Key Questions for Evaluating a Patient with Back Pain
When evaluating a patient with back pain, clinicians should conduct a focused history and physical examination to categorize patients into one of three groups: nonspecific low back pain, back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause. 1, 2
Pain Characteristics
- Ask about location of pain, frequency of symptoms, and duration of pain 1, 2
- Inquire about previous episodes of back pain, treatments tried, and response to treatments 1, 3
- Assess pain intensity and impact on daily activities and function 2
Red Flags for Serious Underlying Conditions
- History of cancer (positive likelihood ratio 14.7) 1
- Unexplained weight loss (positive likelihood ratio 2.7) 1, 2
- Failure to improve after 1 month (positive likelihood ratio 3.0) 1
- Age older than 50 years (positive likelihood ratio 2.7) 1, 2
- Fever or recent infection (may indicate vertebral infection) 1, 3
- History of significant trauma 3, 4
- Intravenous drug use 1
- Immunosuppression 2
Neurological Assessment
- Rapidly progressive or severe neurologic deficits 1
- Motor deficits at more than one level 1, 5
- Fecal incontinence or bladder dysfunction (cauda equina syndrome) 1, 5
- Urinary retention (90% sensitivity for cauda equina syndrome) 1
- Radiating leg pain in a typical lumbar nerve root distribution 1, 5
- Sensory changes in specific dermatomes 5
Physical Examination Elements
- Straight-leg-raise testing (sensitivity 91%, specificity 26% for herniated disc) 1, 5
- Crossed straight-leg-raise test (more specific at 88% but less sensitive at 29%) 5
- Evaluation of knee strength and reflexes (L4 nerve root) 1, 5
- Assessment of great toe and foot dorsiflexion strength (L5 nerve root) 1, 5
- Examination of foot plantarflexion and ankle reflexes (S1 nerve root) 1, 5
- Distribution of sensory symptoms 1
Risk Factors for Specific Conditions
- For vertebral compression fracture: older age, history of osteoporosis, steroid use 1
- For ankylosing spondylitis: younger age, morning stiffness, improvement with exercise, alternating buttock pain, awakening due to back pain during second part of night 1
- For non-spinal causes: assess for symptoms of pancreatitis, nephrolithiasis, aortic aneurysm 1, 3
Psychosocial Assessment
- Evaluate for depression, passive coping strategies, job dissatisfaction, and somatization 2
- Assess psychosocial factors as they are stronger predictors of outcomes than physical examination findings 2, 5
- Screen for risk of disability or chronicity 3, 6
Treatment History
- Previous treatments attempted and their effectiveness 3, 2
- Current medications and their effects 2
- Previous imaging studies and their results 2
Functional Assessment
- Impact of pain on daily activities 2, 6
- Work status and job demands 1, 2
- Sleep disturbances related to pain 2
Patient Expectations
- Patient's understanding of their condition 2
- Goals for treatment 2
- Concerns about serious underlying pathology 2
Common Pitfalls to Avoid
- Failing to recognize red flags that may indicate serious underlying conditions requiring urgent attention 3, 2
- Overreliance on imaging for nonspecific back pain, which may lead to unnecessary interventions 1, 2
- Not assessing psychosocial factors that contribute to pain perception and chronicity 3, 2
- Inadequate neurological assessment in patients with radicular symptoms 5