Diagnosing back pain
Take Home Messages:
Following a structured stepwise pattern of investigation will improve diagnostic accuracy and reduce unnecessary investigations.
Ruling out the possibility of a serious problem should be the clinician’s first priority. Use of flag system is likely to be helpful. History taking and the use of a flag can help identify or exclude serious disorders that should not be missed. Examination alone is unhelpful and unlikely to yield results.
Second priority should be given to ruling out nerve root pain. This should be apparent given the nature and distribution of the pain.
Other types of back pain can be described as non-specific. Imaging of non-specific back pain is unlikely to yield results and should be avoided.
In patients over 50 where systemic disease is suspected, X-ray and blood tests are required.
More expensive tests such as CT and MRI should be reserved for patients who are suitable for surgery.
There is more established research for the diagnosis of lower back problems than neck problems.
Why the research matters:
Neck and low back pain are common and costly problems. Most spinal problems are not serious and are self-limiting. However, missing a serious problem can have devastating repercussions. Doctors must use their history and examination skills as well as specialist diagnostic procedures to help correctly diagnose ailments of the spine.
There are many tests available and it is important that doctors understand when and where to use particular tests. To date, little is known about the accuracy of methods used to diagnose neck and low back pain.
The authors aim to provide a coherent guide to doctors to manage this common and complex complaint.
What the research involved:
The authors looked at studies published in the last ten years that reviewed methods used to diagnose lower back and neck problems.
They then produced a guide for medical practitioners that reviews and provides tips for:
- History taking;
- Examination and specific physical tests;
- Use of imaging formats (such as X-ray or CT scans); and
- Joint injections as a means of investigation and diagnosis.
Summary of research findings:
It is useful to group the causes of a person’s spinal pain as follows:
- Serious conditions such a broken bone or a tumour;
- Radicular pain; which is caused by the compression of a nerve; and
- Less serious, benign conditions such as a muscle strain or spasm.
Following a structured stepwise pattern of investigation will improve diagnostic accuracy and reduce unnecessary investigations.
History taking will provide a good indication as to whether or not there is a serious spinal problem. Examination is unlikely to be useful on its own and should simply be viewed as an adjunct to history taking.
Ruling out the possibility of a serious problem should be the clinician’s first priority. Use of flag system is likely to be helpful.
Second priority should be given to ruling out nerve root pain. This should be apparent given the nature and distribution of the pain. Having ruled out any serious problems and nerve root pain, it is useful to consider the spinal pain as non-specific.
The degree of pain and disability also needs to be considered as it is an important part of the patient’s management.
In patients over 50, blood testing and X-ray should be the standard form of investigation if widespread disease is suspected.
The management of non-specific back pain is unlikely to be altered by imaging, so imaging should be avoided.
There are no large studies that review the accuracy of history taking or diagnostic imaging in patients with neck pain.
More expensive forms of imaging such as CT scan and MRI should only be used on people who are candidates for surgery.
Original Research
A best-evidence review of diagnostic procedures for neck and low-back pain
Rubinstein SM, van Tulder M.
Best Pract Res Clin Rheumatol. 2008 Jun;22(3):471-82. Review.