Back pain is a common presenting complaint associated with a wide range of acute and chronic medical conditions. These can vary in severity from minor complaints such as muscular strain to life-threatening conditions such as a dissecting aortic aneurysm. It is important that a thorough history is obtained to identify any red flags indicating that a patient requires further diagnostic investigations.
Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
Sudden onset of severe central spinal pain which is relieved by lying down
There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
Aged 50 or older
Gradual onset of symptoms
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (e.g. opening bowels, coughing or sneezing), and thoracic pain
Localised spinal tenderness
No symptomatic improvement after four to six weeks of conservative lower back pain therapy
Unexplained weight loss
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasise to the spine
Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess):
Tuberculosis, or recent urinary tract infection
History of intravenous drug use
HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next –“Now I’d like to discuss your past medical history and your medications”
Malignancy –clarify the type of cancer and age of diagnosis
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type/volume/strength of alcohol – history of alcohol abuse is associated with pancreatitis
Recreational drug use – e.g. intravenous drug use – osteomyelitis / vertebral discitis / epidural abscess
What does the job involve? (e.g. heavy lifting, repetitive movements, sitting for prolonged periods, driving)
Is the patient currently able to do their job?
Is the patient satisfied in their job? (job dissatisfaction is associated with chronic lower back pain, furthermore, the longer someone is absent from work due to back pain, the less likely they are to return to work³)
Stress – emotional stress can be associated with musculoskeletal lower back pain
Diet – obesity is a strong risk factor for musculoskeletal back pain
Exercise – baseline level of the patient’s day to day activity (patients participating in contact sports or weightlifting/strength sports may be at an increased risk of back injuries)
House/bungalow? – adaptations / stairs
Who lives with the patient? – Is the patient supported at home?
Any carer input? –What level of care do they receive?
What is their normal level of mobility? – Do they use mobility aids such as walking sticks? Is the back pain impacting their mobility?
Activities of daily living:
Is the patient independent and able to fully care for themselves?
Can they manage self-hygiene/housework/food shopping?
Systemic enquiry involves performing a brief screen for symptoms in other body systems.This may pick up on symptoms the patient failed to mention in the presenting complaint.Some of these symptoms may be relevant to the diagnosis (e.g. weight loss secondary to malignancy).Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
2. Pinheiro M, Ferreira M, Refshauge K, Ordonana J, Machado G, Prado L, Maher C and Ferreira P (2015) Symptoms of Depression and Risk of New Episodes of Low Back Pain: A Systematic Review and Meta-Analysis. Arthritis Care and Research, 67(11), pp.1591-1603.