I was reading an article on low-back pain (LBP) which had a good summary of what I am trying to get out of any new patient consultation. A new patient consultation consists of a decent history, typically followed by a physical examination.
This is the slightly expanded version of what the article set out:
- In general, LBP patients can be effectively divided into two broad categories – nonspecific (the vast majority), and specific (a very small minority). Some clinical guidelines further differentiate this into nonspecific, radicular (nerve root with pain down the leg) or serious pathology.
- The main goal in assessing LBP patients is to rule out potentially harmful spinal pathology. Only about 1% of patients will have such a condition (which is the ‘very small minority’ mentioned above). There are some common red flags I look out for which include age greater than 50, a history of cancer, cauda equina symptoms, urinary retention, a history of steroid use, any unexplained weight loss, night pain, and so on. In these rare cases, advanced imaging and further clinical work up is often required. For the remaining 99%, a thorough history and the appropriate physical examinations should easily be enough to get to a diagnosis. This also precludes the need for imaging or specialist involvement. A decent history alone is also often enough to get to a diagnosis and the physical examination is used just as confirmation of the diagnosis.
- A second goal is to rule out rare but specific causes of LBP other than serious spinal pathology. This refers to such conditions as Ankylosing Spondylitis, kidney pathology, etc.
- Substantial neurological involvement should also be evaluated. This is done thorough history and physical examination. Routine imaging such as using x-rays is not recommended unless patients fail to respond to conservative care. (The original article stated that this “is one recommendation rarely followed by many health care providers”).
- Pain severity and functional limitations should also be addressed.
- Practitioners in all disciplines should also evaluate the risk of chronicity, as this small percentage of patients account for a disproportionate amount of health care spending in the UK. These are patients where significant biopsychosocial factors such as anxiety, depression, work dissatisfaction mean that they are unlikely to follow the usual mending pattern.