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Diagnostic triage for low back pain: a practical approach for primary care

Med J Aust 2017; 206 (6): 268-273. || doi: 10.5694/mja16.00828

Summary

 

  • Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP — informed by a focused history and clinical examination — is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral.
  • The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (< 1% of cases), radicular syndrome (∼ 5–10% of cases) or non-specific LBP (NSLBP), which represents 90–95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis.
  • Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category.
  • A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care.
  • Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.

 

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  • Lynn D Bardin1,2
  • Peter King3
  • Chris G Maher4

  • 1 Austin Health, Melbourne, VIC
  • 2 SuperSpine, Melbourne, VIC
  • 3 King St Medical Centre, Melbourne, VIC
  • 4 George Institute for Global Health, Sydney, NSW

Correspondence: cmaher@george.org.au

Competing interests:

Chris Maher holds a fellowship from the National Health and Medical Research Council (NHMRC), and is chief investigator or associate investigator on multiple previous and current research grants from government research agencies in Australia (NHMRC), Brazil (São Paulo Research Foundation) and the Netherlands (Netherlands Organisation for Health Research and Development). He has also received funding from organisations such as Arthritis Australia and government agencies such as WorkCover, and has received supplementary industry funding for two investigator-initiated NHMRC-funded trialsPACE (; cofunded by GlaxoSmithKline); and PRECISE (NCT00076986; Pfizer supplied the study medicine at no cost but provided no other funding).

  • 1. Australian Institute of Health and Welfare. Back problems: musculoskeletal fact sheet. Canberra: AIHW; 2015. http://www.aihw.gov.au/publication-detail/?id=60129551044 (accessed June 2016).
  • 2. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1603-1658.
  • 3. Koes BW, van Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010; 19: 2075-2094.
  • 4. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478-491.
  • 5. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine 2012; 79: 176-185.
  • 6. Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2013: CD008643.
  • 7. Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011; 154: 181-189.
  • 8. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013; 347: f7095.
  • 9. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002; 137: 586-597.
  • 10. Houden T, Shears B, Brennan G, Dudley K, Haberman P, Jaffe M, Warner S. Primary Care Management of Low Back Pain: Care process model. Intermountain Healthcare 2014 August 2014. Report No.: CPM 009–08/14.
  • 11. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med 2015; 163: 373-381.
  • 12. Poddubnyy D, van Tubergen A, Landewe R, et al. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis 2015; 74: 1483-1487.
  • 13. Rudwaleit M, Sieper J. Referral strategies for early diagnosis of axial spondyloarthritis. Nat Rev Rheumatol 2012; 8: 262-268.
  • 14. Deyo RA, Mirza SK. Clinical practice. Herniated lumbar intervertebral disk. N Engl J Med 2016; 374: 1763-1772.
  • 15. Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ 2016; 352: h6234.
  • 16. Inui Y, Doita M, Ouchi K, et al. Clinical and radiologic features of lumbar spinal stenosis and disc herniation with neuropathic bladder. Spine 2004; 29: 869-873.
  • 17. Germon T, Singleton W, Hobart J. Is NICE guidance for identifying lumbar nerve root compression misguided? Eur Spine J 2014; 23 Suppl 1: S20-S24.
  • 18. Konstantinou K, Dunn KM, Ogollah R, et al. Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. BMC Musculoskelet Disord 2015; 16: 332.
  • 19. Lin CW, Verwoerd AJ, Maher CG, et al. How is radiating leg pain defined in randomized controlled trials of conservative treatments in primary care? A systematic review. Eur J Pain 2014; 18: 455-464.
  • 20. Spijker-Huiges A, Groenhof F, Winters JC, et al. Radiating low back pain in general practice: incidence, prevalence, diagnosis, and long-term clinical course of illness. Scand J Prim Health Care 2015; 33: 27-32.
  • 21. Verwoerd AJ, Peul WC, Willemsen SP, et al. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Spine J 2014; 14: 2028-2037.
  • 22. IASP. C. Spinal pain, Section 1: Spinal and Radicular pain syndromes 2011. http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/ClassificationofChronicPain/PART_I-C.pdf (accessed June 2016).
  • 23. Hancock MJ, Koes B, Ostelo R, et al. Diagnostic accuracy of the clinical examination in identifying the level of herniation in patients with sciatica. Spine 2011; 36: E712-E719.
  • 24. Konstantinou K, Hider SL, Vogel S, et al. Development of an assessment schedule for patients with low back-associated leg pain in primary care: a Delphi consensus study. Eur Spine J 2012; 21: 1241-1249.
  • 25. Vroomen PC, de Krom MC, Wilmink JT, et al. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry 2002; 72: 630-634.
  • 26. Coster S, de Bruijn SF, Tavy DL. Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy. J Neurol 2010; 257: 332-337.
  • 27. Kleinig TJ, Brophy BP, Maher CG. Practical neurology - 3: Back pain and leg weakness. Med J Aust 2011; 195: 454-457. <MJA full text>
  • 28. Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Rel Res 2006; 443: 198-207.
  • 29. Matsumoto M, Watanabe K, Tsuji T, et al. Nocturnal leg cramps: a common complaint in patients with lumbar spinal canal stenosis. Spine 2009; 34: E189-E194.
  • 30. de Schepper EI, Overdevest GM, Suri P, et al. Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine 2013; 38: E469-E481.
  • 31. Hill JC, Konstantinou K, Egbewale BE, et al. Clinical outcomes among low back pain consulters with referred leg pain in primary care. Spine 2011; 36: 2168-2175.
  • 32. Beith ID, Kemp A, Kenyon J, et al. Identifying neuropathic back and leg pain: a cross-sectional study. Pain 2011; 152: 1511-1516.
  • 33. Suri P, Carlson MJ, Rainville J. Nonoperative treatment for lumbosacral radiculopathy: what factors predict treatment failure? Clin Orthop Rel Res 2015; 473: 1931-1939.
  • 34. Porter RW. Spinal stenosis and neurogenic claudication. Spine 1996; 21: 2046-2052.
  • 35. Tomkins-Lane C, Melloh M, Lurie J, et al. Consensus on the clinical diagnosis of lumbar spinal stenosis: results of an international Delphi study. Spine 2016; 41: 1239-1246.
  • 36. Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med 2015; 162: 465-473.
  • 37. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356: 2245-2256.
  • 38. Jacobs WC, van Tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J 2011; 20: 513-522.
  • 39. Legrand E, Bouvard B, Audran M, et al. Sciatica from disk herniation: medical treatment or surgery? Joint Bone Spine 2007; 74: 530-535.
  • 40. Wertli MM, Burgstaller J K, Held U, et al. Baseline characteristics of patients in the Lumbar Spinal Stenosis Outcome Study (LSOS). Spine J 2015; 15: S204-S205.
  • 41. Burgstaller JM, Schuffler PJ, Buhmann JM, et al. Is there an association between pain and magnetic resonance imaging parameters in patients with lumbar spinal stenosis? Spine 2016; 41: E1053-E1062.
  • 42. Cohen SP, Hanling S, Bicket MC, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015; 350: h1748.
  • 43. Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313: 1915-1923.
  • 44. Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012; 344: e497.
  • 45. Spijker-Huiges A, Vermeulen K, Winters JC, et al. Epidural steroids for lumbosacral radicular syndrome compared to usual care: quality of life and cost utility in general practice. Arch Phys Med Rehabil 2015; 96: 381-387.
  • 46. Maher CG, Underwood M, Buchbinder R. Non-specific low back pain. Lancet 2016 doi:10.1016/S0140-6736(16)30970-9 [Epub ahead of print]
  • 47. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571.
  • 48. Linton SJ, Nicholas M, MacDonald S. Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine 2011; 36: 1891-1895.
  • 49. Saragiotto BT, de Almeida MO, Yamato TP, et al. Multidisciplinary biopsychosocial rehabilitation for nonspecific chronic low back pain. Phys Ther 2016; 96: 759-763.
  • 50. Shiri R, Karppinen J, Leino-Arjas P, et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010; 171: 135-154.
  • 51. Waddell G. The back pain revolution. 2nd ed. Edinburgh: Churchill Livingstone; 2004.
  • 52. McCullough BJ, Johnson GR, Martin BI, et al. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.
  • 53. Mettler FA, Jr, Huda W, Yoshizumi TT, et al. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008; 248: 254-263.
  • 54. O’Sullivan P, Lin I. Acute low back pain: beyond drug therapies. Pain Management Today 2014; 1: 8-13.

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