History 

  • chief concern (CC) 
    • LBP
  • history of present illness (HPI) 
    • duration > 3 months for chronic LBP
    • 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 
      • surgery 
      • epidural steroid injection (for suspected radiculopathy)
  • testing to consider if “red flags” may also include
    • CBC
    • ESR
    • C-reactive protein
    • urinalysis if UTI suspected
    • calcium and alkaline phosphatase if metabolic bone disorder suspected