Low back or spinal pain: when to order tests (red flags)
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Non-specific low back pain (no red flags)
- No imaging or laboratory tests: look for red flags at every visit, reassess 2 to 4 weeks after a flare.
Also consider
- Inflammatory low back pain? Low back pain for more than 12 weeks, onset before 45, inflammatory pattern: think of spondyloarthritis (page "Ankylosing spondylitis").
- Osteoporosis or corticosteroids? Think of vertebral compression fracture: see the page "Osteoporosis".
Do not order
Fever or infection-prone patient: spondylodiscitis?
- Neurological deficit or sepsis: hospital emergency. Otherwise, prompt spinal MRI and no antibiotic before sampling.
Laboratory tests the same day
- FBC
- CRP
- Blood cultures (2 sets), before any antibiotic
- ESR (not reimbursed in France)if neededThe IDSA asks for baseline ESR and CRP [7]; ESR is no longer in the NABM [6]. CRP is enough in practice (BioMG choice).
- IGRA (subacute form, origin from or stay in a tuberculosis-endemic area)if needednon-French guidelineSubacute spondylodiscitis in a patient at risk of tuberculosis [7].
After age 60, persistent bone pain or unexplained fracture: myeloma?
Laboratory tests
- FBC
- Serum calcium
- Serum albumin
- Serum protein electrophoresis
- ESR (not reimbursed in France)if neededRequested by NICE (or plasma viscosity) [8]; no longer in the NABM [6].
- Serum free kappa and lambda light chains (not reimbursed in France), or Bence Jones proteinuriaif neededNICE adds serum free light chains, or failing that a urinary Bence Jones protein test [8]. Free light chains are outside the fee schedule [6].
- Serum creatinine with eGFR (looking for kidney involvement)if needednon-French guidelineThe American initial tests for suspected myeloma include a full metabolic panel, including creatinine, renal failure being one of the presentations of myeloma [9]; the NICE list, on which this tab is based, does not cite it [8].
- Imaging according to the examination (X-rays, MRI); history of cancer and suspected metastasis: MRI and specialist opinion.
Also consider
Sources (9)
- Haute Autorité de santé. Prise en charge du patient présentant une lombalgie commune. Rapport d'élaboration, avril 2019.
- Haute Autorité de santé. Prise en charge du patient présentant une lombalgie commune. Fiche mémo, mars 2019.
- Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017;189(45):E1386-E1395.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59, 30 novembre 2016, dernière mise à jour le 29 juillet 2026 (rubrique 1.1, évaluation).
- Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : acte 1139 (25-OH-vitamine D), acte 4103 (IGRA) ; absence d'acte pour la VS et les chaînes légères libres.
- Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-e46.
- National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline NG12, juin 2015, mise à jour du 15 avril 2026 ; recommandations 1.10.4 et 1.10.5 (myélome).
- Hughes PR, Shreve NE, Bloecher PA. Multiple Myeloma: Diagnosis and Treatment. Am Fam Physician. 2026;113(3):244-253.