History Taking Approach for Back Pain Patients
A focused history and physical examination should be conducted to categorize patients with back pain into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. 1
Key Components of History Taking
1. Pain Characteristics
- Inquire about location of pain (localized to back, radiating to extremities) 1
- Determine frequency of symptoms (constant, intermittent) 1
- Document duration of pain (acute <4 weeks, subacute 4-12 weeks, chronic >12 weeks) 2
- Ask about previous episodes, treatments tried, and response to treatments 1
2. Red Flag Assessment
Screen for serious underlying conditions that require prompt evaluation:
- History of cancer (positive likelihood ratio 14.7) 1
- Unexplained weight loss (positive likelihood ratio 2.7) 1
- Failure to improve after 1 month (positive likelihood ratio 3.0) 1
- Age older than 50 years (positive likelihood ratio 2.7) 1
- Fever or recent infection (possible spinal infection) 1
- Significant trauma 1
- Rapidly progressive or severe neurologic deficits 1
- Bladder or bowel dysfunction (cauda equina syndrome) 1
3. Neurological Symptoms Assessment
- Presence of sciatica (radiating leg pain) 1
- Paresthesias or numbness in extremities 3
- Motor weakness 1
- Pseudoclaudication (leg symptoms with walking that improve with rest, suggesting spinal stenosis) 1
4. Psychosocial Risk Factors
- Screen for psychological factors that predict risk for chronic disabling back pain 1
- Assess for depression, anxiety, catastrophizing thoughts about pain 4
- Document work status, disability claims, litigation 2
- Evaluate patient's beliefs and expectations about their condition 4
5. Functional Impact
- Determine how pain affects daily activities 3
- Assess impact on sleep, work, and quality of life 2
- Document specific functional limitations 3
6. Non-Spinal Causes
- Consider problems outside the back that may cause back pain 1
- Screen for conditions such as pancreatitis, nephrolithiasis, aortic aneurysm 1
- Consider systemic illnesses like endocarditis or viral syndromes 1
Diagnostic Categorization
Based on the history and physical examination, patients should be placed into one of three categories:
Nonspecific Low Back Pain (85% of cases) 1
- Localized pain without specific identifiable cause
- No concerning features for serious pathology
- No significant neurological findings
Back Pain with Radiculopathy or Spinal Stenosis 1, 3
- Radicular symptoms (sciatica)
- Neurological deficits corresponding to nerve root involvement
- Pseudoclaudication symptoms
Back Pain with Specific Spinal Cause 1
- Cancer (0.7% of cases)
- Compression fracture (4%)
- Spinal infection (0.01%)
- Ankylosing spondylitis (0.3-5%)
- Cauda equina syndrome (0.04%)
Common Pitfalls to Avoid
- Failing to assess for red flags that indicate serious underlying conditions 1, 2
- Not evaluating psychosocial factors that strongly predict chronicity and disability 1, 4
- Ordering routine imaging for nonspecific low back pain without red flags 1, 3
- Neglecting to consider non-spinal causes of back pain 1
- Focusing solely on anatomical diagnoses without considering the biopsychosocial model 5
- Overlooking the therapeutic effect of a thorough history-taking process itself 4
Next Steps After History Taking
After categorizing the patient based on history and physical examination:
- For nonspecific low back pain: Provide reassurance, education about expected course, and self-care options 1
- For suspected serious pathology: Perform appropriate diagnostic imaging and testing 1
- For persistent symptoms with radiculopathy: Consider MRI if patient is a candidate for surgery or epidural steroid injection 1
- For all patients: Assess psychosocial factors and address barriers to recovery 1, 4
A thorough history taking approach not only helps in accurate diagnosis but may itself have therapeutic effects by reducing pain and fear-avoidance behaviors 4.