Evaluation and Management of Back Pain

Key Components of History Taking

• A focused history and physical examination should be conducted to categorize patients with back pain into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause, as recommended by the American College of Physicians 1, 2
• Inquire about location of pain (localized to back, radiating to extremities) 1
• Determine frequency of symptoms (constant, intermittent) 1
• Ask about previous episodes, treatments tried, and response to treatments 1
• Screen for serious underlying conditions that require prompt evaluation, including history of cancer (positive likelihood ratio 14.7), unexplained weight loss (positive likelihood ratio 2.7), failure to improve after 1 month (positive likelihood ratio 3.0), age older than 50 years (positive likelihood ratio 2.7), fever or recent infection, significant trauma, rapidly progressive or severe neurologic deficits, and bladder or bowel dysfunction (cauda equina syndrome) 1, 3
• Assess for neurological symptoms, including presence of sciatica (radiating leg pain), motor weakness, and pseudoclaudication (leg symptoms with walking that improve with rest, suggesting spinal stenosis) 1
• Screen for psychological factors that predict risk for chronic disabling back pain, as recommended by the American College of Physicians 1, 2
• Consider problems outside the back that may cause back pain, including pancreatitis, nephrolithiasis, aortic aneurysm, and systemic illnesses like endocarditis or viral syndromes 1

Diagnostic Categorization

• Patients should be placed into one of three categories: nonspecific low back pain (85% of cases), back pain with radiculopathy or spinal stenosis, or back pain with specific spinal cause, based on the history and physical examination, as recommended by the American College of Physicians 1
• Nonspecific low back pain is characterized by localized pain without specific identifiable cause and no concerning features for serious pathology 1
• Back pain with radiculopathy or spinal stenosis is characterized by radicular symptoms (sciatica) and neurological deficits corresponding to nerve root involvement 1, 4
• Back pain with specific spinal cause includes conditions such as cancer (0.7% of cases), compression fracture (4%), spinal infection (0.01%), ankylosing spondylitis (0.3-5%), and cauda equina syndrome (0.04%) 1

Next Steps After History Taking

• For nonspecific low back pain, provide reassurance, education about expected course, and self-care options, as recommended by the American College of Physicians 5
• For suspected serious pathology, perform appropriate diagnostic imaging and testing 6
• For persistent symptoms with radiculopathy, consider MRI if patient is a candidate for surgery or epidural steroid injection 4
• For all patients, assess psychosocial factors and address barriers to recovery, as recommended by the American College of Physicians 1