Making Sense of Low Back Pain

Making Sense of Low Back Pain Abstract In 1987, the Quebec Taskforce noted, “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Identify- ing these patterns begins with the patient’s history: “Where is your pain the worst?” “Is your pain constant or intermittent?” “Has there been any change in your bowel or bladder function?” This questioning establishes the mechanical nature of the pain, and a physical examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A failure of the results to fit into one of four syndromes—two back dominant and two leg dominant—suggests a non-mechanical or more complex problem. Key words: patterns of back pain, pain location, pain characteristics, history, physical examination ost patients complaining of grounded in a medical paradigm that low back pain experience emphasizes the serious but uncom- Msymptoms from a minor mon causes of back pain, most physi- mechanical malfunction. Fewer than cians hesitate to offer reassurance. 5% have a more sinister explana- Given the relative rarity of back pain tion such as inflammatory disease, resulting from a systemic illness or infection, or malignancy.1,2 Faced grave local pathology, investigat- with a patient in acute distress and ing all patients with back pain for a About the Authors Yoga Raja Rampersaud, MD, FRCSC, Associate Julia Alleyne, BHSc Professor Department (PT), MD, CCFP, Dip. of Surgery, University of Hamilton Hall, MD, Sport Med MScCH, Toronto, Divisions of Ortho- FRCSC; Professor, Depart- Associate Professor, paedic and Neurosurgery, ment of Surgery, Univer- Department of Family and University Health Network sity of Toronto; Medical Community Medicine, Medical Director, Back and Director, Canadian Back University of Toronto, Neck Specialty Program, Institute; Executive Medical Director, Sport Altum Health, Immediate Director, Canadian Spine CARE, Women’s College Past President Canadian Society, Toronto, ON. Hospital, Toronto, ON. Spine Society, Toronto, ON. 12 Journal of Current Clinical Care Educational Supplement • January 2013 MAKING SENSE OF LOW BACK PAIN range of inflammatory back diseases failure to distinguish a clear pattern (spondyloarthropathies), for exam- or failure of a syndrome to improve ple, will generate unnecessary con- with the specified therapy demands cern, add unjustified expense, and reassessment, including a review of give minimal return for the effort. the symptoms, additional physical Yet these potentially significant diag- tests, and, perhaps, ancillary investi- noses must not be missed; no one gations.3,4,7–11 wants to be guilty of overlooking a In the example of spondyloar- spinal metastasis.3,4 thropathy, the patient who lacks a There is another way. In 1987, clear-cut mechanical presentation or the Quebec Taskforce noted, “Dis- who continues to experience sig- tinct patterns of reliable clinical nificant symptoms after four weeks findings are the only logical basis of suitable care demands particular for back pain categorization and observation.3,4,7–11 The filtering out subsequent treatment.”5 The use of those patients with low back pain of syndromes in the initial assess- who have been accurately identified ment of back pain is gaining renewed and successfully managed (over 90% interest and clinical acceptance. It of the total) greatly increases the avoids many of the pitfalls of the probability of discovering potentially conventional medical model, which menacing non-mechanical diagnoses requires obtaining a patho-anatomi- among the remainder. Syndrome cal diagnosis before proceeding with recognition is a rapid, reliable, management.6 The use of syndromes and efficient triage technique that allows the great majority of patients increases diagnostic accuracy, ena- with back pain to be sorted into four bles patient-specific management, clearly defined groups that have rec- and decreases needless investiga- ognizable mechanical characteristics, tions. and it sets apart the much smaller number who present with atypical, The History possibly ominous symptoms. Identifying the pattern begins with a A syndrome can be defined as a concise history, which starts with two constellation of signs and symptoms questions: “Where is your pain the Key Point that appear together in a consistent worst?” and “Is your pain constant or manner and respond in a predict- intermittent?” Two of the syndromes The use of able fashion. With low back pain, the are back dominant, with the pain felt syndromes key is to identify the correct pat- most intensely in the low back, in the in the initial tern.6 This identification depends buttocks, or over the outer aspects of the assessment on a precise history and a concord- hips. The other two syndromes exhibit of back pain ant physical examination. The third leg dominant pain, where the symptoms is gaining component of the process is the are worst around and below the inferior renewed anticipated positive response. A gluteal fold: in the thigh, calf, or foot. interest mechanical syndrome will respond to Patients frequently have pain in both the and clinical the appropriate mechanical therapy back and leg; but with careful question- acceptance. within weeks, often within days. The ing, it is possible to determine which site Journal of Current Clinical Care Educational Supplement • January 2013 13 PMHTHAAKINGLATE SENS INSE 5-OFA LMOWINO BSACKALICY PLAINATES predominates. This can be challenging, about relying so heavily on the his- but distinguishing the site of dominant tory and physical examination. pain is essential for pattern recognition. The third mandatory ques- Axial (back dominant) pain arises from tion is, “Since the start of your back trouble, has there been any change in your bowel or bladder function?” DETERMINING IF THE PAIN IS CONSTANT OR Rather than initially searching for a detailed description, the query is INTERMITTENT CAN BE EQUALLY OR MORE deliberately vague in nature. Speci- DIFFICULT. fying changes only since the start of the attack avoids unnecessary worry about previous, unrelated a spinal structure but may have accom- disorders. A report of “no change” panying referred pain into the leg. When removes the necessity to go further. forced to choose, patients with axial Any positive response requires a pain will acknowledge that the back pain more thorough investigation. Uri- is worse. Radicular (leg dominant) pain nary retention followed by insen- indicates direct nerve root involvement sible, uncontrolled overflow and in addition to the mechanical malfunc- fecal incontinence is indicative of tion. Again, patients often report pain an acute cauda equina syndrome: a in the back as well as in the leg; but for surgical emergency.3,12 those with radicular pain, leg pain below Five remaining questions com- the buttock will be the chief complaint. plete the clinical picture and estab- Determining if the pain is con- lish a link to the past history and the stant or intermittent can be equally level of present disability: or more difficult. Most patients who endure prolonged discomfort 1. “What are the aggravating Key Point describe their symptoms as con- movements or positions?” stant. The inquiry, therefore, must 2. “What are the relieving Syndrome be clear and specific. It is best asked movements or positions?” recognition in two parts: “Is there ever a time 3. “Have you had this same is a rapid, in the day when your pain stops, pain before?” reliable, and for a brief moment, even though it 4. “What treatment have you efficient triage quickly returns?” and “When your had in the past, and did it technique pain stops, does it disappear com- work?” that increases pletely? Are you then totally free of 5. “What can’t you do now diagnostic pain?” Truly intermittent back domi- that you could do before accuracy, nant pain is never the result of spi- you had the pain?” enables nal malignancy or an infection. The patient-specific power of these questions, properly Mechanical back pain is responsive management, asked and answered, is enormous. to movement and position. Discover- and decreases They can eliminate the chance of the ing the aggravating and relieving fac- needless clinician missing a sinister pathol- tors helps identify the syndrome and investigations. ogy, one of the commonest concerns suggests a pain control strategy. Back 14 Journal of Current Clinical Care Educational Supplement • January 2013 THE PATIENT WITH NEWLYMAKING DIAGNOSE SENSDE UOFLCERA LOWT BIVEACK COLI PAINTIS pain is a recurrent complaint that Straight leg raising is a meas- tends to worsen with time.13 In a sur- ure of sciatic nerve root irritation vey of patients seeking care, over half (L4, L5, S1, S2). Lift the supine had suffered more than 10 attacks patient’s leg while the patient’s knee and over 60% believed that their present attack was, in at least one respect, worse than the preceding THE PRODUCTION OF BACK PAIN WITH one.14 The degree of physical limita- tion and the value of past therapies STRAIGHT LEG RAISING MERELY REFLECTS influence the current choices. THE MECHANICAL PROBLEM; IT IS NOT A The Physical Examination POSITIVE TEST. The history defines the syndrome. But the history must be supported by a con- is extended. To minimize hamstring cordant physical examination. The back tightness and a possible misinterpre- examination is not an independent event. tation of the results, the contralat- Its components are chosen in response to eral hip and knee should be flexed. the patient’s story, and its goal is to verify If positive, the test aggravates the or refute the diagnostic assumptions patient’s typical leg dominant pain. made on the basis of the history. The production of back pain is not Your examination begins with relevant and merely reflects the observation including their gait, underlying mechanical difficulty. The posture and preferred position in test results are positive when straight the office.

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