Low back pain in primary care

#### Key points A woman aged 71 with smoking related lung disease and frequent use of corticosteroids presented to clinic with acute severe low back pain. The pain began yesterday after she moved furniture in her apartment, is centrally located in the upper lumbar region without radiation to the legs, and is worse with movement. On examination, she has tenderness to palpation over the upper lumbar spine. Many observers argue that lumbar spine imaging is overused in developed countries because of a low yield of clinically useful findings, a high yield of misleading findings, radiation exposure (especially to the gonads), and costs. This is a particular concern in the United States, where imaging capacity is high, and spine specialists commonly have their own imaging facilities. These concerns are valid, despite the broad differential diagnosis of back pain, which includes not only degenerative changes but deformity, fracture, and underlying systemic diseases such as malignancy, infection, or ankylosing spondylitis. Though metastatic cancer might be the most common of these systemic conditions, its prevalence in …