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Low back pain
Most low back pain is non-specific and settles within weeks; the doctor's job is to look for "red flags" that need urgent work-up, and without them — to avoid imaging and encourage movement.
Why it matters in the exam
The exam describes patients with back pain and asks who needs imaging now: a man over 50 with a past cancer, a patient with fever who injects drugs, urinary retention with saddle anaesthesia, or a young person with inflammatory pain and morning stiffness. Other questions test the first-line treatment and the natural course of sciatica.
Distinguish mechanical from inflammatory pain (spondyloarthritis), and remember that in an adolescent athlete with pain on extension you think of spondylolysis.
Back pain is one of the most common reasons for visiting a family doctor and for sick leave. A good explanation of the natural course, evidence-based reassurance and an early return to activity prevent chronic pain better than imaging or prolonged rest.
Other questions focus on back pain lasting over 12 weeks: here treatment is supervised exercise, physiotherapy and cognitive behavioural therapy, not opioids or surgery without a neurological deficit. Questions about an adolescent athlete with pain on extension also appear.
Key points
- Most back pain is non-specific and settles within weeks.
- No red flags — no imaging in the first 4–6 weeks.
- Urinary retention and saddle anaesthesia — urgent MRI.
- Stay active; short-term NSAIDs; no bed rest.
- Inflammatory pain under 40 — spondyloarthritis.
Summary table
| Condition | Clues | Work-up | Treatment |
|---|---|---|---|
| Non-specific back pain | Mechanical pain, no red flags, no neurological deficit | No imaging in the first 4–6 weeks | Stay active, local heat, NSAIDs |
| Sciatica (radiculopathy) | Pain radiating below the knee, positive straight-leg raise | MRI if it lasts over 6 weeks and the patient is a surgical candidate, or a progressive deficit | Conservative; most improve within 6 weeks |
| Cauda equina syndrome | Urinary retention, saddle anaesthesia, bilateral weakness | Urgent MRI | Urgent surgical referral |
| Malignancy or infection | Age over 50, past cancer, weight loss, fever, injecting drug use, night pain | Blood count, ESR, CRP, MRI | According to the finding |
| Compression fracture | Older age, steroids, osteoporosis, trauma | X-ray; in a young patient — work-up for secondary osteoporosis | Analgesia, osteoporosis treatment |
| Inflammatory back pain | Under 40, gradual onset, morning stiffness over 30 minutes, improves with activity | HLA-B27, MRI of the sacroiliac joints | NSAIDs and activity; biologics as needed |
A free exam question
בן 40, פונה עקב תפרחת שלא נעלמת בלחיצה. באיזה מקרה יש לשלוח בדיקת דם ל-Antinuclear Antibody ול-Rheumatoid factor? (the question as examined, in Hebrew)
- א. נגעי ecchymoses קטנים מ 6 ס"מ, ממוקמים בשוקיים
- ב. נגעי purpura נמושים (מורמים מעט)
- ג. תפרחת מלווה בחום גבוה ואוושה לבבית
- ד. התפרחת הופיעה לאחר כמה ימי טיפול ב-Ibuprofen לכאבי גב
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- NICE guideline NG59, 2016 (updated 2020) — Low back pain and sciatica in over 16s: assessment and management
- American College of Physicians, 2017 — Noninvasive treatments for acute, subacute and chronic low back pain
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Approach to the patient with low back pain
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.