Lower Back Pain: History and Examination

History and Symptoms

• A thorough history of the presenting complaint is essential. This includes the onset, duration, location, and radiation of pain.
• Note any aggravating or relieving factors, such as posture, movement, or activity.
• Document associated symptoms: numbness, tingling, weakness, bowel or bladder dysfunction, fever, or trauma.
• Determine if the pain is chronic or acute, and note any relevant past medical history.
• Assess functional limitations, such as difficulty with daily activities like walking, dressing, or lifting.
• A detailed social history, including occupational factors and lifestyle habits (e.g., smoking, alcohol), is vital.

Physical Examination

• Inspection: Visual assessment of posture, gait, and visible deformities (e.g., scoliosis).
• Palpation: Systematic palpation of the lumbar spine, sacrum, and pelvis, noting tenderness, muscle spasm, or bony abnormalities. Carefully palpate specific areas of concern.
• Range of Motion: Full assessment of spinal range of motion (ROM), including flexion, extension, lateral flexion, and rotation for both the lumbar spine and hips. Observe for pain during each movement.
• Neurological Examination: Crucial for identifying potential nerve root compression. Assess muscle strength, reflexes, sensation (light touch, pinprick, vibration), and dermatomal distribution.
• Straight Leg Raise (SLR): Used to evaluate nerve root irritation. Patient lies supine while the examiner elevates the affected leg. Observe for pain radiating into the buttock or leg. Note the elevation degree at which pain occurs; this differentiates from hamstring impingement pain.
• Slump Test: Assesses nerve root impingement. Patient sits while flexing the neck and maintaining flexion, and observes for worsening radicular symptoms with passive stretching of the knee and ankle.
• Slump Test Variations: These tests evaluate the effect of different positions and stretches on nerve root symptoms.
• Functional Assessments: Assess the patient's ability to perform specific functional tasks (e.g., rising from a chair, climbing stairs). Note any difficulties or pain.
• Special tests (if indicated): Include tests for specific conditions (e.g., Patrick's test for hip pathologies, femoral nerve stretch test).
• Hip Examination: Assess the hip joint's ROM, stability, and integrity to differentiate hip from lumbar spine pathology.

Diagnostic Considerations

• Red Flags: Symptoms suggesting serious underlying conditions (e.g., cancer, infection, fracture) require immediate attention. Look for signs of systemic illness, unexplained weight loss, recent trauma, history of infection or cancer, and significant bowel/bladder disturbances.
• Differential Diagnosis: Consider various possible causes of pain, from muscle strains and ligament sprains to herniated discs, spinal stenosis, osteoarthritis, facet syndrome, and spondylolisthesis.
• Imaging: Radiographs, CT scans, or MRIs might be indicated to assess for structural abnormalities. The decision to order imaging is based on physical exam findings, patient history, and suspicion for underlying conditions.
• Further Investigations: Blood tests might be needed to rule out systemic conditions.

Management Strategies

• Conservative Management: Often the initial approach, including pain management (analgesics, NSAIDs), activity modification, physical therapy, and manual therapy.
• Surgical Intervention: Reserved for cases that fail conservative management, indicated by severe, persistent pain, progressive neurological deficits, or significant functional impairment.
• Posture and/or Ergonomics Modifications: Identify risk factors to prevent future episodes, such as prolonged sitting, poor posture, or improper lifting techniques.
• Patient Education: Crucial to educate patients about their condition, self-management strategies, and contributing factors.
• Multidisciplinary Approach: In cases of complicated pain, involve other professionals (e.g., physiatrists, psychologists, nutritionists) for a comprehensive management approach.

Learn about the history taking and physical examination techniques used to evaluate lower back pain. Key aspects include detailed history of pain, aggravating/relieving factors, associated symptoms, and functional limitations. Physical examination involves inspection and palpation.