Causes of Back Pain

Key Historical Findings

Onset

Acute onset with associated activity suggests mechanical process

Acute onset without trigger, particularly if severe pain may suggest vascular process

Progressive onset without trigger suggests non-mechanical process (i.e. malignancy)

Aggravating/Alleviating Factors

Worsening with cough/valsalva suggests herniated disk

Relief with flexion associated with spinal stenosis

Location/Radiation

Radicular pain typically extends below knee, associated with nerve root involvement

Radiation to/from chest or abdomen suggests visceral source

Flank location suggests retroperitoneal source

History/Associated Symptoms

Fever

Medications (particularly anti-coagulants)

Hematuria

Malignancy

IVDA

Vascular disease

Key Physical Findings

• Abnormal vital signs
  • Fever: abscess, osteomyelitis, discitis
  • Hypertension: dissection
  • Shock: AAA
• Localize point of greatest tenderness
• Examine abdomen for pulsatile mass
• Perform thorough neurological examination including rectal tone and perianal sensation
• Positive straight leg raise associated with sciatic nerve root irritation and is sensitive (but not specific) for disk disease.

References

1. Mahoney, B. (2013). Back Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 278-284). Elsevier Health Sciences.
2. WikEM: Lower back pain