red flag findings may indicate serious SPECIFIC causes of chronic LBP and include
age >50 years
fever
chills
recent UTI or skin infection
significant trauma
unrelenting night pain
pain at rest
progressive motor or sensory deficit
saddle anesthesia
bilateral sciatica or leg weakness
difficulty urinating
fecal incontinence
unexplained weight loss
history or strong suspicion of cancer
history of osteoporosis
immunosuppression
chronic oral steroid use
IV drug use
substance abuse
failure to improve after 6 weeks conservative therapy
past medical history (PMH)
ask about previous problems with back pain
ask about depression and previous treatment success or failures
social history (SH)
ask about substances abuse and disability compensation
review of systems (ROS)
ask about
unexplained fevers
weight loss
morning stiffness
gynecologic symptoms
urinary problems
gastrointestinal problems
psychological symptoms
Physical
neurology
straight leg raise exam
positive test is pain with leg fully extended at knee and flexed at hip between 30 and 70 degrees
may detect lumbar disk herniation
contralateral pain more specific for detecting herniation
ipsilateral pain more sensitive for ruling out herniation)
focused neuromuscular exam may help identify involved nerve roots
Making the diagnosis
American College of Physicians/American Pain Society (ACP/APS) joint guideline recommendations on diagnosis of LBP
conduct focused history (including psychosocial risk factors) and physical exam to categorize LBP
nonspecific LBP (excluding pathology of specific cause)
back pain potentially associated with radiculopathy or spinal stenosis
back pain potentially associated with another specific spinal cause
Testing
ACP/APS joint guideline recommendations
do not routinely obtain imaging studies or other diagnostic tests in patients with nonspecific LBP
perform diagnostic imaging (preferably with MRI) and testing for patients with LBP if severe or progressive neurologic deficits or serious underlying conditions suspected
radiograph
consider if risk factor for cancer without signs of spinal cord compression
delaying imaging for 1 month may be reasonable if age > 50 years is only risk factor
evaluate patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or computed tomography ONLY if they are potential candidates for
