What are the assessment tests for lumbar (lower back) pain?

From the Guidelines

Low back pain assessment should start with a focused history and physical examination to categorize patients into nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. This approach is supported by the American College of Physicians and the American Pain Society, as outlined in their 2007 joint clinical practice guideline 1.

Key Components of Assessment

• A thorough history to assess psychosocial risk factors, which predict the risk for chronic disabling back pain 1
• Physical examination to identify signs of radiculopathy, spinal stenosis, or other specific spinal causes
• Red flag screening to rule out serious pathology like cauda equina syndrome or malignancy

Use of Diagnostic Tests

• Imaging or other diagnostic tests should not be routinely obtained in patients with nonspecific low back pain 1
• Diagnostic imaging and testing should be performed when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination 1
• For patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis, magnetic resonance imaging (MRI) or computed tomography (CT) should only be considered if they are potential candidates for surgery or epidural steroid injection 1

Additional Diagnostic Tools

• Straight leg raise test to assess for nerve root compression
• Crossed straight leg raise test for disc herniation
• Slump test to assess nerve root tension
• Extension and rotation tests for facet joint involvement
• FABER test for sacroiliac joint issues
• Palpation of paraspinal muscles for tenderness and assessment of range of motion limitations
• Neurological examination including strength, sensation, and reflexes to identify nerve involvement

Management Approach

• Provide patients with evidence-based information on low back pain, including expected course and self-care options 1
• Advise patients to remain active and consider the use of medications with proven benefits, such as acetaminophen or nonsteroidal anti-inflammatory drugs, in conjunction with back care information and self-care 1

From the Research

Low Back Pain Assessment Tests

• The straight leg raise test (SLR) is a commonly used physical test to detect lumbar disc herniation (LDH) in patients with low back pain, showing high sensitivity but heterogeneous or low specificity 2, 3.
• An extended SLR (ESLR) test, which adds location-specific structural differentiation movements to the traditional SLR, has been shown to have high validity in detecting neural symptoms and is strongly associated with pathology seen in MRI 2.
• The ESLR test has been found to have a sensitivity of 0.85 and specificity of 0.45 for LDH, and a sensitivity of 0.75 and specificity of 0.50 for nerve root compression 2.
• The use of MRI results as a reference standard has been used to assess the validity of the SLR test, with studies showing low accuracy of the SLR in diagnosis of LDH compared to MRI results 3.
• A thorough history and physical examination are essential in assessing low back pain, and can help identify 'red flag' conditions and 'yellow flags' such as psychosocial stress factors 4, 5, 6.
• Other assessment tests and tools, such as magnetic resonance imaging (MRI) or computed tomography (CT), may be used to establish a diagnosis and guide management in patients with low back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause 4.