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
- ask about
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
- straight leg raise exam
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
- conduct focused history (including psychosocial risk factors) and physical exam to categorize LBP
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