Assessment of Back Pain

Assessment
of back pain
Straight to the point of care
Last updated: Jun 16, 2020

Table of Contents
Overview 3
Summary 3
Theory 4
Aetiology 4
Emergencies 12
Urgent considerations 12
Diagnosis 14
Approach 14
Differentials overview 19
Differentials 20
Guidelines 35
Evidence tables 37
References 41
Images 48
Disclaimer 57
Assessment of back pain Overview
Summary
Low back pain (LBP) causes more disability globally than any other condition.[1] The point prevalence is
9.4% and the lifetime prevalence exceeds 80%.[1] [2] LBP accounts for over 4% of accident and emergency
OVERVIEW
department visits, making it one of the ten most common presenting complaints.[3]
The primary purpose of the initial encounter is to evaluate whether the symptoms suggest a more serious
underlying condition. The general prognosis of acute LBP is favourable, as 90% of patients recover without
sequelae.[4] Recurrences are common, but most relapses are not disabling.
A smaller subset of the population may be incapacitated from chronic LBP, defined as symptoms persistent
for >6 months. Several factors have been found to increase the risk of developing disabling LBP. These
include maladaptive pain coping behaviours, non-organic signs, functional impairment, poor general health
status, and psychiatric comorbidities.[5] The clinician should be aware of these risk factors when counselling
and treating patients.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 16, 2020.
BMJ Best Practice topics are regularly updated and the most recent version
3
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2020. All rights reserved.
Assessment of back pain Theory
Aetiology
Various spinal structures including ligaments, facet joints, paravertebral musculature and fascia,
intervertebral discs, and spinal nerve roots have been implicated as pain generators.[6]
THEORY
Nevertheless, even after a thorough work-up, 85% of patients with isolated back pain still do not have a
definitive cause identified for their symptoms.[7]
The aetiologies can be subdivided into 3 groups: mechanical, systemic, and referred. By far, the most
common cause is mechanical (97%).[6]
Mechanical
Mechanical back pain is defined as pain that is elicited with spinal motion and decreases with rest.
Lumbar strain/sprain
• The most common cause of mechanical back pain.[8]

• Strain: disruption of the muscle fibres at various locations within the muscle belly or musculotendinous
junction. Patients experience intense pain for 24 to 48 hours then experience muscle spasm.
• Sprain: subcatastrophic stretch of ≥1 spinal ligaments. Some fibres are injured but the overall
continuity of the ligament is maintained.
Degenerative disc and/or facets
• The pain generator is yet to be discovered, but the disc, ligaments, and facets have all been
implicated.[9]
• The disc is presumed to be the primary source of pain (discogenic).[10] [11]
• Many patients have asymptomatic degenerative discs.

• Discogenic pain increases with flexion, sitting, and coughing/sneezing due to an increase in
intradiscal pressures.
• Facet joints may cause back pain that increases with extension as the facet joints are mechanically
loaded.[12]
• The facet capsule has been demonstrated anatomically to contain nociceptive fibres.[13] [14] [15]
Herniated nucleus pulposus
• Natural history is of clinical improvement in most patients with only 10% requiring surgical
intervention.[16] [17]
• Leg pain is usually greater than back pain with pain radiating into the lower extremity in a dermatomal
distribution.
• Back pain may occur as a result of referred pain from a corresponding tear in the annulus fibrosus.
Spinal stenosis
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 16, 2020.
THEORY
Magnetic resonance imaging of spinal stenosis: (A) demarcates the normal sagittal
diameter of the spinal canal. (B) demarcates severe narrowing of the spinal canal
Courtesy of Dr K. Singh; used with permission
5
THEORY Assessment of back pain Theory
Magnetic resonance imaging of spinal stenosis: arrow points to the moderately

stenotic spinal canal caused by hypertrophic facets and ligament flavum
• A narrowing of the anatomical dimensions of the spinal canal secondary to disc osteophyte formation
and facet/ligamentum flavum hypertrophy.
• Patients may manifest back pain that is often referred to as neurogenic secondary to mechanical
constriction of the lumbar nerve roots.[18]
Spondylolysis and/or spondylolisthesis
• General population has a pars interarticularis defect incidence of 3% to 6%,[19] [20] [21] but most are
asymptomatic.
• Patients have pain in the lower back with occasional radiation to the posterior thigh. Pain is aggravated
by extension.
• If spondylolisthesis is severe, an exaggerated lordosis, heart-shaped buttock, or midline step off of the
spinous processes may be present.
Compression fracture
X-ray of a compression fracture: a lateral x-ray of an L2

THEORY
compression fracture (A). Wedging of the vertebral body is seen
• May occur without recognised trauma and patients should have a medical work-up performed for the
evaluation of osteoporosis, osteomalacia, and malignancy, depending on the fracture mechanism.
• Work-up for osteoporosis is key for future prevention.
• May be associated with a radiculopathy secondary to neuroforaminal encroachment from vertebral
body height loss.
• If a compression fracture occurs through a low-energy mechanism one should find metabolic reasons
for the fracture, and osteoporosis should be aggressively treated to prevent further fractures.
Sacroiliitis
7
• The sacroiliac joint has been implicated in low back pain.[22] There may also be associated referred
lower extremity pain.
• The primary cause of sacroiliitis is usually degenerative, although it may be associated with
inflammatory arthritis. It is common as a degenerative problem in middle to old age, but is uncommon
THEORY
as a secondary inflammatory problem.

• Sacroiliitis is estimated to occur in 10% to 25% of patients with persistent axial low back pain without
disc herniation, discogenic pain, or radiculitis.[23]
Systemic
Systemic aetiologies are much less common (1%) than mechanical back pain, but these causes usually
warrant further work-up and signal possible urgent referral to a spine surgeon.[6] [24]
Tumour and infection are the more common causes of systemic aetiologies of back pain.
The term 'inflammatory spondyloarthropathy' incorporates several inflammatory conditions with similar
features (mostly axial spondyloarthritis including ankylosing spondylitis, or psoriatic arthritis). Axial and
peripheral joints can be affected.
Systemic aetiologies include:
• Infection
• Untreated discitis, osteomyelitis, or epidural abscess can lead to sepsis, progressive kyphotic
deformity, and/or neurological deficit.
• Malignancy
THEORY
X-ray of tumour: lymphoma (A) destroying the L5 vertebra
9
THEORY Assessment of back pain Theory
Magnetic resonance imaging of lymphoma: arrowhead indicates a soft-tissue mass protruding

into the spinal canal. Arrow points to the tumour protruding anterior to the L5 vertebral body
• Inflammatory spondyloarthropathy (e.g., ankylosing spondylitis, psoriatic arthritis, enteropathic
arthritis)[25]
• Connective tissue disorder.
Referred
Sources are typically non-spine related and include intra/retroperitoneal pathologies. Much like systemic
causes, these aetiologies are less common (2%) than mechanical back pain.[6]
• Aortic aneurysm
• Acute pancreatitis
• Acute pyelonephritis
• Renal colic
• Peptic ulcer disease.
THEORY
11
Assessment of back pain Emergencies
Urgent considerations
(See Differentials for more details)
Suspected infection or tumour causing back pain requires urgent work-up. Patients at high risk of a condition
requiring urgent investigation include those on immunosuppressive therapies, and those with a history of
intravenous drug use.
Other red flags from the history include unrelenting pain despite treatment, systemic ailments (i.e., fevers,
chills, general malaise, history of malignancy, unexplained weight loss), and profound neurological deficits.
These risk factors and features warrant urgent advanced imaging studies such as magnetic resonance
imaging or computed tomography.
Imaging is also indicated in patients following trauma, especially minor trauma in older adults, and those with
osteoporosis.[26]
Cauda equina syndrome

EMERGENCIES
A presumed diagnosis of cauda equina syndrome necessitates an urgent work-up. Bowel or bladder
dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the
cauda equina.
The aetiology is usually a large central herniated disc or a pathological or traumatic fracture.
A complete history and physical examination should identify impending neurological compromise and the
need for emergent referral to a spinal surgeon.
Trauma
Obtain standard anteroposterior (AP) pelvis and cervical spine x-rays. If patients have back pain, obtain AP
and lateral x-rays of the lumbar spine. Neurological compromise, gross spinal deformities, or manual step-off
on spinal palpation warrant emergent CT to understand the bony anatomy.
Of note, spinal precautions should be taken when moving trauma patients until the spine is cleared by the
trauma or spinal surgeon. If any abnormalities are noted on imaging, a spinal surgeon should be consulted
for further management.
Epidural abscess
This rare condition is characterised by inflammation with pus within the epidural space.
Risk factors for epidural abscess include diabetes mellitus, intravenous drug use, or an immunocompromised
state, recent spinal surgery or trauma, and presence of indwelling spinal catheter, pre-existing infection, renal
failure, alcohol abuse, and endocarditis.
Spinal epidural abscess can present with fever, back or neck pain, and neurological deficits. However,
this triad of symptoms is only present in 10% to 15% of cases and therefore having a low threshold for
considering this diagnosis in patients at risk is crucial.[24] Back or neck pain is the most common symptom
in individuals with spinal epidural abscess, occurring in 70% to 100% of cases.[27] Pain is increased with
weight-bearing and not relieved by rest.
Neurological loss develops rapidly. Patients require urgent investigation with MRI.
Assessment of back pain Emergencies
For all patients, treatment includes empirical and subsequent culture-directed definitive antibiotic therapy.
For patients with neurological deficit, decompressive surgery is essential. In these patients, the single most
important predictor of the final neurological outcome is the patient's neurological status immediately before
decompressive surgery.
Acute pancreatitis
Typically presents with sudden-onset mid-epigastric or left upper quadrant abdominal pain, which often
radiates to the back (usually the lower thoracic area but can be a band-like wraparound pattern).[28]
Classically, the pain is relieved when the patient leans forward. Often there are associated symptoms of
nausea and vomiting. Patients may have fever, jaundice, tachycardia and/or tenderness and guarding of the
abdomen. Risk factors include gallstones and excessive alcohol intake.
Serum lipase or amylase >3 times the upper limit of normal confirms the diagnosis.[29] Serum lipase and
amylase have similar sensitivity and specificity but lipase levels remain elevated for longer (up to 14 days
after symptom onset vs. 5 days for amylase), providing a higher likelihood of picking up the diagnosis in
EMERGENCIES
patients with a delayed presentation.[30]
Assess haemodynamic status and resuscitate the patient with crystalloid intravenous fluids. Patients are
often not given enough intravenous fluid, which increases the risk of organ failure.[29] Assess for signs of
organ dysfunction immediately on presentation, particularly cardiovascular, respiratory, or renal. Systemic
inflammatory response syndrome (SIRS) and/or multi-organ failure are the biggest risk to life in the first
week. Consider intensive care unit transfer for any patient who has SIRS or early signs of organ failure.[29]
Treat pain promptly using a standard 'pain ladder' approach.[31] Opioids may be needed for effective pain
control.[32]
Ruptured abdominal aortic aneurysm

Patients with the triad of abdominal and/or back pain, pulsatile abdominal mass, and hypotension warrant
immediate resuscitation and surgical evaluation as repair offers the only potential cure.[33]
Initiate standard resuscitation measures immediately, including:
• Airway management (supplemental oxygen and endotracheal intubation and assisted ventilation if the
patient is unconscious).
• Intravenous access (central venous catheter).
• Arterial catheter; urinary catheter.
• Hypotensive resuscitation: aggressive fluid replacement may cause dilutional and hypothermic
coagulopathy and secondary clot disruption from increased blood flow, increased perfusion pressure,
and decreased blood viscosity, thereby exacerbating bleeding. A target systolic BP of 50 to 70 mmHg
and withholding fluids is advocated preoperatively.[34]
• Blood product (packed red cells, platelets, and fresh frozen plasma) availability and transfusion for
resuscitation, severe anaemia, and coagulopathy.
13
Assessment of back pain Diagnosis
Approach
Although the causes are numerous, a thorough history and physical examination helps elucidate the
diagnosis in most patients.
History
The primary purpose of the initial encounter is to evaluate whether the symptoms suggest a more serious
underlying condition.[35]
Red flag signs and symptoms warranting additional diagnostic imaging and emergent referral to a spine
specialist for ongoing management include:[36] [37] [26]
• Saddle anaesthesia
• Sphincter disturbance (bladder or bowel dysfunction)
• Profound or progressive neurological deficit i.e., severe or incapacitating back or leg pain that stops
the patient walking or severely limits activities of daily living
• History of malignancy with new onset back pain
• Systemic ailments, including fever, chills, night sweats, and/or unexplained weight loss
• Intravenous drug use
• History of osteoporosis
• Prolonged corticosteroid drugs or other immunosuppressive therapies
• Trauma/high-speed injury
• Pain that is refractory to medicine/injections; thoracic pain; non-mechanical pain (i.e., systemic or
referred causes of pain)
• Age <20 or >50 years
• Presence of contusion or abrasions over the spine.
Patients should be questioned regarding prior back pain episodes and treatments, onset, duration, location,
radiation, character, aggravating and relieving factors, and severity.
DIAGNOSIS
Further inquiry into functional, occupational, social, and psychiatric history should be sought to address risk
factors, including obesity, occupational risks, smoking, and psychosocial stressors.[38]
Symptoms of severe compression of the cauda equina
Bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe
compression of the cauda equina. The aetiology is usually a large central herniated disc or a pathologic or
traumatic fracture. A complete history and physical exam should identify impending neurological compromise
and the need for emergent referral to a spinal surgeon.
Infections
Important infections to consider are spinal epidural abscess, osteomyelitis of the spine and discitis. Spinal
epidural abscess can present with fever, back or neck pain, and neurological deficits. However, this triad of
symptoms is only present in 10% to 15% of cases and therefore having a low threshold for considering this
diagnosis in patients at risk is crucial.[24]
Risk factors for epidural abscess include diabetes mellitus, intravenous drug use, an immunocompromised
state, recent spinal surgery or trauma, and presence of indwelling spinal catheter, pre-existing infection, renal
failure, alcohol abuse, and endocarditis.
Osteomyelitis and discitis of the lumbar vertebrae can present with low back pain and a low grade fever. It
may be associated with intravenous drug use, lower extremity and hip infections, and tuberculosis, due to the
anatomy of the Batson's plexus.[39] [40]
It is important to consider vertebral osteomyelitis and discitis in older adults with back pain and urinary tract
symptoms as the urinary tract may be a source of infection from gram-negative organisms.[41]
Spinal metastasis
Metastasis to the spine needs to be excluded, especially in an older patient with a history of cancer and new
onset back pain. Breast, prostate, and lung cancer are responsible for more than 80% of cases of metastatic
bone disease and the spine is the most common site of bone metastasis.[42]
Spinal compression fractures
Should be considered in patients who are at risk of osteoporotic disease. Older people and those on long-
term corticosteroid therapy are particularly at risk.
Many osteoporotic spinal compression fractures are asymptomatic with no recognised trauma and are
identified incidentally on x-ray while investigating other pathologies. However, some patients can present with
acute onset back pain from minor trauma such as coughing or sneezing. The pain often disturbs sleep, is
aggravated by movement and can radiate bilaterally to the abdomen.
Inflammatory spondyloarthropathy
Back pain due to inflammatory spondyloarthropathy more commonly starts before the age of 35 years. There
may be a family history of psoriasis or spondyloarthritis, or a history of recent genitourinary infection.
Musculoskeletal symptoms apart from chronic back pain include dactylitis and enthesitis. Extra-articular
symptoms include uveitis and psoriasis (including psoriatic nail symptoms).
It is important to be aware that the diagnosis of spondyloarthritis is sometimes missed or delayed.[43]
DIAGNOSIS
Prompt referral to a rheumatologist is therefore essential for further diagnostic tests and appropriate
management.
Non-specific causes of back pain
It is important to identify any less serious or non-specific causes of back pain to ensure appropriate
management and maximum quality of life for these patients.
Risk stratification tools can be used (e.g., the STarT Back risk assessment tool) at first point of contact for
each new episode of low back pain, with or without sciatica, to inform shared decision-making about stratified
management.[35]
Physical examination
Perform a focused musculoskeletal and neurological examination.
A musculoskeletal examination consists of the following:
Inspection
15
Looking for obvious deformity (e.g., in fractures) and abnormal curvature (scoliosis, kyphosis, lordosis),
which can create pain in a minority of cases. This should prompt the clinician to order x-rays to document
baseline curvature and orthopaedic referral for moderate to severe cases. Patients with spondylolisthesis
may have an exaggerated lordosis and heart-shaped buttock.
Palpation
Palpation of the spinous processes and musculature: to localise any tenderness and to detect the presence
of a midline 'step-off' of the spinous processes that may indicate spondylolisthesis.[44] Tenderness on
palpation over the sacroiliac joint may indicate sacroiliitis.
Movement
Active and passive range of motion (ROM) assessment:[45] patients are asked in standing position to
actively flex, extend, and laterally bend as far as they can. Pain on flexion that radiates to the leg suggests
disc herniation with impingement on a nerve root; pain on extension can suggest either facet arthropathy or
spinal stenosis. Greatly restricted ROM in a younger patient may suggest ankylosing spondylitis.
Patient gait and ability to walk should be also be observed.
Provocative tests
A number of provocative tests may be performed.
• The straight-leg raise or contralateral straight-leg raise test which, when positive, indicates a possible
herniated nucleus pulposus (HNP). A straight-leg raise is performed with the patient supine and the
hip flexed gradually with the knee extended. Pain that is reproduced below 60° of hip flexion on the
ipsilateral side is considered a positive straight-leg raise and is more sensitive. Reproduced pain on
the contralateral side indicates a positive contralateral straight-leg raise and is more specific. Pain
that occurs above 60° is usually secondary to hamstring tightness.[46] [47] [48] The pain associated
with HNP is usually worse in the leg than in the back, with pain radiating to the lower extremity in a
dermatomal distribution. However, the absence of a positive straight-leg raise test and dermatomal
DIAGNOSIS
pain does not exclude disc herniation.[49]

• The femoral stretch or contralateral femoral stretch tests can be used to assess for upper lumbar disc
herniation. The test is typically performed with the patient prone. The knee is flexed, and then the leg
is extended. If it reproduces the leg pain, it is considered positive.[50]
• The Gaenslen’s test, pelvic compression test (applying compression across the sacroiliac joints
while the patient lies on their side), and FABER test are provocation tests that may be positive with
sacroiliitis.[23] A single test has low sensitivity and specificity for the diagnosis of sacroiliitis. The
Gaenslen’s test is performed by asking the patient to lie supine with the symptomatic leg hanging over
the edge of the examination table. The non-symptomatic leg is flexed at the hip and knee. A rotational
force is then applied across the sacroiliac joint by applying pressure to the flexed knee outwards, while
simultaneously applying pressure downwards on the affected sacroiliac joint with the other hand.
• The FABER test is performed by asking the patient to bend their knee on the affected side and
externally rotate at the hip, resting the foot across the opposite knee, so creating the shape of the
number 4 with the legs. Pressure is then applied downwards on the knee on the affected side, while
simultaneously using the other hand to apply pressure downwards on the opposite iliac crest.
Neurological examination
A thorough neurological examination should follow. Specific neurological deficits, such as weakness,
spasticity, or hyper/hyporeflexia, should be noted. These suggest more profound neurological compression;
prompt referral to a spinal surgeon is indicated for further evaluation and management.[36] Decreased rectal
tone is an important examination finding, as it suggests sacral root encroachment from significant intraspinal
compression.[36]
Vascular examination
A vascular examination is important in differentiating vascular versus neurogenic claudication. Vascular

claudication typically worsens with ambulation in any position and is relieved immediately by rest. Neurogenic
claudication worsens with ambulation in an extended posture and improves with forward flexion of the lumbar
spine.[36] Patients with claudication may have concomitant vascular and spinal pathologies.
Other features that may aid diagnosis
A general physical examination may detect other features to aid diagnosis. For instance, when pain is
referred:
• Patients with abdominal aortic aneurysm may have a detectable pulsatile abdominal mass
• Patients with peptic ulcer may have epigastric tenderness and melaena on rectal examination
• Patients with renal colic or pyelonephritis may have flank or costovertebral tenderness
• Patients with pancreatitis may have a fever and tenderness/guarding of abdomen.
Laboratory tests
Routine laboratory studies are not necessary in the evaluation of back pain unless the physician is
concerned about the possibility of malignancy or infection (i.e., non-mechanical back pain, fever, chills,
night sweats, and/or weight loss). In these cases full blood count, erythrocyte sedimentation rate, C-reactive
protein, and blood cultures are typically obtained.
DIAGNOSIS
Though non-specific in nature, these values should not be elevated in the setting of mechanical back pain
and may indicate to the physician that a systemic process such as infection or inflammation is occurring if the
results are abnormal.
A urinalysis and urine culture should be ordered when considering the possibility of pyelonephritis or renal
colic.
Imaging
Most patients with low back pain, with or without sciatica, do not routinely require imaging when presenting
in a non-specialist setting.[35] [Evidence C] If there are no red flags or high-risk features, they should be
reassured that their symptoms will respond to conservative treatment. If symptoms persist longer than 6 to
8 weeks, plain x-rays should be obtained at that time, as most patients with benign low back pain aetiology
should have improved.[47] [51] [52] [53] [54]
High-risk patients who present with back pain (i.e., those taking corticosteroids or another
immunosuppressive therapy, and those with a history of intravenous drug use) should undergo imaging
studies. Patients with other red flag symptoms or signs, for example, unrelenting pain, systemic ailments (i.e.,
fevers, chills, general malaise, history of malignancy, unexplained weight loss), and profound neurological
17
deficits, warrant urgent advanced imaging studies, such as magnetic resonance imaging (MRI) or computed
tomography (CT).
Imaging is indicated in patients with trauma, especially minor trauma in older adults, and those with
osteoporosis.[55]
Neurological compromise, suspected infection or suspected tumour
MRI or CT is indicated if neurological compromise is present, or if infection or tumour is considered. In

general, if patients have non-mechanical back pain or neurological compromise, an MRI is the preferred
study.
If a patient has metal in their spine or is unable to undergo an MRI, a CT myelogram is usually warranted.
MRI scan of the sacroiliac joints is not generally required but is recommended when inflammatory spondylitis
is suspected as the cause of back pain but the clinical examination and plain x-ray has not established the
diagnosis.[56]
Plain x-rays are performed in people with suspected sacroiliitis to rule out other causes of pain, but there are
no pathognomonic findings specific to sacroiliac joint pain.
Degenerative and disc abnormalities are found in many asymptomatic patients, causing over-diagnosis and
unwarranted patient anxiety.[47] [51] [52] [53] [54] [57] [58] Degenerative findings do not necessarily equate
to symptomatic lesions.[59] [60] Furthermore, there is no correlation between severity of symptoms and
findings on MRI.[61] Therefore, imaging studies should be ordered after discussion with a spinal surgeon or
by the spinal surgeon in most cases to prevent ordering of unnecessary tests.
Trauma
In trauma situations, obtain standard anteroposterior (AP) pelvis and cervical spine x-rays. If patients have
back pain, request AP and lateral x-rays of the lumbar spine.
Neurological compromise, gross spinal deformities, or manual step-off on spinal palpation also warrant CT to
DIAGNOSIS
understand the bony anatomy.
Of note, spinal precautions should be taken when moving trauma patients until the spine is cleared by the
trauma or spinal surgeon. If any abnormalities are noted on imaging, a spinal surgeon should be consulted
for further management.
Further investigations
Diagnosis of sacroiliitis as the cause of back pain is usually made by physical examination. However,
further investigations include diagnostic local anaesthetic block injection of the sacroiliac joint under C-arm
fluoroscopic guidance that, when positive, provides corresponding pain relief.
Other investigations, including laboratory, imaging, and endoscopic tests, are used when pain is suspected to
be non-spine related (e.g., referred from intra/retroperitoneal pathologies).
Differentials overview
Common
Lumbar muscular strain/sprain
Spinal stenosis
Compression fracture
Degenerative disc disease or facet arthropathy
Sacroiliitis
Uncommon
Spondylolysis and/or spondylolisthesis
Vertebral discitis/osteomyelitis
Malignancy
Inflammatory spondyloarthropathy
Connective tissue disease
DIAGNOSIS
Aortic abdominal aneurysm
Pancreatitis
Pyelonephritis
Renal colic
Peptic ulcer disease
Spinal epidural abscess
19
Differentials
Common
◊ Lumbar muscular strain/sprain
History Exam 1st Test Other tests
sharp intense pain for benign physical »none: clinical »plain x-rays: no
1 to 2 days; muscle examination, diagnosis diagnosis abnormalities (e.g.,
spasm; most patients is one of exclusion Most patients with spondylolisthesis) or
recover within 3 low back pain with fractures are normally
months[4] seen
or without sciatica
If a patient does not
do not routinely
respond to conservative
require imaging when
treatment in 6 to 8
presenting in a non-
weeks, an x-ray should
specialist setting.[62]
be obtained to rule out
other pathologies not
considered at the initial
visit.
»magnetic
resonance imaging
(MRI): no abnormality
seen
MRI is indicated
if neurological
compromise present or
if infection or tumour is
considered.
DIAGNOSIS
radiating lower positive straight-leg »magnetic »plain x-rays: no

extremity pain raise or contralateral resonance imaging abnormalities are
in a dermatomal straight leg (reproduced (MRI): herniated disc normally found on plain
distribution; history below 60° of hip If patients present with x-rays
of bowel or bladder flexion; pain that occurs symptoms of severe Useful to rule out other
dysfunction, bilateral above 60° is usually pathologies including
sciatica, and saddle secondary to hamstring neurological deficits or
anaesthesia may be tightness);[46] [47] [48] symptoms consistent tumour, infection or
symptoms of severe positive femoral stretch with cauda equina, MRI fracture.
compression of the test may suggest should be obtained.
cauda equina upper lumbar disc
herniation[50]
Common
◊ Spinal stenosis
intermittent pain patients walk with a »magnetic »plain x-rays:

radiating to the thigh forward flexed gait; resonance imaging: degenerative
or legs, worse with patients with vascular spinal stenosis; arthritis; diffuse
prolonged standing, claudication have hypertrophy of the osteophyte formation
activity, or lumbar diminished pulses and facet joints and/or normally seen with
extension; pain is typical skin changes, ligamentum flavum an accompanying
typically relieved by such as mottled with corresponding degenerative
sitting, lying down, discolouration, thinning decrease in spinal spondylolisthesis or
and/or lumbar flexion; and shiny skin canal diameter scoliosis
patient may describe dimension Useful to rule out other
intermittent burning, Radiologists usually pathologies. Spinal
numbness, heaviness, state stenosis as
or weakness in their stenosis is typically
legs, unilateral or mild, moderate, or diagnosed by magnetic
bilateral radicular severe. Referral to resonance imaging and
pain, motor deficits, spinal surgeon for clinical diagnosis, not a
bowel and bladder consideration of
dysfunction, and back plain x-ray finding.
and buttock pain operative management.
with standing and
ambulation
DIAGNOSIS
Magnetic resonance
imaging of spinal
stenosis: arrow
points to the
moderately
stenotic spinal
canal caused by
hypertrophic facets
and ligament flavum
Courtesy of Dr
K. Singh; used
with permission
21
Common
◊ Compression fracture
typically history of tenderness to palpation »plain x-rays: »bone scan or

trauma, although over the midline; wedging of the magnetic resonance
acute event not always increased kyphosis, vertebral bodies, imaging: can
recalled; pain at normal neurological typically anteriorly; demonstrate if the
rest and at night, examination unless kyphotic deformity; fracture is acute or
previous history of there is retropulsion of only the anterior half chronic to help guide
fractures (e.g., distal bone into the neural of the vertebral body is appropriate treatment
radius, hip or other elements, such as in involved in compression Acute fractures
vertebral compression burst fractures fractures can be treated with
fractures); history of Consider referral to
osteoporosis or at bracing, temporary
spine surgeon if pain
risk of osteoporosis bed rest, calcitonin,
(i.e., older age, post is refractory to medical
and/or kyphoplasty or
menopausal, prolonged management and
vertebroplasty. Chronic
steroid therapy) bracing.
compression fractures
should be treated as
musculoskeletal back
pain.
X-ray of a
compression fracture:
a lateral x-ray of
DIAGNOSIS
an L2 compression
fracture (A). Wedging
of the vertebral
body is seen
Courtesy of Dr
K. Singh; used
with permission
◊ Degenerative disc disease or facet arthropathy
symptoms worsen decreased range of »plain x-rays: »magnetic

with forward flexion, motion due to pain degenerative arthritis resonance imaging
coughing/sneezing, and mild tenderness and diffuse osteophyte (MRI): degenerative
or heavy lifting; facet on palpation; pain is formation disc disease: loss
mediated pain is reproduced with flexion If patient does not of disc height, end
in discogenic pain and respond to conservative plate collapse, and
Common
◊ Degenerative disc disease or facet arthropathy

typically worse with extension with facet treatment in 6 to 8 usually decreased
extension arthropathy weeks, an x-ray should T2 signal in the disc;
facet arthropathy:
be obtained to rule out hypertrophy of the facet
other pathologies not and possible T2 signal
considered at the initial in the joint
visit. May suggest disc
height loss, annular
tears, end plate
collapse, and/or facet
arthropathy.
High-intensity zones
(HIZ) found on
T2-weighted MRI
(representing a tear in
the posterior annulus)
have been implicated
as a specific marker
for discogenic back
pain. However, some
studies have found that
asymptomatic patients
with degenerative disc
disease may also have
DIAGNOSIS
HIZ on MRI.[63]
◊ Sacroiliitis
low back pain, may be tenderness on »none: clinical »plain x-rays: no other
lower extremity pain palpation at the diagnosis abnormalities normally
sacroiliac joint; seen
Gaenslen's test, pelvic »diagnostic
compression test, and local anaesthetic
FABER test may be block injection to
positive[23] sacroiliac joint with
C-arm fluoroscopic
guidance: significant
decrease in pain after
sacroiliac joint injection
23
Uncommon
◊ Spondylolysis and/or spondylolisthesis
most are asymptomatic; exaggerated lordosis, »plain x-rays: linear »magnetic

pain in the lower heart-shaped buttock, lucency in the pars resonance imaging:
back with occasional or midline 'step-off' of interarticularis acute stress reaction in
radiation to the the spinous processes If patient does not the pars interarticularis;
posterior thigh may be present; respond to conservative fracture
and aggravated by pain with single-leg Typically, confirmatory.
extension hyperextension test treatment in 6 to 8
may be present (this weeks, an x-ray should
test has low sensitivity be obtained to rule out
and specificity; a other pathologies not
combination of findings
are required for considered at the initial
diagnosis).[64] [65] visit.
infection should be generalised »full blood count: »plain x-rays:

considered for patients appearance of elevated white blood may demonstrate
with a history of fever, malaise; fever; cell count, particularly endplate/vertebral
weight loss, and non- localised tenderness the neutrophil count body destruction
mechanical back pain present particularly Will need to rule with resultant spinal
(i.e., pain that occurs with percussion; out other sources of deformity
even without motion, neurological findings
infection, such as »magnetic
particularly at rest and absent resonance imaging:
at night); history of urinary and respiratory
reveals increased T2
DIAGNOSIS
intravenous drug use, system. signal intensity that

immunosuppression, or localises to the disc
diabetes »erythrocyte space and vertebral
sedimentation rate: body
elevated
May suggest the
Will need to rule
presence of a fluid
out other sources of
collection such as an
infection, such as
epidural abscess that
urinary and respiratory
may be associated
system.
with the discitis/
»C-reactive protein: osteomyelitis.
elevated
Will need to rule
out other sources of
infection, such as
urinary and respiratory
system.
Uncommon

»blood cultures:
Staphylococcus aureus
and Streptococcus
common
To identify a
haematogenous
source.
Magnetic resonance
imaging of
osteomyelitis: T11-
T12 disc space is
involved with discitis
(A). There is bony
involvement of both
vertebrae indicated
by high T2 signal
of the vertebral
bodies. Arrow
indicates a normal
healthy vertebral disc
Courtesy of Dr
K. Singh; used
DIAGNOSIS
with permission
Malignancy
history of malignancy generalised systemic »plain x-rays: may

(breast, lung, prostate, symptoms including demonstrate lysis of
thyroid, kidney), age fevers/chills, weight the vertebral body or
>50 years, back loss, and malaise; posterior elements
pain at night and focal tenderness Bony metastases may
at rest; may have and/or neurological cause destruction of the
neurological deficits deficits may be present
if tumour destruction depending on tumour pedicle resulting in the
is extensive and size and location 'winking owl' sign.
causes neurological
compression
25
Uncommon
Malignancy
The 'winking
owl' sign (arrow):
asymmetrical
appearance of
spine on plain
x-rays caused
by destruction
of the pedicle
Created by BMJ
Publishing Group
DIAGNOSIS
Uncommon
Malignancy
Spine x-ray: the

'winking owl' sign
(asymmetrical
appearance caused
by destruction
of the pedicle)
Courtesy of Dr
D. Park; used
with permission
»magnetic
resonance imaging:
either a lytic or blastic
lesion with varying T2
DIAGNOSIS
signal intensity; lesion
typically does not cross
the end plate, but soft
tissue extension may
be present
Important to
differentiate findings
from that of an
infection. Typically
infections cross the disc
space, whereas tumour
destructions rarely
cross the intervertebral
disc. Extent of
destruction and neural
compression should be
observed.
27
Uncommon
Malignancy
Magnetic resonance
imaging of
lymphoma:
arrowhead indicates
a soft-tissue mass
protruding into the
spinal canal. Arrow
points to the tumour
protruding anterior to
the L5 vertebral body
Courtesy of Dr
K. Singh; used
with permission
»computed
tomography: lytic
DIAGNOSIS
destruction of the
vertebral body with
possible soft tissue
extension; blastic
lesions possible
Extent of bony
destruction observed.
◊ Inflammatory spondyloarthropathy
male predominance in axial »plain x-ray »magnetic

ankylosing spondylitis, spondyloarthropathy or sacroiliac joints: resonance imaging:
early-morning stiffness, ankylosing spondylitis: erosion of sacroiliac spondylitis; fractures
nocturnal back pain, stiffness of spine with joint (squaring of Not generally required.
fatigue, weight loss, kyphosis, limited range lumbar vertebrae) If indicated, National
diffuse non-specific of movement of lower and later narrowing
pain radiating bilaterally spine, tenderness and fusion (bamboo Institute for Health and
to buttocks; pain on palpation; extra- Care Excellence (NICE)
Uncommon

improves after physical articular signs (e.g., spine) is suggestive of guidelines recommend
activity; may have psoriasis, uveitis) may ankylosing spondylitis including short T1
family history of be present Often normal in early
arthritis or psoriasis; inversion recovery, T1
disease. Imaging of
history of inflammatory (both views), cervical,
bowel disease may other symptomatic
thoracic and lumbar
be suggestive of sites (e.g., hands and
(whole spine, sagittal
enteropathic arthritis feet with suspected
view), and sacroiliac
psoriatic arthritis) may
joints (coronal oblique
be indicated.[43]
view).[43]
Plain x-ray showing

bilateral sacroiliitis
in a patient Coronal STIR
with ankylosing (short tau inversion
spondylitis recovery) magnetic
BMJ resonance image
2006;333;581-585. showing unilateral
© BMJ Publishing (right) sacroiliitis
Group Ltd 2009 BMJ
DIAGNOSIS
2006;333;581-585.
© BMJ Publishing
Group Ltd 2009
»full blood count:

white blood cell count
may be elevated
»C-reactive protein:
may be normal or
elevated
»erythrocyte
sedimentation rate:
may be normal or
elevated
»human leukocyte
antigen B27: may be
positive or negative
Not diagnostic but
may be helpful in
29
Uncommon

aiding decisions on
further investigations or
referral.[43]
◊ Connective tissue disease
arthralgias, evidence of organ »full blood count: »chest x-ray:

polyarthritis, systemic involvement (e.g., rash, leukopenia normal; mediastinal
symptoms of fever, lymphadenopathy, lymphadenopathy;
»serum antibodies:
weight loss, and fatigue wheeze, signs of interstitial lung disease;
elevated
malabsorption, joint pericardial effusion
Antinuclear antibodies,
tenderness, joint
double-stranded DNA, »plain x-ray of spine:
effusion and swelling, may be evidence of
signs of uveitis, anti-Smith antibodies, rheumatoid arthritis
conjunctivitis) anticardiolipin
antibodies.
»rheumatoid factor:
elevated in rheumatoid
disease
»erythrocyte
sedimentation rate:
elevated
Non-specific sign of
DIAGNOSIS
inflammation.
Aortic abdominal aneurysm
sudden onset of pulsatile abdominal »abdominal »computed

intermittent or mass, hypotension ultrasound: extent tomography
continuous abdominal or hypertension, and size of aneurysm angiography: clearly
pain, radiating to tachycardia defines aneurysm and
the back; patient involvement of visceral
may collapse; older arteries
age; history of Sensitive and specific.
cardiovascular disease
Uncommon
◊ Pancreatitis
sudden onset of tachycardia, fever, »serum lipase: can »endoscopic

epigastric pain; radiates jaundice, tenderness/ be elevated if amylase retrograde
to back; may be guarding of abdomen is normal[30] cholangiopancreatography:
relieved by sitting More sensitive than identifies stones, duct-
forwards; associated amylase. filling defects and
with nausea and strictures
vomiting; history »ultrasound: may Allows retrieval of
of alcohol use or show pancreatic stones; diagnostic as
gallstones inflammation, well as therapeutic
peripancreatic
if suspected biliary
stranding, calcifications,
or fluid collections obstruction.
»contrast-
enhanced computed
tomography:
fluid collections;
pseudocysts; abscess
◊ Pyelonephritis
urinary symptoms of flank or costovertebral »urinalysis: pyuria, »contrast computed

dysuria, frequency, and tenderness microscopic haematuria tomography: altered
hesitancy; flank pain renal parenchymal
»urine culture:
may radiate to back; perfusion; altered
positive
fever, chills, fatigue excretion of contrast;
DIAGNOSIS
»renal ultrasound: perinephric fluid; non-
gross structural renal disease
abnormalities; Rarely indicated unless
hydronephrosis;
patient deteriorates
stones; perirenal fluid
collections and/or at risk of
Accessible and does complications.
not involve exposure to
radiation or dyes.
◊ Renal colic
severe, acute flank flank or costovertebral »urinalysis: »non-contrast

pain that may radiate angle tenderness; may microscopic haematuria computed
to the ipsilateral groin; have macroscopic Present in 90% of tomography:
associated nausea haematuria patients. calcification seen in
and vomiting; history
of volume depletion
31
Uncommon
◊ Renal colic

or stone-inducing renal collecting system
medications (e.g., or ureter
antacids, carbonic
anhydrase inhibitors,
sodium- and calcium-
containing medications,
vitamins C and D,
indinavir)
◊ Peptic ulcer disease
epigastric, burning epigastric tenderness, »upper

pain; radiates to may be melaena on gastrointestinal
back; usually occurs rectal examination endoscopy: detects
in association with site of bleeding and
meals; may be ulceration
relieved by antacids; Most sensitive
haematemesis or and specific test.
melaena in advanced
disease Enables sampling for
Helicobacter pylori
and biopsy to exclude
malignancy.

DIAGNOSIS
focal spinal process fever with sweats »WBC: leukocytosis »Direct abscess
pain, often with and rigors or afebrile; Usually elevated, aspiration for
paravertebral spasm; signs and symptoms although a non-specific culture: identifies
pain is increased with of neurological causative organism
weight-bearing and is loss; weakness of marker.
If blood cultures are
not relieved by rest; extremities is common negative, tissue may
»CRP: elevated
history of diabetes and may indicate
mellitus, intravenous impending motor Usually elevated, be obtained by local
drug use, HIV infection, weakness; sensory although a non-specific aspiration for culture.
recent invasive disturbance, abnormal marker.
procedures (e.g., reflexes (ranging »Polymerase chain
previous spinal surgery from hyperreflexia to reaction (PCR) of
Should be repeated
or trauma, previous reduced or absent aspirate: identifies
every 7 to 10 days to causative organism
neuraxial anaesthesia responses), and
associated with isolated sphincter monitor response to PCR for suspected
indwelling [intrathecal/ dysfunction therapy. organisms may help
epidural] catheter
placement), chronic »ESR: elevated
Uncommon

renal disease and renal Usually elevated, identify causative
failure, alcohol abuse, although a non-specific organisms.[68] [69]
and obesity; existing
conditions (e.g., marker.
infective endocarditis,
chronic liver disease, Should be repeated
or urinary tract every 7 to 10 days to
infection) may be a monitor response to
source of infection
therapy.
by haematogenous
spread; focus of »Gadolinium-
pre-existing local enhanced diffusion-
infection should also weighted MRI
be ascertained, as spine: infection in
direct extension from epidural space ± bone
vertebral osteomyelitis, involvement
a psoas abscess, or
The most sensitive,
a retropharyngeal
abscess may be the specific, and accurate
source imaging method
for spinal epidural
abscess.[66]
The degree of thecal

sac compression
is prognostic:
compression >50%
DIAGNOSIS
increases incidence
of progressive
neurological injury and
late recurrences.[67]
»blood cultures:
identifies causative
organism
All patients should
have blood cultures
before antibiotic
therapy. The most
common pathogen is
Staphylococcus aureus
(63%).
33
Uncommon
bowel or bladder or sensory changes in »MRI with or without »CT myelography:

sexual dysfunction, saddle or perianal contrast: compression compression of the
back pain with or area; sensory changes of the cauda equina cauda equina
without sciatica; or numbness in the Use of contrast Useful if MRI is
symptoms may come lower limbs; lower limb depends on clinical contraindicated or non-
on gradually; history of weakness, reduction
lumbar disc herniation, or loss of reflexes in circumstances. MRI of diagnostic.[51]
spinal stenosis, lower limbs; reduced the lumbar spine should
spinal injury, spinal anal tone be considered for those
neoplasm (primary or patients presenting
metastasis), infection
(e.g., tuberculosis), with red flags raising
spinal surgery suspicion for a serious
underlying condition,
such as cauda
equina syndrome
(CES), malignancy, or
infection.[51]
DIAGNOSIS
Assessment of back pain Guidelines
Guidelines
Europe
Spondyloarthritis in over 16s: diagnosis and management (ht tps://

www.nice.org.uk/guidance/ng65)
Published by: National Institute for Health and Care Excellence

Last published: 2017
Low back pain and sciatica in over 16s: assessment and management (ht tps://
www.nice.org.uk/guidance/ng59)
Published by: National Institute for Health and Care Excellence

GUIDELINES
EULAR recommendations for the use of imaging in the diagnosis and
management of spondyloarthritis in clinical practice (ht tp://www.eular.org/
recommendations_management.cfm)
Published by: European League Against Rheumatism

North America
VA/DoD clinical practice guideline for diagnosis and treatment of low back
pain (ht tps://www.healthquality.va.gov/)
Published by: US Department of Veterans Affairs; Department of Defense

Non-specific back pain guideline (ht tps://wa.kaiserpermanente.org/

healthAndWellness?item=%2Fcommon%2FhealthAndWellness
%2FcareDecisions%2FyourCare%2Fguidelines.html)
Published by: Kaiser Permanente

ACR Appropriateness Criteria: chronic back pain - suspected sacroiliitis/

spondyloarthropathy (ht tps://www.acr.org/Quality-Safety/Appropriateness-
Criteria)
Published by: American College of Radiology

35
Assessment of back pain Guidelines
North America
ACR Appropriateness Criteria: low back pain (ht tps://www.acr.org/Quality-

Safety/Appropriateness-Criteria)
Published by: American College of Radiology

GUIDELINES
Assessment of back pain Evidence tables
Evidence tables
What are the effects of X-ray imaging or magnetic resonance imaging (MRI)
EVIDENCE TABLES
compared with no investigation in people with low back and/or sciatica?[35]
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)
that focuses on the above important clinical question.
View the full source guideline (https://www.nice.org.uk/guidance/ng59/evidence)
Evidence C * Confidence in the evidence is very low or low where GRADE has been performed
and there may be no difference in effectiveness between the intervention and
comparison for key outcomes. However, this is uncertain and new evidence could
change this in the future.
Population: People aged 16 or over with non-specific low back pain and/or sciatica
Intervention: MRI or X-ray imaging
Comparison: No imaging
† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)
Health-related quality of life No statistically significant Low

(Short Form [SF-36]) bodily difference
pain ≤ 4 months
Health-related quality of No statistically significant Low

life (SF-36) general health difference
perception ≤ 4 months
Health-related quality of life Favours intervention Very Low

(SF-36) vitality ≤ 4 months
Health-related quality of No statistically significant Low

life (SF-36) role-physical difference
functioning ≤ 4 months
Health-related quality of life No statistically significant Very Low

(SF-36) social functioning ≤ 4 difference
months

(SF-36) mental health ≤ 4
months
37
† ‡
Health-related quality of life No statistically significant Low

EVIDENCE TABLES
(SF-36) physical functioning ≤ difference

4 months
Health-related quality of No statistically significant Very Low

life (SF-36) role-emotional difference
functioning ≤ 4 months

(EQ-5D) Visual Analogue difference
Scale (VAS) ≤ 4 months
Pain severity (Aberdeen Low Favours intervention Very Low

Back Pain [ALBP] score) > 4
months
Function (Roland Morris No statistically significant Very Low

Disability Questionnaire difference
[RMDQ]) ≤ 4 months
Function (RMDQ) > 4 months No statistically significant Low

difference
Psychological distress No statistically significant Very Low

(Hospital Anxiety and difference
Depression Scale [HADS]
Anxiety Score) ≤ 4 months
Psychological distress (HADS No statistically significant differenc Low

Anxiety Score) > 4 months
Psychological distress (HADS No statistically significant Low

Depression Score) ≤ 4 months difference
Psychological distress (HADS No statistically significant Low

Depression Score) > 4 months difference

(SF-36) bodily pain > 4 months

(SF-36) mental health > 4
months

(SF-36) physical functioning > difference
4 months
† ‡
EVIDENCE TABLES
(SF-36) social functioning > 4
months

(SF-36) role reported health difference
transition > 4 months

(SF-36) vitality > 4 months

life (SF-36) general health difference
perception > 4 month

life (SF-36) role-physical difference
functioning > 4 months

life (SF-36) role-emotional difference
functioning >4 months

(EQ-5D, 0-1) > 4 months

(EQ-5D) VAS > 4 months difference
Recommendations as stated in the source guideline

• The guideline development group states that imaging should not be routinely offered in a non-
specialist setting for people with low back pain with or without sciatica.
• Explain to people with low back pain with or without sciatica that if they are being referred for specialist
opinion, they may not need imaging.
• Consider imaging in specialist settings of care (e.g., a musculoskeletal interface clinic or hospital) for
people with low back pain with or without sciatica only if the result is likely to change management.
Note
• The guideline development group has described the outcomes in this table as critical. Healthcare
utilisation, responder criteria and adverse events are also included in the guideline as important
outcomes; no evidence was found for the latter two. Please see the full-text guideline document for
more information on these outcomes.
• The results in this table are based on randomised controlled trial (RCT) evidence, four of which
compared X-ray with no imaging while the fifth compared MRI with no imaging. Most of the evidence
39
in favour of imaging came from a single RCT in a secondary care setting. However, the guideline
development group also notes that very low-quality cohort study evidence comparing X-ray with no
imaging showed no clinical difference or clinical benefit in favour of no imaging for quality of life at both
EVIDENCE TABLES
short and longer term follow-ups.
• It also acknowledged that, for most comparisons, the evidence was limited and from a small number of
studies.
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit (https://
bestpractice.bmj.com/info/evidence-tables/) for details.
Confidence in evidence
A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low
† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.
‡ Grade certainty ratings
High The authors are very confident that the true

effect is similar to the estimated effect.
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE? (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-
is-grade/)
Assessment of back pain References
Key articles
• Rossiter DJ, Haider Z, David B, et al. How not to miss major spinal pathology in patients with back
REFERENCES
pain. Br J Hosp Med (Lond). 2017 May 2;78(5):C66-9. Abstract
• Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and
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Full text (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012010.pub2/full) Abstract
• Henschke N, Maher CG, Refshauge KM. A systematic review identifies five "red flags" to screen for
vertebral fracture in patients with low back pain. J Clin Epidemiol. 2008 Feb;61(2):110-18. Abstract
• American College of Radiology. ACR appropriateness criteria: low back pain. 2015 [internet
publication]. Full text (https://acsearch.acr.org/docs/69483/Narrative/)
• Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-
analysis. Lancet. 2009 Feb 7;373(9662):463-72. Abstract
• 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 Feb 1;154(3):181-9.
Abstract
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47
Assessment of back pain Images
Images
IMAGES
Figure 1: Magnetic resonance imaging of spinal stenosis: (A) demarcates the normal sagittal diameter of the
spinal canal. (B) demarcates severe narrowing of the spinal canal
IMAGES
Figure 2: Magnetic resonance imaging of spinal stenosis: arrow points to the moderately stenotic spinal canal
caused by hypertrophic facets and ligament flavum
49
IMAGES Assessment of back pain Images
Figure 3: X-ray of a compression fracture: a lateral x-ray of an L2 compression fracture (A). Wedging of the
vertebral body is seen
IMAGES
Figure 4: X-ray of tumour: lymphoma (A) destroying the L5 vertebra
51
Figure 5: Magnetic resonance imaging of lymphoma: arrowhead indicates a soft-tissue mass protruding into
the spinal canal. Arrow points to the tumour protruding anterior to the L5 vertebral body
IMAGES
Figure 6: Magnetic resonance imaging of osteomyelitis: T11-T12 disc space is involved with discitis (A).
There is bony involvement of both vertebrae indicated by high T2 signal of the vertebral bodies. Arrow
indicates a normal healthy vertebral disc
53
Figure 7: The 'winking owl' sign (arrow): asymmetrical appearance of spine on plain x-rays caused by
destruction of the pedicle
Created by BMJ Publishing Group
IMAGES
Figure 8: Spine x-ray: the 'winking owl' sign (asymmetrical appearance caused by destruction of the pedicle)
Courtesy of Dr D. Park; used with permission
55
Figure 9: Plain x-ray showing bilateral sacroiliitis in a patient with ankylosing spondylitis
IMAGES
BMJ 2006;333;581-585. © BMJ Publishing Group Ltd 2009
Figure 10: Coronal STIR (short tau inversion recovery) magnetic resonance image showing unilateral (right)
sacroiliitis
BMJ 2006;333;581-585. © BMJ Publishing Group Ltd 2009
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DISCLAIMER
Contributors:
// Authors:
Daniel K. Park, MD
Associate Professor
Department of Orthopedic Surgery, William Beaumont Hospital, Royal Oak, MI
DISCLOSURES: DKP is a paid consultant for Stryker, K2M, and Aegis Spine; and has received royalties
from HD LifeSciences.
Kern Singh, MD
Professor
Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
DISCLOSURES: KS has received royalties from Zimmer, Stryker, Pioneer, Lippincott Williams & Wilkins,
Thieme, Jaypee Publishing, and Slack Publishing. He holds stock in Avaz Surgical, LLC, and Vital 5, has
consulted for Depuy, Zimmer, and Stryker, and is on the board of directors for CSRS, ISASS, AAOS, SRS,
Vertebral Column - ISASS. KS has received a CSRS resident grant.
// Acknowledgements:
Dr Daniel K. Park and Dr Kern Singh would like to gratefully acknowledge Dr Howard S. An, a previous
contributor to this topic. HSA declares that he has no competing interests.
// Peer Reviewers:
Eric L. Mat teson, MD

Professor of Medicine
Mayo Clinic College of Medicine, Division of Rheumatology, Rochester, MN
DISCLOSURES: ELM declares that he has no competing interests.

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Assessment

Straight to the point of care

Last updated: Jun 16, 2020

• The most common cause of mechanical back pain.[8]

• Many patients have asymptomatic degenerative discs.

Herniated nucleus pulposus

Magnetic resonance imaging of spinal stenosis: arrow points to the moderately

X-ray of a compression fracture: a lateral x-ray of an L2

as a secondary inflammatory problem.

Systemic aetiologies include:

Magnetic resonance imaging of lymphoma: arrowhead indicates a soft-tissue mass protruding

Cauda equina syndrome

Ruptured abdominal aortic aneurysm

Initiate standard resuscitation measures immediately, including:

Symptoms of severe compression of the cauda equina

Spinal compression fractures

It is important to be aware that the diagnosis of spondyloarthritis is sometimes missed or delayed.[43]

Non-specific causes of back pain

A musculoskeletal examination consists of the following:

Patient gait and ability to walk should be also be observed.

A number of provocative tests may be performed.

pain does not exclude disc herniation.[49]

A vascular examination is important in differentiating vascular versus neurogenic claudication. Vascular

Other features that may aid diagnosis

• Patients with pancreatitis may have a fever and tenderness/guarding of abdomen.

Neurological compromise, suspected infection or suspected tumour

MRI or CT is indicated if neurological compromise is present, or if infection or tumour is considered. In

understand the bony anatomy.

Lumbar muscular strain/sprain

Herniated nucleus pulposus

Degenerative disc disease or facet arthropathy

Spondylolysis and/or spondylolisthesis

Connective tissue disease

Peptic ulcer disease

Spinal epidural abscess

Cauda equina syndrome

◊ Lumbar muscular strain/sprain

History Exam 1st Test Other tests

Herniated nucleus pulposus

History Exam 1st Test Other tests

radiating lower positive straight-leg »magnetic »plain x-rays: no

History Exam 1st Test Other tests

intermittent pain patients walk with a »magnetic »plain x-rays:

History Exam 1st Test Other tests

typically history of tenderness to palpation »plain x-rays: »bone scan or

◊ Degenerative disc disease or facet arthropathy

History Exam 1st Test Other tests

symptoms worsen decreased range of »plain x-rays: »magnetic

◊ Degenerative disc disease or facet arthropathy

History Exam 1st Test Other tests

History Exam 1st Test Other tests

◊ Spondylolysis and/or spondylolisthesis

History Exam 1st Test Other tests

most are asymptomatic; exaggerated lordosis, »plain x-rays: linear »magnetic

History Exam 1st Test Other tests

infection should be generalised »full blood count: »plain x-rays:

intravenous drug use, system. signal intensity that

History Exam 1st Test Other tests

History Exam 1st Test Other tests

history of malignancy generalised systemic »plain x-rays: may

History Exam 1st Test Other tests

History Exam 1st Test Other tests

Spine x-ray: the