Lower Back pain is one of the commonest and most troublesome of complaints; its
causes are legion and an exact diagnosis is often difficult. The disability with
which it is usually associated is often severe and prolonged; therapy is often
ineffective, and the anxious, impatient and dissatisfied sufferer often resorts
to lines of treatment which are unproven, illogical and irrational. In this
difficult area it is not possible to provide a guide to pathology and diagnosis
which is simple and at the same time comprehensive and foolproof.
Nevertheless, it may be helpful to consider this subject under three headings:
Lower Back pain due to clearly defined spinal pathology,
such as vertebral
infections, tumours, ankylosing spondylitis, polyarthritis, Pager’s disease,
and primary neurological disease. osteoporotic spinal fractures, senile
kyphosis. spondylolisthesis, Scheuermann’s disease (spinal
osteochondrosis), and osteoarthritis.
Back pain associated with nerve root pain,
where the commonest causes
are intervertebral disc prolapse and compression of nerve roots within the
3. Lower Back pain caused by a disturbance of the mechanics of the spine
(mechanical back pain), where in the majority of cases it is not possible to
discover the exact cause with any degree of accuracy. This is the largest
group of conditions causing back pain, and formerly attracted many
emotive but valueless names (such as lumbago, low -back strain etc).
In taking a history, examining and investigating a patient suffering from back
pain, possible extraspinal causes should be excluded and an attempt should
be made to place the patient in one of the three groups described above.
Thereafter, and if possible, a more precise diagnosis may be attempted.
Important points in history taking:
1. Note the patient’s age and occupation: both may be relevant
2. Ask about the onset of the pain:
When did the symptoms commence?
(b) Was the onset slow and insidious, rapid, or sudden? The latter is
strongly suggestive of mechanical factors.
Was there a history of an injury, such as, for example, a sudden twist
or strain, or a sneeze occurring when the patient was in a flexed
position? (This is a common history in cases of intervertebral disc
3. Ask about any directly relevant previous history:
(a) Is there a history of a previous similar attack?
(b) Is there a history of any previous trouble with the spine?
4. Ask about the site and nature of the pain:
Where is the pain situated? Is it well localized, or is it diffuse?
(b) Is the pain always present, or does it disappear at times? The latter is
suggestive of a mechanical cause.
Are there any factors that aggravate or alleviate the pain? Note that
with mechanical Lower back pain bending or sudden movement may make
the pain worse, whereas lying flat, particularly on a hard surface, or
applying local heat, or even sitting, may relieve the pain. In the case
of backache associated with spinal pathology — particularly in the case
of tumour, infections or inflammatory disease — the patient may be
unable to find a position of rest; constant night pain (as distinct from
short-lived pain when turning in bed) is a feature.