Clerking back pain

Even after thoroughly clerking back pain, a lot of times, the actual cause is still not apparent. However, initial assessment usually rules out serious underlying conditions.

History

Obtain the patient’s biodata, taking note of the age especially.

With the mnemonic ‘SOCRATES’ as a guide, ask about the following to characterise the pain:

  • Site of the pain; whether the pain is localised or diffuse
  • Onset of the pain; whether sudden or gradual
  • Character of the pain: dull, sharp or stabbing
  • Whether the pain Radiates or migrates down the back or lower limbs
  • Associated symptoms like bone pain, urinary symptoms 
  • Timing of the pain; whether worse at any time, continuously present, or intermittently with pain-free periods in between.
  • Exacerbating and relieving factors
  • Severity of the pain, usually using a pain scale

More specific questions may then be asked as follows depending on the possible differentials already generated after characterising the pain. 

Common differentials:

  • Lumbar muscular strain/sprain:

sharp intense pain for 1 to 2 days; muscle spasm; most patients recover within 3 months

  • Herniated nucleus pulposus (HNP):

radiating lower extremity pain in a dermatomal distribution; history of bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the cauda equina

  • Spinal stenosis:

intermittent pain radiating to the thigh or legs, worse with prolonged standing, activity, or lumbar extension; pain is typically relieved by sitting, lying down, and/or lumbar flexion; patient may describe intermittent burning, numbness, heaviness, or weakness in their legs, unilateral or bilateral radicular pain, motor deficits, bowel and bladder dysfunction, and back and buttock pain with standing and ambulation

  • Compression fracture:

typically history of trauma, although acute event not always recalled; pain at rest and at night, previous history of fractures (e.g., distal radius, hip or other vertebral compression fractures)

  • Degenerative disc disease or facet arthropathy:

symptoms worsen with forward flexion, coughing/sneezing, or heavy lifting; facet mediated pain is typically worse with extension

Uncommon:

  • Spondylolysis and/or spondylolisthesis:

most are asymptomatic; pain in the lower back with occasional radiation to the posterior thigh and aggravated by extension

  • Vertebral discitis/osteomyelitis:

infection should be considered for patients with a history of fever, weight loss, and non-mechanical back pain (i.e., pain that occurs even without motion, particularly at rest and at night); hx of intravenous drug use, immunosuppression, or diabetes

  • Malignancy:

history of malignancy (breast, lung, prostate, thyroid, kidney), age >50 years, back pain at night and at rest; may have neurological deficits if tumour destruction is extensive and causes neurological compression

  • Inflammatory spondyloarthropathy:

male predominance in ankylosing spondylitis, early-morning stiffness, nocturnal back pain, fatigue, weight loss, diffuse non-specific pain radiating bilaterally to buttocks; pain improves after physical activity; may have FHx of arthritis or psoriasis; hx of inflammatory bowel disease may be suggestive of enteropathic arthritis

  • Connective tissue disease:

arthralgias, polyarthritis, systemic symptoms of fever, weight loss, and fatigue

  • Aortic abdominal aneurysm:

sudden onset of intermittent or continuous abdominal pain, radiating to the back; patient may collapse; older age; hx of cardiovascular disease

  • Pancreatitis:

sudden onset of epigastric pain; radiates to back; may be relieved by sitting forwards; associated with nausea and vomiting; hx of alcohol use or gallstones

  • Pyelonephritis:

urinary symptoms of dysuria, frequency, and hesitancy; flank pain may radiate to back; fever, chills, fatigue

  • Renal colic:

severe, acute flank pain that may radiate to the ipsilateral groin; associated nausea and vomiting; hx of volume depletion or stone-inducing medications

  • Peptic ulcer disease:

epigastric, burning pain; radiates to back; usually occurs in association with meals; may be relieved by antacids; haematemesis or melaena in advanced disease

Physical Examination

A general physical examination is followed by a musculoskeletal examination, and then any other suspected implicated system based on the history.

  • Lumbar muscular strain/sprain:

benign physical examination, diagnosis is one of exclusion

  • Herniated nucleus pulposus (HNP):

positive straight-leg raise or contralateral straight leg (reproduced below 60° of hip flexion); positive femoral stretch test may suggest upper lumbar disc herniation

  • Spinal stenosis:

patients walk with a forward flexed gait; patients with vascular claudication have diminished pulses and typical skin changes, such as mottled discolouration, thinning and shiny skin

  • Compression fracture:

tenderness to palpation over the midline; increased kyphosis, normal neurological examination unless there is retropulsion of bone into the neural elements, such as in burst fractures

  • Degenerative disc disease or facet arthropathy:

decreased range of motion due to pain and mild tenderness on palpation; pain is reproduced with flexion in discogenic pain and extension with facet arthropathy

Uncommon:

  • Spondylolysis and/or spondylolisthesis:

exaggerated lordosis, heart-shaped buttock, or midline step-off of the spinous processes may be present; pain with single-leg hyperextension test

  • Vertebral discitis/osteomyelitis:

generalised appearance of malaise; fever; localised tenderness present particularly with percussion; neurological findings absent

  • Malignancy:

generalised systemic symptoms including fevers/chills, weight loss, and malaise; focal tenderness and/or neurological deficits may be present depending on tumour size and location

  • Inflammatory spondyloarthropathy:

axial spondyloarthropathy or ankylosing spondylitis: stiffness of spine with kyphosis, limited range of movement of lower spine, tenderness on palpation; extra-articular signs (e.g., psoriasis, uveitis) may be present

  • Connective tissue disease:

evidence of organ involvement (e.g., rash, lymphadenopathy, wheezing, oesophageal dysmotility, malabsorption, joint tenderness, joint effusion and swelling, uveitis, conjunctivitis)

  • Aortic abdominal aneurysm:

pulsatile abdominal mass, hypotension or hypertension, tachycardia

  • Pancreatitis:

tachycardia, fever, jaundice, tenderness/guarding of abdomen

  • Pyelonephritis:

flank or costovertebral tenderness

  • Renal colic:

flank or costovertebral angle tenderness; may have macroscopic haematuria

  • Peptic ulcer disease:

epigastric tenderness, may be melaena on rectal examination.

Appropriate lab investigations may then be requested to strengthen clinical impression made at the end of history and examination.