What is the appropriate approach to assess and manage back pain in a patient, considering their age, occupation, lifestyle, and past medical history?

How to Assess Back Pain

Begin by systematically ruling out red flags through targeted history and physical examination, then stratify patients by symptom duration and psychosocial risk factors to guide imaging decisions and treatment intensity.

Immediate Red Flag Assessment

Screen for emergent conditions that require urgent imaging and specialist consultation:

• Cauda equina syndrome: Ask specifically about urinary retention, fecal incontinence, saddle anesthesia, and progressive bilateral leg weakness 1, 2
• Malignancy risk: History of cancer (especially breast, prostate, lung, kidney, thyroid), unexplained weight loss >10 lbs, age >50 years, and failure to improve after 1 month 1, 2
• Infection indicators: Fever, recent bacterial infection, IV drug use, immunosuppression, or midline tenderness with constitutional symptoms 2, 3
• Fracture risk: Age >70 years, significant trauma, prolonged corticosteroid use, osteoporosis, postmenopausal status without hormone replacement, or medications like aromatase inhibitors 4, 2

If any red flags are present, obtain immediate MRI (preferred over CT) and arrange urgent specialist consultation 1, 2, 3

Focused Neurological Examination

Perform a targeted examination to identify radiculopathy or spinal stenosis:

• Straight-leg raise test: Positive if sciatica reproduces between 30-70 degrees of leg elevation (sensitivity 91%, specificity 26% for herniated disc) 1
• Crossed straight-leg raise: More specific (88%) but less sensitive (29%) for disc herniation 1
• Motor strength testing: Assess knee extension (L4), great toe/foot dorsiflexion (L5), and foot plantarflexion (S1) 1, 2
• Reflex examination: Check knee reflexes (L4) and ankle reflexes (S1) 1, 2
• Sensory distribution: Map dermatomal patterns corresponding to suspected nerve root involvement 1, 2

For suspected spinal stenosis, ask about pseudoclaudication (leg pain with walking that improves with sitting or leaning forward) and assess symptoms during downhill treadmill testing if available 1

Psychosocial Risk Factor Evaluation

Psychosocial factors are stronger predictors of outcomes than physical findings or pain severity 1, 2

Assess for factors predicting chronicity and delayed recovery:

• Depression or anxiety symptoms 1, 2
• Passive coping strategies and catastrophizing 1, 3
• Job dissatisfaction or disputed compensation claims 1, 2
• Fear-avoidance beliefs (fear that activity will worsen pain) 3
• Somatization tendencies 1, 2

Use the STarT Back tool at 2 weeks to risk-stratify patients into low, medium, or high-risk categories for developing chronic disability 3

Pain Characterization

Document specific pain characteristics to guide differential diagnosis:

• Location and radiation: Localized back pain versus leg pain in dermatomal distribution 1, 5
• Temporal pattern: Acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks) 3, 6
• Aggravating/relieving factors: Pain with sitting (suggests disc pathology), relief with sitting (suggests stenosis), morning stiffness improving with exercise (suggests inflammatory arthropathy) 1
• Functional impact: Difficulty with ambulation, activities of daily living, work capacity 2, 5

For patients >50 years, specifically ask about inflammatory back pain features: improvement with exercise, alternating buttock pain, awakening during the second part of the night, and morning stiffness >30 minutes 1

Imaging Decision Algorithm

Do NOT routinely obtain imaging for nonspecific low back pain without red flags 1

Imaging is indicated in these specific scenarios:

Immediate MRI or CT Required:

• Severe or progressive neurologic deficits 1
• Suspected cauda equina syndrome 1, 3
• History of cancer with new-onset back pain 1, 2
• Constitutional symptoms suggesting infection or malignancy 2, 3

Plain Radiography Appropriate:

• Suspected vertebral compression fracture in high-risk patients (osteoporosis, steroid use, age >70) 1, 2
• Persistent symptoms after 4-6 weeks of conservative therapy without radicular symptoms 1, 4, 3

MRI for Persistent Radiculopathy/Stenosis:

• Back and leg pain persisting >4 weeks despite conservative therapy AND patient is a candidate for surgery or epidural steroid injection 1, 5
• MRI is preferred over CT because it avoids radiation and provides superior soft tissue visualization 1, 4

Common pitfall: Routine imaging exposes patients to unnecessary radiation, identifies abnormalities poorly correlated with symptoms, and may lead to unnecessary interventions 1, 2

Age-Specific Considerations

For elderly patients (>65-70 years), lower the threshold for imaging and earlier reassessment 1, 4, 2

• Higher prevalence of serious pathology (cancer, fracture, infection) 2
• Increased risk of undertreatment (42% of patients >70 receive inadequate analgesia) 2
• Consider cognitive impairment impact on pain reporting—use observational pain behaviors (facial expressions, vocalizations, body movements) in patients with dementia 2

Reassessment Timeline

Most acute low back pain improves substantially within the first month 1

Standard reassessment approach:

• Reevaluate patients with persistent, unimproved symptoms after 1 month 1, 4
• Earlier or more frequent reevaluation warranted for: severe pain, functional deficits, age >65-70 years, signs of radiculopathy or spinal stenosis 1, 2, 3
• If symptoms persist beyond 4-6 weeks without improvement, consider imaging if not previously performed 4, 3

Special Population: Chronic Kidney Disease

For patients with CKD, modify assessment and medication approach:

• Acetaminophen is first-line analgesic (up to 4g daily with monitoring for aminotransferase elevations) 4
• Avoid NSAIDs or use with extreme caution if GFR <45 due to significant renovascular risk 4
• Monitor renal function (creatinine and GFR) within 1-2 weeks if any NSAIDs are used 4

Classification for Treatment Planning

Categorize patients into one of four groups to guide management:

1. Nonspecific low back pain (no red flags, no radicular symptoms) 5, 6
2. Back pain with radiculopathy or spinal stenosis (positive neurologic findings) 1, 5
3. Back pain from nonspinal source (referred pain from abdominal/pelvic pathology) 7, 5
4. Back pain with specific spinal cause (fracture, infection, malignancy, inflammatory arthropathy) 5, 6

Critical pitfall: Failing to assess psychosocial factors leads to missed opportunities for early intervention in patients at high risk for chronic disability 1, 2, 3