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.
Opening the consultation
Introduce yourself – name/role Confirm patient details – name/DOB
Explain the need to take a history
Ensure the patient is comfortable
It’s important to use open questioning to elicit the patient’s presenting complaint “So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required. “Ok, so tell me more about that” “Can you explain what that back pain is like?”
History of presenting complaint
Gain further details about the back pain using the SOCRATES framework.
Site – where is the pain?
- Cervical / Thoracic / Lumbar / Sacral / Coccygeal / Paraspinal
- Pain directly overlying the spine – fracture/arthritis
- Paraspinal – muscle spasm/muscle sprain
- Lateral back pain – renal pain / pleuritic pain (e.g. pulmonary embolism or pneumonia) / hip pain
- Unilateral flank pain – pyelonephritis / renal colic
- Pain between the scapula – dissecting thoracic aortic aneurysm / myocardial infarction
To clarify the location of the pain it may be helpful to ask the patient to point to the location on themselves or yourself.
- When did the pain first start?
- Did the pain come on suddenly or has it been gradually worsening?
- What was the patient doing at the time of onset? – fracture and muscular related pain often has a sudden onset associated with some form of trauma (fall/heavy lifting/sudden twisting motion)
- Is the pain constant (e.g. spinal fracture/inflammatory arthritis) or intermittent (e.g. muscular spasm)?
- Is the pain present at rest? / Does the pain wake the patient at night? – consider inflammatory causes (e.g. rheumatoid arthritis/ankylosing spondylitis) and malignancy (e.g. metastatic deposits)
- Has the patient suffered pain like this before? / What was felt to be the cause? / How was it managed?
- Type of pain – sharp / dull ache / burning / tearing / crushing
- Pain described as “burning” in nature is typically neuropathic in origin (e.g. nerve root compression)
- Tearing/ripping thoracic back pain is typically associated with aortic dissection
- Crushing thoracic back pain is associated with myocardial infarction
- Sharp pain is less specific but is associated with acute spinal fracture, muscular spasm and pulmonary embolism (pleuritic)
Radiation (“Does the pain move anywhere else?”):
- Buttocks or legs – sciatic nerve compression/irritation (“sciatica”)
- Upper/lower limbs – radiculopathy (spinal nerve root compression)
- Flank to the ipsilateral groin – renal colic
- Chest – myocardial infarction / dissecting aortic aneurysm
- Epigastrium – peptic ulcer disease
- Abdomen – abdominal aortic aneurysm dissection / ischaemic bowel
- Sensory disturbances – radiculopathy / cauda equina syndrome (e.g. saddle paresthesia) / spinal cord compression
- Motor disturbances (weakness) – cord compression (displaced fracture/prolapsed intervertebral disc/epidural abscess/haematoma)
- Urinary retention – cauda equina syndrome / spinal cord compression / severe back pain
- Urinary incontinence – cauda equina syndrome / spinal cord compression
- Other urinary symptoms (e.g. dysuria, increased frequency, haematuria) – urinary tract infections / pyelonephritis
- Fever/chills – pyelonephritis / pneumonia / vertebral discitis
- Nausea and vomiting – pyelonephritis / renal colic / myocardial infarction
- Fatigue/malaise – pyelonephritis / inflammatory arthritis / malignancy
- Weight loss – malignancy
- Haematemesis or melaena – peptic ulcer / duodenal ulcer / gastrointestinal malignancy
- Early morning stiffness – ankylosing spondylitis / rheumatoid arthritis
- Diaphoresis/dyspnoea – myocardial infarction
- Muscular spasms – can occur alongside fracture/trauma
- Duration –minutes / hours / days / weeks
- Course – worsening / improving / fluctuating
- Does anything make the pain worse?
- Sneezing or coughing – acute fracture / pulmonary embolism / pneumonia
- Worse following meals – duodenal ulcer
- Worse at night – ankylosing spondylitis / spinal malignancy / radiculopathy
- Physical activity – osteoarthritis / fracture
- Does anything relieve or reduce the pain?
- Physical activity – ankylosing spondylitis / rheumatoid arthritis
- Analgesic medication
Severity – on a scale of 0-10 how severe is the pain?
Red flags for back pain (history only) ¹
Cauda equina syndrome:
- Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
- Recent-onset urinary retention and/or urinary incontinence
- Recent-onset faecal incontinence
- 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”
Past medical history
Previous episodes of back pain:
- Were the episodes similar to the current?
- Did the patient seek medical attention?
- Was a diagnosis made?
Previous treatment for back pain (e.g. physiotherapy, analgesia, steroid injections)
Surgical history – “Have you ever had any spinal surgery?”
Osteoporosis – increased risk of spinal fracture
Trauma – “Have you ever injured your back in the past?”
Acute hospital admissions – When and why?
Congenital spinal problems (e.g. scoliosis)
Malignancy – consider metastases to the spine
Cardiovascular disease – myocardial infarction / aortic aneurysms
Recent infections – osteomyelitis / vertebral discitis
Immunosuppression – osteomyelitis / vertebral discitis
Depression – associated with chronic and recurring back pain ²
Analgesia for back pain:
- Paracetamol, NSAIDs, opioid analgesics (i.e. codeine, tramadol or oral morphine)
- Benzodiazepines to relieve muscle spasms
- Gabapentin/Pregabalin are often used for chronic back pain
Corticosteroids – increased risk of vertebral fractures if using long-term
Over the counter drugs – important to clarify what analgesics they are purchasing over the counter to ensure they are not overdosing (e.g. using regular paracetamol in addition to co-codamol)
ALLERGIES – ensure to document these clearly
Rheumatological disease – rheumatoid arthritis/ankylosing spondylitis
Degenerative disc disease – musculoskeletal lower back pain
Osteoporosis – fractures
Cardiovascular disease – myocardial infraction/aortic aneurysm
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.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
Summarise the history
1. Sciatica (lumbar radiculopathy); NICE Clinical Knowledge Summary. Published: April 2015. Available from: http://cks.nice.org.uk/sciatica-lumbar-radiculopathy.
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.
3. BMJ Best Practice: Assessment of Back Pain. Published June 12th, 2017. Available from: http://bestpractice.bmj.com/best-practice/monograph/189.html.