Chronic back pain: Evaluation

Back pain is the most common cause of discomfort and disability in the United States. Sources of pain may be multiple, and include: intervertebral discs, vertebral bodies, facet joints, nerve roots, surrounding muscles/ligaments and abdominal/pelvic viscera. Pain that originates from the spine, usually presents as low back or neck pain– it infrequently presents as upper lumbar and mid-back pain. Pain is typically categorized as acute (2-4 weeks duration), subacute (up to 12 wks) or chronic (>12 wks).

Proper clinical evaluation of a patient’s pain should always begin with a thorough H&P, and should include information about: location, radiation, pain characteristics, severity, circumstances of onset, alleviating/exacerbating factors, patient’s age, presence/absence of constitutional factors, special pain features (night/bone pain, claudication, AM stiffness), neurological symptoms (numbness, weakness, incontinence), history of previous treatments and their efficacy, impact of pain on patient’s activities and work, and psychological factors that may be affecting pain.

The following are Red Flags:

• Age <20: higher incidence of congenital and developmental anomalies
• Age >50: higher incidence of neoplasms, pathological fractures, serious infections, etc.
• Duration: symptoms <3 months duration (chronic conditions usually indicate a less serious etiology)
• History of trauma
• Constitutional symptoms: fevers, chills, malaise, night sweats, unexplained/sudden weight loss
• Systemic illness: History cancer, infection (URI/UTI), IVDU, immunosuppression, chronic steroid use
• Unrelenting pain: benign pain usually resolves with rest/analgesia. Pain from a pathological condition is often worse at night, and unresponsive to rest/analgesia.
• Cauda equine syndrome

In the absence of red flags, diagnostic studies are not recommended for low back pain of less than 4-6 weeks duration, since 90% of patients will recover spontaneously during that time. Diagnostic testing should be used to corroborate clinical findings and determine the appropriate site(s) for intervention.