When Back Pain Keeps Coming Back: Back Pain Basics (A Diagnostic Evaluation of Back Pain)

The evaluation of back pain can be a pain in the neck or a back-breaking exercise, so to speak.

However, the diagnosis hinges always on a focused History and Physical Exam and not really on labs or imaging. Knowing what to ask and where to look can make the evaluation of this all-too-common condition manageable for the internist. 

This lecture focuses on the evaluation of low back pain and will guide the reader on the key points in the Hx and PE and prevent unnecessary testing/imaging.

It also presents 3 “unusual” cases of low back pain of which may be disabling if not recognized immediately.

The pandemic provides a current challenge in evaluating back pain (or musculoskeletal [MSK] pain in general) in that a lot of patients would prefer to do telemedicine rather than a clinic visit. Telemedicine, while convenient, makes it difficult to evaluate MSK conditions because of the inability of the clinician to perform a full Physical Examination. Though it carries the advantage of doing screening and History-taking before a 1st clinic visit, the lack of physical interaction to do maneuvers such as palpation, percussion, auscultation make the virtual encounter challenging.

Fortunately, there are still several things that can be done with inspection, and with the proper guidance/demonstration, one can do a demonstration over camera of some simple maneuvers that a patient can do, to elicit some important clinical findings. I found this journal to be helpful and I am linking the article below:

https://journals.sagepub.com/doi/full/10.1177/2192568220944129

The journal article talks about the requirements and barriers to telemedicine for spine examination and provides suggestions on how to maintain patient rapport and and instructions on how to conduct a virtual Physical Examination. They also have a short instructional video and some tables on how this could be done.

Overall, the evaluation of back pain is difficult, especially with the limited face to face encounters nowadays, but with a good fund of knowledge of what to ask and where to look and with the ability to leverage technology to our advantage, then we should be able to assist and take care of our patients with this condition better.