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Evaluating Lower Back Pain: An Imaging Strategy



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Am Fam Physician. 2002 Oct 1;66(7):1330-1332.

An evaluation of lower back pain often does not provide a specific pathophysiologic diagnosis that leads to a specific treatment. Even anatomic abnormalities that are found on diagnostic testing are often present in patients without back pain. Further complications include mood disorders, varying pain perceptions, and a variety of social factors. Deyo reviewed the difficulties inherent in making a specific diagnosis in many patients with lower back pain.

The history and physical examination may provide clues to the presence of an underlying systemic disease or a serious neurologic condition. The majority of patients seen in a primary care practice for lower back pain have nonspecific symptoms, with or without degenerative changes. Patients who see other specialists for lower back pain are somewhat more likely to have an identifiable pathologic cause for their complaints. Anatomic abnormalities noted on imaging tests are only significant when they correlate with corresponding symptoms and signs. Specific abnormalities that are more likely to be significant include severe central spinal stenosis, nerve root impingement, and extruded disks. These disorders are not emergencies, which allows physicians to observe these patients for improvement before initiating imaging tests.

Specific therapy for lower back pain is reserved for conditions such as major neural compression, malignancy, or infection. Most patients do not have these conditions and can be treated more conservatively. Bed rest and traction appear to be ineffective. Exercise does not help the acute-pain phase but may be useful for more chronic conditions. Nonsteroidal anti-inflammatory drugs may be useful regardless of the pathology causing the pain.

The author concludes by suggesting that patients be screened for serious problems using a history and a physical examination and then, assuming that no “red flags” are present (see accompanying table), the patient can be observed for improvement over six weeks. If the pain continues beyond this observation period, imaging tests would be appropriate.

In the same journal, Abraham and Killackey-Jones point out that there are many potential etiologies for lower back pain, including inflammations of specific muscles, tendons, and ligaments. Each of these specific diagnoses requires knowledge on the part of the examiner and provides an opportunity for specific treatment. They conclude that acute lower back pain is a heterogeneous condition with varied identifiable etiologies and that making a diagnosis allows better treatment and enhances research opportunities.

Red Flags that Suggest a Need for Early Imaging in Adult Patients with Lower Back Pain

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Deyo RA. Diagnostic evaluation of LBP. Arch Intern Med. July 8 2002;162:1444–7, and Abraham I, Killackey-Jones B. Lack of evidence-based research for idiopathic low back pain. Arch Intern Med July 8, 2002;162:1442–4.

editor's note: Lower back pain is a common problem, and about two thirds of adults will develop this symptom at some time in their lives. The Agency for Healthcare Research and Quality has supported studies on lower back pain, several of which have been published by Deyo, the author of this article. These studies note that most lower back pain is nonspecific and that most cases of lower back pain spontaneously resolve within several weeks. Imaging and testing are not needed for most patients with lower back pain, and the emphasis should be on conservative care, time, reassurance, and education. Bed rest should be minimal, and physical therapy should be offered to patients who do not improve over two to four weeks. Recurrence is common. (Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med February 2001;16:120–31.) When possible, physicians should strive to identify clear causes of lower back pain and apply an appropriate specific treatment. Although Deyo seems to provide the most logical approach to lower back pain, his suggestions may be taking the easy way out. Physicians need to learn more about how to examine patients with this pervasive symptom and how to identify specific causes.—r.s.

 


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