, or referred pain and incorporating neurologic constructs (dermatomes, myotomes, and sclerotomes) into diagnostic reasoning. Early identification of red flags, including neurologic deficits, systemic symptoms, trauma, or history of malignancy, is essential to guide timely imaging and referral.

Through illustrative patient cases, the presenters demonstrated how to differentiate common pain generators, such as lumbar radiculopathy, facet joint pain, and sacroiliac joint dysfunction. Physical examination techniques, including strength and reflex testing, dural tension maneuvers (eg, straight leg raise), and sacroiliac joint provocative tests, were highlighted as critical tools for localizing pathology and guiding management decisions.

Management strategies were aligned with current clinical practice guidelines, emphasizing a stepwise and patient-centered approach. For acute LBP, clinicians should prioritize education, reassurance, and maintenance of activity, given the favorable natural history of most cases. Nonpharmacologic therapies, including heat, massage, acupuncture, and spinal manipulation, are recommended first-line, with NSAIDs or skeletal muscle relaxants used selectively for symptom relief. The presenters also highlighted emerging therapies, including suzetrigine, a novel nonopioid oral sodium channel blocker approved by the FDA in 2025 for moderate-to-severe acute pain. However, its role in low back pain management has not yet been established.

For chronic LBP, the presenters emphasized a multimodal approach centered on exercise therapy, rehabilitation, and behavioral interventions, such as cognitive behavioral therapy and mindfulness-based stress reduction.

Pharmacologic therapy should be individualized, with NSAIDs as first-line treatment and agents such as duloxetine or tramadol considered when needed. The evidence for acetaminophen and gabapentinoids remains limited, and opioid therapy should be reserved for carefully selected patients, after weighing risks and benefits, and using the lowest effective dose.

For patients with persistent or refractory symptoms, interventional options, including epidural steroid injections, facet joint interventions, sacroiliac joint injections, and spinal cord stimulation, may provide targeted relief. The session reinforced the importance of integrating pharmacologic, nonpharmacologic, and interventional modalities within a comprehensive care plan to optimize functional outcomes and recovery.

Reference:
Snodgrass B, Stanos S. A Primary Care Approach to Acute and Chronic Low Back Pain. Presented at: Practical Updates in Primary Care; 2026. https://www.hmpglobalevents.com/pupc