3 Questions You Need to Ask About Low Back Pain

February 16, 2016

Another complaint of low back pain, another day in primary care. But make sure you ask these questions every time.

[[{"type":"media","view_mode":"media_crop","fid":"45898","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5674196185600","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5282","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 249px; width: 250px; float: right;","title":"©Lightspring/Shutterstock.com ","typeof":"foaf:Image"}}]]On any given day, primary care physicians (PCPs) evaluate and recommend treatment for at least several patients who present with low back pain (LBP). In fact, the lifetime incidence of LBP is estimated to be between 51% and 84%.1 A recent review directed at primary care, “Evaluation and Treatment of Low Back Pain: A Clinically focused Review for Primary care Specialists,” published in the Mayo Clinic Proceedings, is a well-informed guide on the topic.2

Here I offer brief answers to 3 essential questions that must be addressed during a primary care work up for LBP.

1. After history and physical, what are “red flag” symptoms/signs?

When interviewing, ask about important risk factors for the more dangerous etiologies for LBP. For example, vertebral compression fractures are associated with female sex, age greater than 70 years, trauma, and corticosteroid use. Has there been recent significant trauma? Is there a history of malignancy? On examination, is there a contusion? When examining the patient, a finding of radiculopathy and bowel/bladder complaints are disturbing accompaniments. Another red flag is any sign that LBP may be a result of cauda equina syndrome. This is a surgical emergency and is associated with sudden onset of axial or radicular pain, leg weakness, bowel and/or bladder dysfunction, and loss of perineal sensation, which may manifest in saddle anesthesia.

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2. What symptoms best predict lumbar spinal stenosis?

The symptom to explore that may be the best predictor of this problem is neurogenic claudication. The complaints that accompany neurogenic claudication include: onset or worsening of radicular pain when standing or walking and pain rapidly improves with sitting. Many of these patients are older than 65 years of age. They often complain of bilateral buttock and leg pain.

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3. When is diagnostic testing appropriate?

Early imaging of any type has never been demonstrated to improve outcomes in persons with LBP. An excellent refernce in this regard is a guideline published by the American College of Physicians.3 Immediate imaging should be reserved for persons with cancer or major risk factors for cancer; concern about the presence of a spinal infection; and severe neurologic defects or signs of cauda equina syndrome. Imaging can be deferred, but still completed later for people with risk factors for spinal inflammation, compression fractures, signs of radiculopathy or signs of spinal stenosis. If a patient’s pain improves or resolves by 1 month after treatment, no imaging is necessary.

This short question and answer about LBP covers only a small amount of the article. Justice to the review will be done best by your own perusal. The published manuscript also covers anatomy and offers evidence-based treatment options. For the office-based PCP, it can serve as a great source of reference for a most common clinical problem.


1. Murray CJ, Atkinson C, Bhalla K, et al. US burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013; 310:591-608.

2. Hooten WM, Cohen SP. Evaluation and treatment of low back pain: a clinically focused review for primary care specialists. Mayo Clin. Proc. 2015; 90:1699-1718.

3. Chou R, Qaseem A, Owens DK, et al Clinical Guidelines Committee of the American College of Physicians. Diagnostic Imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011; 154:181-189.