31 History and physical examination

Suspect discogenic or degenerative disease

Abnormal neurologic signs/symptoms

Suspect osseous lesion, systemic or metabolic cause

Trial of treatment

Diagnostic evaluation

Levels of spinal involvement

Spine radiographs Oblique radiographs flexion-extension radiographs

Not determined?

Determined Bone Scan ESR Arthropathy work-up Metabolic work-up

Pain control phase (week 0 to 1) Rest Medication Physical therapy (passive) McKenzie exercises

Fail Work-up negative

Myelopathy? Infection? Cancer?

Bony lesion? Fracture? Sacroilitis?

MRI or CT

Further clarification

Stabilization (week 2 to 4) Therapeutic injections, including lumbar epidural corticosteroid injections

Fail Work-up negative

Myelography, EMG or SSEPs

Negative

Positive

Multidisciplinary Spinal evaluation Functional restoration (week 4 to 12) Work conditioning Work simulation Disability management (week 8) Time-contingent treatment and discharge week 8 to 12 Fail No surgery indicated Provocative radiology (.i.e., discography)

Appropriate treatment including surgery or spinal intervention procedures

Nonconfirmatory

Confirmatory

Selective or differential blocks

Surgery or spinal intervention procedures

Home program Nondiagnostic Continue indefinitely Pain management Diagnostic Surgery or spinal intervention procedures.

FIGURE 1. Algorithm for management of low back pain and sciatica. (ESR erythrocyte sedimentation rate; MRI = magnetic resonance imaging; CT = computed tomography; EMG = electromyography; SEEPs somatosensory evoked potentials).Adapted from reference 44.