Red Flags

• Take note of symptoms that may be secondary to underlying diseases
  • Incapacitating pain
  • Unrelenting night pain
• Cancer
• Infection (tuberculosis, pyogenic abscess)
• Fracture
• Cauda equina
  • Bowel/bladder dysfunction
  • Saddle anesthesia
  • Bilateral radiculopathy
• Progressive motor weakness

Yellow Flags

• Psychosocial factors that may contribute to the chronicity of the disease
• Mood changes
• Level of job satisfaction
• Attitude toward treatment participation
• Attitude towards the disease
• Involvement of loved ones with the management

Non-specific Low Back Pain

• Low back pain without identifiable specific causes
• Makes up 85-90% of all low back pain cases
• Also includes pain felt in the proximal lower extremities

Specific Spinal Pathology

• Patients with low back pain with associated mobility deficits caused by severe or progressive neurologic disorders or comorbidities
• Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, inflammatory disorders

Low Back Pain Associated with Radiculopathy or Spinal Stenosis

• Dermatomal pain with or without neurologic deficits
• Most often caused by nerve root compression

Pain Intensity Level

Visual Analog Scale

• A subjective examination that quantifies how patients rate the level of pain

Oswestry Disability Index (ODI)

• A subjective tool used to evaluate a patient’s perceived functional disability

Score	Perceived Disability Level
0-20%	Minimal disability
21-40%	Moderate disability
41-60%	Severe disability
61-80%	Crippled
81-100%	Bedridden

Roland-Morris Disability Questionnaire (RMDQ)

• A disability measure to assess the subject’s disability caused by back pain
• Patients with minimal disability perceive their pain as a disease that can be managed even without treatment
• Patients with scores of 21-40% experience pain with regular movements (sitting, standing) and may complain of difficulty going to work
  • May demand conservative treatments
• Patients with severely disabling pain are apprehensive to go about with their daily life if rigorous examinations and treatments are not provided
• Patients with ODI scores of 61-80% are those whose everyday activities are greatly affected
  • Treatments and positive interventions are highly suggested

Pertinent Features

• Location of pain
• Duration of pain
• Frequency of symptoms
• Medical history (previous history of pain, treatment and treatment response)
• Presence of weakness or neurologic deficits
• Presence of red flags

Duration of Symptoms

Acute

• Onset of symptoms <4 weeks

Subacute

• Symptoms appeared 4-12 weeks prior to consult

Chronic

• Onset of symptoms >12 weeks before consultation
• Continuous or recurrent pain
  • Experience pain for at least half the days in the past 6 months

Neurologic Exam

• Examine muscle strength, deep tendon reflexes and sensation
• Presence of muscle atrophy

• Complete blood count (CBC), erythrocyte sedimentation rate (ESR)
• Used to rule out presence of tumor or infection

• Not recommended for patients with non-specific low back pain
• Should be considered if red flags are suspected, surgery is being contemplated, and presentation is unconventional

Magnetic Resonance Imaging (MRI)

• Imaging modality of choice
• Should be considered for assessment of radicular symptoms, asymptomatic low back pain, chronic low back pain with red flags, subacute or chronic radicular pain with no improvement seen after 6 weeks of treatment
• Indications:
  
  • Neurologic deficit (foot drop, hip flexion, knee extension)
  • Cauda equina syndrome
  • Persistent and progressive severe pain even with conservative treatments
  • Neoplasm is highly suspected
  • Presence of infection highly likely
  • Trauma
  • Unresponsiveness to therapy and surgery is being considered

Computed Tomography (CT)

• May be considered in patients with acute or subacute radicular pain unresponsive after 4-6 weeks of therapy, presence of red flags
• CT myelography may be considered in patients with contraindications to MRI, if MRI is inconclusive, if with suspected bone neoplasms or with severe incapacitating back/leg pain

Radiography

• Recommended for the evaluation of obvious deformities, acute low back pain with presence of red flags, and vertebral compression fracture
• Anteroposterior (AP) and lateral views are indicated for acute low back pain that persists for >2 weeks without red flags
• Flexion extension and oblique views are indicated when lumbosacral spine instability, spondylolysis or spondylolisthesis is suspected
• Myelography may be considered if presentation of disease is uncommon

Radionuclide Scanning

• May be used in patients suspected to have vertebral cancer

• Successfully identify precise cause of nonradicular pain
• May be considered for patients at high risk for extra-spinal pathologies

Electromyography (EMG)

• May be considered for assessing acute low back symptoms and chronic non-specific low back pain
• Needle EMG may be considered in patients with probable nerve root dysfunction of the lower extremities whose symptoms persist for >4 weeks

Spinal Diagnostic Interventional Techniques

• Eg facet joint nerve block, sacroiliac joint injection, provocation discography
• Consistent pain relief every time the affected nerve is anesthetized repeatedly may accurately identify the cause of low back pain

Lumbar Provocation Discography

• Identifies intervertebral disc pathologies causing low back pain
• Indicated for patients with chronic low back pain with symptoms inconsistent with findings of MRI/CT scan 
• Studies show that lumbar discography is more accurate than myelography