What is the focus of the clinical history to evaluate mechanical back pain?

Updated: Aug 27, 2020
  • Author: Debra G Perina, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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A thorough history and physical examination is paramount to arrive at a diagnosis, and initially imaging is often unnecessary. [6]  Patients most often complain of pain in the lumbosacral area. Determine whether pain is exacerbated by movement or by prolonged sitting or standing; the duration of pain; and whether the pain is relieved by lying down.

Establish if pain was sudden in onset or gradual over days or months, and determine whether pain is worse in the morning or at night. Find out if the patient can identify a precipitating event such as lifting or moving furniture. Explore the presence of systemic symptoms such as fever, weight loss, dysuria, cough, and bowel or bladder problems.

Inquire about current medications that may produce symptomatology. Chronic steroids may predispose to infection or compression fractures. Anticoagulants may result in a bleed or hematoma. Any history of new-onset bowel or bladder dysfunction (eg, urinary hesitancy, overflow incontinence) with back pain is suggestive of cauda equina syndrome. This is particularly true if other, new neurologic deficits are also present. Additional signs and symptoms include loss of anal sphincter tone or fecal incontinence, saddle anesthesia, and global or progressive weakness in the lower limbs. [5]

The existence of traditional red flags for occult vertebral fractures, such as advancing age, long-term steroid use, spinal point tenderness, and minor trauma, appear to be relatively poor indicators if used individually. The presence of 2 or more of these should raise the index of suspicion for the clinician. [19]

A history of cancer, unexpected weight loss, immunosuppresion, urinary infection, intravenous drug use, prolonged use of steroids, and/or back pain that does not improve with conservative management suggest a malignancy or infectious cause for the pain. [5]  

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