History taking in a case of back pain

Back pain is one of the commonest presenting complaint in an Orthopedic clinic.
Often, a definite diagnosis is not possible.


However, it is useful if we classify the problem under 3 headings :

a) Back pain which is due to pure spinal pathology : For eg, Vertebral infections, tumours, Ankylosing spondylitis, Primary neurological disease, Paget's disease, Polyarthritis, Osteoporotic spinal fractures, Senile kyphosis, Scheuermann's disease, etc

b) Back pain which is due to mechanical disturbances to the spine : This category of back pain is the commonest where the cause is usually unknown. Also known as mechanical back pain.

c) Back pain which is related to nerve root pathology, such as Prolapse Intervetebral disc (PID) and nerve root compression within the vertebral canals

In your history taking, the vital information that need to be sought from the patient includes :

1) Age and Occupation
2) Onset of pain

When did the pain started?
It is slow, insidious, or rapid, sudden? (The latter is more suggestive of mechanical back pain)
Is there history of straining/twisting of back or sneezing in a flexed body position (typically in PID)

3) Site and nature of pain

Where exactly is the pain? Is it diffuse or localised?
Does the pain always present? (continuous) or it disappears at time? (intermittent)
What aggravates or relieves the pain?

Often, a mechanical back pain is aggravated by sudden bending/movement, relieved by lying down on a hard surface, or simply just by sitting down or application of local heat.
Whereas a back pain due to true spinal pathology often causing continuous pain, which the patient finds it difficult to find for a position of rest. A characteristic night pain may be present.

4) Radiation of pain

Does the pain radiates down the legs?
If so, where is the exact location of radiation?
Can you describe the character of pain?
Is there tingling or numbness sensation?

Pain that radiates down the leg doesn't necessarily caused by nerve root compression.
At times, irritation of facet joints, ligaments and muscles can cause dull-aching pain over the back, buttocks and thighs.
However, if there's nerve root compression, the pain is often sharp and knife like.
The commonest nerve root being compressed is usually L5 and S1, which pain is always felt below knee, involving the ankle and foot.
Is important to note the exact location of radiation to determine which level does the nerve root compression occurs (according to the sensory dermatomes)

5) Muscle involvement

Is there any weakness of limb?
Notice any wasting of muscles?
Is there problem with balance or gait recently?
Do you have problems lifting up your foot while you're walking? (footdrop)

6) Systemic review

Is there pain in other joints?
Is there fever, malaise, lethargy, night sweats?
Is there genitourinary symptoms, especially urinary retention or incontinence?
Is there any lower abdominal symptoms?
Is there any breathing difficulties?

7) Previous history

Is there previous similar attacks?
Are you suffering from any disease related to the spine?

*Always keep in mind of metastatic bone disease in elderly (Breast, prostate, colon, lungs)

Category: Orthopedics Notes