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

Lynn D Bardin, Peter King and Chris G Maher
Med J Aust 2017; 206 (6): 268-273. || doi: 10.5694/mja16.00828
Published online: 3 April 2017

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.

 

  • 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).

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