ABSTRACT: Low back pain (LBP) is a major public health problem and a common reason for patient visits to a primary care physician. A pathoanatomically precise diagnosis cannot be made in most patients, and the primary care physician typically has only limited time to conduct a complete examination. A brief visit that is highly structured for efficiency can provide direction about the underlying pathology of acute LBP, leading to appropriate pharmacotherapy and adjunctive measures. Asking targeted questions during the history taking is the key to a successful diagnosis. Patient education helps ensure a successful outcome. Use of analgesics and skeletal muscle relaxants can help relieve symptoms in many patients. (J Musculoskel Med. 2008;25:162-168)
Acute painful musculoskeletal symptoms are commonplace in primary care, and low back pain (LBP) is the most frequently reported subcategory. In fact, acute LBP is one of the most common reasons why patients visit a primary care clinician. LBP is a major public health problem that decreases quality of life and increases health care costs. Patients may become significantly restricted in their activities; low back problems are the most common cause of disability in persons younger than 45 years.1
The history taking and physical examination usually allow for categorization of LBP, and conservative treatment often is effective in relieving symptoms and returning patients to activity. For most patients, however, a discrete pathological entity causing LBP is not identifiable. Rather, the job of the clinician is to detect secondary causes of back pain (eg, disk space infection, ankylosing spondylitis, or primary or metastatic neoplasia); confirm the absence of LBP requiring urgent intervention (eg, cauda equina syndrome); and expeditiously manage the remaining vast majority of patients with LBP, who can be aptly grouped as having mechanical LBP. A precise diagnosis cannot be made for more than 85% of patients presenting with LBP.2 However, a competent targeted examination generally is adequate to attain these goals.
Busy primary care physicians can find an answer to this vexing problem in the 10-minute examination for LBP. This quick, effective approach to diagnosis and management promotes efficiency and improves the chances of a successful outcome by combining an element of structure with simultaneous, targeted questions and patient education. A highly structured visit such as this helps physicians quickly discern between patients who can be treated conservatively with short-term pharmacotherapy and consideration of physical therapy and those who require more aggressive investigation and treatment. Ultimately, a small percentage of patients with LBP (typically fewer than 5%) will require referral for specialty care. In this article,we outline the simple steps to take in this approach.
Background and anatomy
Knowledge of the anatomy is useful for making the diagnosis and providing appropriate treatment. The spine is a complex structure that protects the spinal cord and transfers loads from the head and trunk to the pelvis. Each vertebra articulates with adjacent ones to permit motion in 3 planes. Intrinsic stability is gained from the intervertebral disks and surrounding ligaments, and extrinsic support comes from the surrounding muscles.
The lumbar spine is composed of 5 vertebrae, each consisting of a body anteriorly and a neural arch posteriorly that encloses the vertebral canal. The spinal cord and cauda equina pass through, protected by the structures surrounding the canal.
