Acute Lower Back Problems in Adults - Initial Assessment, Findings

2. Initial Assessment Methods

Panel findings and recommendations:

• Information about the patient's age, the duration and description of symptoms, the impact of symptoms on activity, and the response to previous therapy are important in the care of back problems. (Strength of Evidence = B.)
  
• Inquiries about history of cancer, unexplained weight loss, immunosuppression, intravenous drug use, history of urinary infection, pain increased by rest, and presence of fever are recommended to elicit red flags for possible cancer or infection. Such inquiries are especially important in patients over age 50. (Strength of Evidence = B.)
  
• Inquiries about signs and symptoms of cauda equina syndrome, such as a bladder dysfunction and saddle anesthesia in addition to major limb motor weakness, are recommended to elicit red flags for severe neurologic risk to the patient. (Strength of Evidence = C.)
  
• Inquiries about history of significant trauma relative to age (for example, a fall from height or motor vehicle accident in a young adult or a minor fall or heavy lift in a potentially osteoporotic or older patient) are recommended to avoid delays in diagnosing fracture. (Strength of Evidence = C.)
  
• Attention to psychological and socioeconomic problems in the individual's life is recommended since such nonphysical factors can complicate both assessment and treatment. (Strength of Evidence = C.)
  
• Use of instruments such as a pain drawing or visual analog scale is an option to augment the history. (Strength of Evidence = D.)
  
• Recording the results of straight leg raising (SLR) is recommended in the assessment of sciatica in young adults. In older patients with spinal stenosis, SLR may be normal. (Strength of Evidence = B.)
  
• A neurologic examination emphasizing ankle and knee reflexes, ankle and great toe dorsiflexion strength, and distribution of sensory complaints is recommended to document the presence of neurologic deficits. (Strength of Evidence = B.)

The initial assessment

<Acute Low Back Problems in Adults> of a patient with activity intolerance due to acute low back symptoms consists of a focused medical history, a physical examination, and related decisions. A careful medical history and physical examination are critical. The primary purpose is to seek medical history responses or physical examination findings suggesting a serious underlying condition such as fracture, tumor, infection, or cauda equina syndrome. These responses or findings are referred to as red flags. They alert clinicians to the possibility that low back symptoms may be related to a dangerous condition. However, serious conditions presenting as low back problems are relatively rare.

The initial assessment categorizes back symptoms without red flags as either primarily back (nonneurologic) or sciatic (neurologic) and defines the duration of these symptoms to guide both what type of special studies may be considered and when they should be considered. In the absence of red flags, special tests are not usually required in the first month of low back symptoms because most patients recover from their activity limitations within 1 month.

The initial assessment also provides an opportunity for the clinician to establish rapport with the patient, to find out patient expectations, and to become aware of potential psychological and socioeconomic factors that can alter response to care.

Assessment Literature Reviewed

Of the 214 articles screened for this topic, 34 met the article selection criteria for efficacy. [20] <http://text.nlm.nih.gov>–[53] <http://text.nlm.nih.gov>

The important points in these articles are well summarized in review articles by Deyo, Rainville, and Kent [54] <http://text.nlm.nih.gov> and Waddell, Main, Morris, et al. [55] <http://text.nlm.nih.gov> Both reviews elaborate on the reproducibility and accuracy of specific medical history findings (Table 1) <http://text.nlm.nih.gov> and physical examination findings (Table 2) <http://text.nlm.nih.gov> for assessing low back problems. Other articles not meeting selection criteria are cited where appropriate since they contain information used in formulating recommendations. [56 <http://text.nlm.nih.gov>–65] <http://text.nlm.nih.gov>

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.