How is chronic low back pain (cLBP) evaluated?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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In most cases, chronic LBP has been investigated with the appropriate physician evaluation and perhaps imaging studies. Characterization of the pain as mechanical is a primary goal when a history is obtained from a patient with cLBP and sciatica. Mechanical or activity-related spinal pain is most often aggravated by static loading of the spine (eg, prolonged sitting or standing), long-lever activities (eg, vacuuming or working with the arms elevated and away from the body), and levered postures (eg, forward bending of the lumbar spine). Pain is reduced when multidirectional forces balance the spine eg, walking or constantly changing positions) and when the spine is unloaded (eg, reclining). Patients with mechanical LBP often prefer to lie still in bed, whereas those with a vascular or visceral cause are often found writhing in pain, unable to find a comfortable position.

Unrelenting pain at rest should suggest a serious cause, such as cancer or infection. Imaging studies and a blood workup are usually mandatory in these cases and in cases with progressive neurological deficits. Other historical, behavioral, and clinical signs that should alert the physician to a nonmechanical etiology requiring diagnostic evaluation are outlined below.

Diagnostic red flags

See the list below:

  • Pain unrelieved by rest or any postural modification

  • Pain unchanged despite treatment for 2-4 weeks

  • Writhing pain behavior

  • Colicky pain or pain associated with a visceral function

  • Known or previous cancer

  • Fever or immunosuppressed status

  • High risk for fracture (eg, older age, osteoporosis)

  • Associated malaise, fatigue, or weight loss

  • Progressive neurological impairment

  • Bowel or bladder dysfunction

  • Severe morning stiffness as the primary complaint

  • Patients unable to ambulate or care for self

Nonphysiological or implausible descriptions of pain may provide clues that operant or other psychosocial influences coexist.

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