SUMMARY

Backpainisthesecondmostcommonsymptomaticreasonformedicalofficevisitsinthe
US.Riskfactorsincludeage,generalhealth,occupation,lifestyle,psychosocial,and
culturalfactors.(See'Epidemiology'above.)
Patientswithlowbackpainshouldundergoafocusedhistoryandexamination.The
historyshouldincludelocation,duration,andseverityofthepain,anddetailsofany
priorbackpain.Patientsshouldbeaskedaboutfeaturesthatsuggestaserious
underlyingcause(table6).(See'History'above.)
Aspecificetiologycannotbereliablyestablishedformostpatientswithlowbackpain,
andlessthan5percenthaveaserioussystemicpathology.Systemicdiseaseissuggested
byageover50years,historyofcancer,unexplainedweightloss,durationofpaingreater
thanonemonth,nighttimepain,orunresponsivenesstoprevioustherapies.Spinal
infectionissuggestedbyfever,historyofinjectiondruguse,orrecentskinorurinary
infection.(See'Underlyingsystemicdiagnosis'above.)
Neurologicinvolvementissuggestedbysymptomsofsciaticaorpseudoclaudication.Pain
radiatingbelowthekneeismorelikelytorepresenttrueradiculopathythanpain
radiatingonlytotheposteriorthigh.Numbnessorweaknessinthelegsincreasesthe
likelihoodofneurologicinvolvement.(See'Sciatica'above.)
Thecaudaequinasyndromeisasurgicalemergency.Commonfindingsarebladder
dysfunction(especiallyurinaryretention)andsaddleanesthesia,inadditiontosciatica
andweakness.(See'Caudaequina'above.)
Lumbarspinalstenosismaypresentwithpseudoclaudication,characterizedbylegpain
duringambulationthatimproveswithrest,andmayincludenumbnessandpainradiating
tothefoot.(See'Spinalstenosis'above.)
Thephysicalexaminationshouldinclude:observationofwalking,changingpositions,and
spinalmotionperipheralpulses(inolderpatientswithlegsymptoms)afocused
neurologicexaminationbasedonhistory,withtestingofL5andS1nerverootsin
patientswithlegsymptomsandanappropriatedetailedexaminationrelatedtoanyred
flagsfoundinthehistory.Patientswithbackpainandpsychologicaldistressmaydisplay
anatomically"inappropriate"signsofpainamplification.(See'Physical
examination'above.)
Imagingstudiesinthefirstfourtosixweeksarenotnecessary,unlessthereare
progressiveneurologicalfindingsorahighsuspicionofasystemicetiology.Aplain
anteroposteriorandlateralXrayofthelumbarspineisappropriateifclinical
improvementhasnotoccurredafterfourtosixweeks.(See'Plainradiographs'above.)
CTandMRIstudiesaremoresensitivethanplainfilmsfordetectinginfection,cancer,
discpathology,andspinalstenosis.However,bulgingdiscsareseeninmorethan50
percentofasymptomaticpatientsasymptomaticherniateddiscsareseenaswell,though
lessfrequently.Discextrusionshavemorediagnosticsignificancethandiscprotrusions.
CTorMRIisindicatedforprogressiveneurologicdeficits,highsuspicionofcanceror
infection,orafter12weeksofpersistentlowbackpain.(See'CTandMRI
scanning'above.)
Urgentreferralisindicatedforpatientswithsuspectedcaudaequinasyndromeorspinal
cordcompression.Surgicalreferralisalsoindicatedforpatientswithprogressiveor
severeneurologicdeficits.Patientswithpersistentsciatica,sensorydeficits,orreflexloss
afterfourtosixweeks,andwhohaveconsistentclinicalfindings,mayalsobenefitfrom
aspecialistevaluation.(See'Indicationsforreferral'above.)