Back Pain History Taking

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The ability to take a thorough back pain history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a back pain history in an OSCE setting.

Back pain is a common presenting complaint associated with a wide range of acute and chronic medical conditions. These can vary in severity from simple muscular strain to life-threatening conditions such as a dissecting aortic aneurysm. It is essential that a thorough history is obtained to identify any red flags of serious underlying pathology.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”
  • “Can you explain what that pain was like?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

The SOCRATES acronym (explained below) is a useful tool that can be used to explore a patient’s back pain.

Site

Ask about the location of the back pain:

  • “Where is the pain?”
  • “Can you point to where you experience the pain?”
Common back pain locations

Pathology typically associated with different back pain locations:

  • Pain directly overlying the spine: spinal fracture or arthritis.
  • Paraspinal: muscle spasm or muscle sprain.
  • Lateral back pain: renal pain (e.g. pyelonephritis, renal colic), pleuritic pain (e.g. pulmonary embolism or pneumonia) or hip pain (e.g. arthritis).
  • Unilateral flank pain: renal pain (e.g. pyelonephritis, renal colic).
  • Pain between the scapula: spinal fracture, dissecting thoracic aortic aneurysm or myocardial infarction.

Onset

Clarify how and when the back pain developed:

  • “Did the pain come on suddenly or gradually?”
  • “When did the pain first start?”
  • “What were you doing when the pain first started?”
  • “How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the back pain:

  • “How would you describe the pain?” (e.g. dull ache, burning, tearing, sharp)
  • “Is the pain constant or does it come and go?”
  • “Is the pain present at rest?”
  • “Does the pain wake you at night?”

Back pain that is present at rest and wakes the patient at night is typically associated with inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis) and malignancy (e.g. spinal metastases).

Pain that is described as burning in nature is typically neuropathic in origin (e.g. nerve root compression).

Tearing thoracic back pain is typically associated with aortic dissection.

Sharp back pain is less specific but can be associated with spinal fracture, muscular spasms and pulmonary embolism.

Radiation

Ask if the back pain moves anywhere else:

  • “Does the pain spread elsewhere?”

Typical areas that back pain can radiate to include:

  • Head (e.g. cervicogenic headache)
  • Buttocks or legs (e.g. sciatic nerve compression)
  • Upper/lower limbs (e.g. radiculopathy secondary to spinal nerve root compression)
  • Flank to the ipsilateral groin (e.g. renal colic)
  • Chest (e.g. myocardial infarction, dissecting aortic aneurysm)
  • Epigastrium (e.g. peptic ulcer disease)
  • Abdomen (e.g. constipation, abdominal aortic aneurysm dissection, ischaemic bowel)

Associated symptoms

Ask if there are other symptoms which are associated with the back pain:

  • “Are there any other symptoms that seem associated with the pain?”

See the key symptoms section below for examples.

Time course

Clarify how the back pain has changed over time:

  • “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the back pain worse or better:

  • “Does anything make the pain worse?”
  • “Does anything make the pain better?”

Triggers for back pain may include walking, coughing and lifting objects.

Relieving factors for back pain may include analgesia (e.g. paracetamol), muscle relaxants (e.g. diazepam) and lying down.

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

  • “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Key symptoms to ask about

Key symptoms to ask about when taking a back pain history include:

  • Motor or sensory disturbances: suggestive of nerve root (i.e. radiculopathy) or spinal cord compression (e.g. cauda equina syndrome). Ask specifically about saddle anaesthesia if cauda equina syndrome is a possibility. Causes include prolapsed intervertebral disc, displaced vertebral fracture, haemorrhage and epidural abscess.
  • Urinary retention or incontinence: typical features of cauda equina syndrome.
  • Haematuria: may occur secondary to back trauma (due to renal injury), urinary tract infection and renal tract malignancy.
  • Fever: typically associated with urinary tract infection, pneumonia and discitis.
  • Malaise: associated with a wide range of pathology but in the context of back pain consider discitis or malignancy.
  • Weight loss: associated with malignancy.
  • Early morning stiffness: associated with inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis).
  • Muscular spasms: may be associated with spinal fracture or primary muscular injury.
Red flag presentations ¹

Red flags for cauda equina syndrome include:

  • 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)

Red flags for spinal fracture include:

  • 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

Red flags for cancer include:

  • 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

Red flags for spinal infections (e.g. discitis, epidural abscess) include:

  • Fever
  • Tuberculosis, or recent urinary tract infection
  • Diabetes
  • History of intravenous drug use
  • HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

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

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next“Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Systemic: fevers (e.g. discitis), weight change (e.g. malignancy)
  • Cardiovascular: chest pain (e.g. aortic dissection)
  • Respiratory: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism)
  • Gastrointestinal: abdominal pain (e.g. constipation)
  • Genitourinary: loin pain, haematuria, dysuria (e.g. pyelonephritis)
  • Neurological: headache (e.g. cervicogenic headache), motor or sensory disturbances (e.g. spinal cord compression)
  • Musculoskeletal: trauma
  • Dermatological: rashes (e.g. psoriasis)

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously had back problems and if so explore what treatments and investigations they received:

  • “Have you had problems with your back in the past?”
  • “Have you ever been given a diagnosis for your back problems?”
  • “Have you previously had any scans or other investigations for your back problem?”

Ask if the patient has previously undergone any surgery or procedures (e.g. spinal surgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Examples of relevant medical conditions

Medical history of particular relevance to back pain includes:

  • Previous back problems including investigations and treatments
  • Osteoporosis (increased risk of spinal fracture)
  • Recent trauma
  • Scoliosis
  • Malignancy (risk of metastases)
  • Cardiovascular disease (e.g. myocardial infarction, aortic aneurysm)
  • Recent infections (e.g. UTIs – increased risk of discitis)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
Medication examples

Medications commonly prescribed to patients with back pain:

  • Paracetamol
  • NSAIDs (e.g. ibuprofen, diclofenac)
  • Opioids (e.g. codeine, tramadol, morphine)
  • Benzodiazepines (e.g. diazepam)
  • Pregabalin

Patients on corticosteroids are at an increased risk of developing fractures.


Family history

Ask the patient if there is any family history of back problems, inflammatory arthritis, malignancy or cardiovascular disease:

  • “Do any of your parents or siblings have any back problems or arthritis?” 
  • “Is there any family history of cancer in your first-degree relatives?”
  • “Have any of your first-degree relatives had problems with their hearts or major blood vessels?”

Social history

Explore the patient’s social history to both understand their social context and identify potential risk factors for back pain.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

Smoking is an important risk factor for malignancy, osteoporosis, bone fractures and aortic aneurysms.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis.

Chronic excessive alcohol use is a risk factor for osteoporosis and trauma.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

Intravenous drug use is a risk factor for discitis.

Occupation

Ask about the patient’s current occupation:

  • Assess the impact of the back pain on their ability to work.
  • Clarify what their job role involves and identify tasks that increase the risk of back injury (e.g. heavy lifting).

Hobbies

Explore the patient’s hobbies to identify potential risk factors for back injury (e.g. contact sports).


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. Sciatica (lumbar radiculopathy); NICE Clinical Knowledge Summary. Published: April 2015. Available from: [LINK].

 

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