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Approximately 90 percent of adults experience back pain at some time in life, and 50 percent of persons in the working population have back pain every year.

Evaluation of low back pain

A comprehensive history and physical examination can identify the small percentage of patients with serious conditions such as infection, malignancy, rheumatologic diseases and neurologic disorders. The possibility of referred pain from other organ systems should also be considered.

The history and review of systems include patient age, constitutional symptoms and the presence of night pain, bone pain or morning stiffness. The patient should be asked about the occurrence of visceral pain, claudication, numbness, weakness, radiating pain, and bowel and bladder dysfunction.

Specific characteristics and severity of the pain, a history of trauma, previous therapy and its efficacy, and the functional impact of the pain on the patient’s work and activities of daily living should be assessed.
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History and Physical Examination in the Patient with Acute Low Back Pain

History Onset of pain (eg, time of day, activity) Location of pain (eg, specific site, radiation of pain) Type and character of pain (sharp, dull) Aggravating and relieving factors Medical history, including previous injuries Psychosocial stressors at home or work “Red flags”: age greater than 50 years, fever, weight loss

Physical examination Informal observation (eg, patient’s posture, expressions, pain behavior) Comprehensive general physical examination, with attention to specific areas as indicated by the history

Neurologic evaluation Back examination

Palpation

Range of motion or painful arc Stance Gait Mobility (test by having the patient sit, lie down and stand up) Straight leg raise test
Differential Diagnosis of Acute Low Back Pain
The most common levels for a herniated disc are L4_5 and L5_S1. The onset of symptoms is characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee. Pain is generally superficial and localized, and is often associated with numbness or tingling. In more advanced cases, motor deficit, diminished reflexes or weakness may occur.

If a disc herniation is responsible for the back pain, the patient can usually recall the time of onset and contributing factors, whereas if the pain is of a gradual onset, other degenerative diseases are more probable than disc herniation.

Rheumatoid arthritis often begins in the appendicular skeleton before progressing to the spine. Inflammatory arthritides, such as ankylosing spondylitis, cause generalized pain and stiffness that are worse in the morning and relieved somewhat throughout the day.