History

With a new presentation of back pain, it is essential to use the history to pick up any specific
causes of low back pain and any associated nerve root pain. The patient should be allowed to tell
the story initially, with open questions bringing out as much information as possible from the
outset. Then some detailed questions may be used to check for specific points in the history. The
patient's age can help suggest the most likely cause and may guide the history taking. Any
history of injury is important, so is stiffness or pain which eases with movement. This could
suggest inflammation such as discitis or spondyloarthropathy. Associated symptoms such as
numbness, weakness and bowel or bladder symptoms are important red flags which may
suggest a complication of underlying serious conditions
Red Flags
Factors that should alert you to the possibility of serious underlying pathology

Less than 20 or greater than 55 years of age

Non-mechanical back painparticularly pain that worsens when supine or night-time

pain

Thoracic pain

History of carcinomaconsider spinal cord compression. If suspected refer as an

emergency to oncology.

HIV

Immune suppression

Intravenous drug use

Taking steroids

Unwell or septic

Weight loss

Widespread neurology

Structural deformitygibbus (angular kyphosis)

Yellow flags are characteristics that help identify patients at a higher risk of developing chronic
problems. This allows for intense intervention at an early stage in the hope of resolving the pain
early

Yellow Flags
Risk factors for developing chronic pain/long-term disability

Belief that pain and activity are harmful

Sickness behaviours such as extended rest

Social withdrawal

Emotional problems, for example low/negative mood, depression, anxiety, stress

Problems with claims or compensation or time off work

Overprotective family or lack of support

Inappropriate expectations of treatment, for example low expectations of active

participation in treatment

Examination
The examination starts the second the patient walks into the consultation room. Watch how easily
the patient manages to sit down, as this is a good indication of the current severity of the pain
and stiffness. Some patients cannot even sit down and have to pace the room. Others may not be
able to get to the surgery at all and require a home visit.
With the patient standing, an inspection of the back can show scoliosis, kyphosis such as that
seen in association with ankylosing spondylitis or the loss of lumbar lordosis which is common
in mechanical back pain. Finding tenderness or deformity on lumbar vertebrae palpation is rare
but may indicate bony pathology such as an osteoporotic fracture; muscle spasm of the paravertebral muscles is a more common finding.
While the patient is still standing flexion, extension, lateral flexion and rotation of the back can
be assessed. Pressing down on the vertex should not exacerbate low back pain.
Another guide to the severity of the patient's symptoms is the ease with which the patient can get
onto the examination couch. In the lower limbs, inspect for muscle wasting and leg shortening.
Assess the power in the main muscle groups and assess any sensory loss, as well as the knee and
ankle reflexes. Signs associated with each nerve root entrapment are shown in (Table 2). Straight
leg-raising stretches the nerves coming from the spine into the leg. Pain on doing this is an
important indicator of nerve root irritation. Note the angle at which the patient develops pain.
Significant bilateral restriction in straight leg raise may indicate central disc prolapse and should
alert you to the possibility of cauda equina syndrome.