Seven Questions To Ask In The Workup Of Low Back Pain

Up to 85% of the time in the primary care setting, back pain patients cannot be given an exact diagnosis for their back pain.

One of the most important parts of the low back pain workup is the patient history which includes basically the How, What, and Why types of questions.

How long has the pain been going on and when it occurs how long does it last? Most back pain resolves within 6 to 12 weeks, a longer duration means it's chronic and may need additional workup.

Is there a specific time of day that it occurs? For instance pain that occurs while sitting at one's desk is very different than during recreational activity after work. If pain comes on out of the blue there is a higher chance it could be associated with a tumor or infection. The vast majority of the time (over 90%) with acute back pain the cause is non life threatening, but the answer to the question should be placed into the context of other answers for a concern level.

What is the quality of the pain and where is it? Pain that is burning and goes into the legs from the back is often indicative of sciatica from a pinched nerve. Pain that is simply located in the back and irritated by activity is often caused by facet joint arthritis, called facet syndrome, and is a normal part and parcel of aging.

Does it radiate somewhere else? Pain that radiates into the lower extremities is often indicative of a pinched nerve and may necessitate imaging studies such as an MRI to define where the disc herniation or spinal stenosis is occurring.

Does it wake you up at night? Pain that wakes the patient up at night is concerning and may represent a tumor or infection. This is called a red flag symptom.

How did it start? If there was an injury or a fall a patient may have a fracture or ligamentous injury. For instance if the patient is a diabetic then infection is a significant concern especially if the blood sugars are not controlled and a recent hospitalization has occurred secondary to that problem. Let the patient explain fully the circumstances, it can open up the yellow brick road to the diagnosis.

Any problems with bowel or bladder function? If there is a problem in the spine that is pressing on the anatomic area called the Cauda Equina, the most common problem seen is urinary retention. One also may have loss of bladder or bowel control. This is a red flag surgical emergency, as if it's not surgically addressed within 24 to 48 hours that function may not return. Narcotics may cause constipation as well and that's obviously not a surgical emergency.

The most important part in obtaining a patient history is understanding what constitutes a red flag versus what is simply a normal back pain situation. The red flag situation requires further workup with potential imaging studies, bloodwork, or in rare circumstances like cauda equina syndrome emergency surgery.