Comprehensive Evaluation of Chronic Back Pain

Daniel J. Mazanec, MD, FACP, FACR, FAADEP Dept. Chairman, Center for the Spine Cleveland Clinic Cleveland, OH, USA

The natural history of acute low back pain is very favorable.With simple education, activity modification and over-the-counter analgesics, most people recover fully within two to four weeks. However, when symptoms persist without significant improvement, further evaluation is required. A careful medical assessment is crucial to identify previously unrecognized conditions, inappropriate initial treatment and unrecognized complicating psychosocial issues.

Since most people with back pain improve within a few weeks, exhaustive evaluation is not appropriate and not usually performed at the initial evaluation. When symptoms persist, a careful history and physical examination focused on identifying rare but serious medical causes, such as malignancy or infection, should be performed. In many cases, historical red flags (e.g., weight loss, inability to find a comfortable position) prompts a more aggressive evaluation. A careful medical assessment for non-spinal “mimics” of spinal disorders, including abdominal aortic aneurysm, prostate disease or rheumatic disease, is appropriate in many patients with persistent back pain.

The search for a precise anatomic cause of the patient’s pain is complicated by the poor correlation between abnormal imaging findings on MRI or CT and symptoms. Determining whether to assign symptomatic to a particular finding in a patient with chronic back pain often is the key issue for the clinician. Results of diagnostic injections, such as facet blocks, selective discography or selective nerve blocks, must be carefully considered in the context of the patient’s symptoms and co-existing psychosocial view. For example, recent studies have demonstrated the unreliability of discography in patients with non-organic issues.

Finally, previous treatment in people with chronic back pain must be carefully assessed. Excessively passive treatment of acute low back pain delays recovery and promotes de-conditioning, sick role behavior and fear of re-injury. Ensuring that patients have an adequate trial of aggressive non-operative treatment incorporating active therapy and appropriate medication is important prior to pursuing more invasive surgical therapy in most patients.