Diagnostic triage

This triage is based on an initial presentation to an occupational physician or general practioner. It is aimed at excluding specific spinal pathology and nerve root pain (1).

Acute back problems can be divided into (‘diagnostic triage’):

• simple backache/non-specific low back pian
• nerve root pain/radicular pain
• serious spinal pathology (2)
• pathologies where back pain is an associated presentation

The first step is undertaking a history and examination.

• patient history may reveal the cause
  • stiffness or pain which eases with movement indicates a inflammatory process such as discitis or spondyloarthropathy
  • history of major trauma (1).
• examination will generally focus on the function of the back and legs and may reveal
  • structural abnormalities of the spine e.g. - scoliosis, kyphosis, lumbar lordosis
  • nerve root irritation – indicated by pain on straight leg raising
  • hip pain - should be differentiated from back pain by investigating the movement of the hip joint (3)
• however features from the history may focus other parts of the examination e.g. a history of peripheral vascular disease should alert the examiner to the possibilty of an abdominal aortic aneurysm being a cause of back pain.

Routine lumbar spine X-rays should be avoided in patients with non-specific low back pain (3). Other investigations (e.g. ESR and rheumatoid factor in a case of suspected ankylosing spondylitis) may be suggested by the history.

The characteristics of simple backache and nerve root pain are listed in the menu items.

Simple backache can be managed by the general practioner. Nerve root pain can be initially managed by a general practioner providing there is no progressive or major motor weakness. Indications for urgent referral and factors suggesting serious spinal pathology are indicated in the menu items.

Reference:

• (1) Koes BW et al. Diagnosis and treatment of low back pain. BMJ. 2006; 332(7555):1430–1434
• (2) Back pain Europe. European Guidelines for the management of acute non-specific low back pain in primary care
• (3) Davies R. Low back pain. InnovAiT 2008;1(6):440-445