Lower back pain: clinical features and examination of patients

Abstract

This article discusses the clinical and paraclinical aspects of pain syndromes of the lumbosacral localization. The past medical history (including the working conditions of the patient and the presence of constant stress), physical and paraclinical examination, and assessment of psychological condition are important for establishing the correct diagnosis. It should be noted that there is no strict parallelism between the presence of back pain and the results of paraclinical examination of the spine. Therefore, the comprehensive assessment of the patient's clinical status, including the state of the musculoskeletal system, has a leading value for correct diagnosis and selection of therapy. Increasing pain when coughing or sneezing is noted in patients with discogenic pain syndromes; the development of pain along the root innervation often occurs simultaneously with the reduction of localized pain in the lumbar region. The diagnostic value of the radiography and neuroimaging data is unquestioned; however, these methods allow one to evaluate mainly the anatomical rather than pathophysiological changes. The direct dependence between the anatomical changes and the clinical situation is not typical of back pain. Magnetic resonance imaging (MRI) is when the injury level is unclear and the clinical examination data indicate pathology of the spinal cord or soft tissues. Moreover, MRI data help either to eliminate or confirm a tumor or the inflammatory nature of the pain syndrome. MRI is also an informative method in patients who have undergone surgery for vertebral pathology. Computed tomography is an effective diagnosis method only in those cases where the symptomatology clearly indicates the injury level and the bone changes are the pain cause with a high degree of probability. Electromyography (EMG) is very informative in patients with radiculopathies; it allows one to evaluate the pathophysiological changes in such patients. However, there usually is no need for using EMG upon clinically apparent lesion of the root. In a number of cases, additional information can be obtained using blocks with an analgesics or pain-provoking agents. The lack of close relation between the neuroimaging data and the clinical aspect of a disease may underlie the unreasonably broad application of these methods and overestimation of their results. Hence, there may emerge undue anxiety, since both the patient and the physician can set an unreasonably high value on paraclinical data, while the actual role of these results is insignificant. Upon that, an incorrect assessment of the situation results in inadequate and ineffective therapy.

Keywords

• back pain
• diagnosis
• differential diagnosis.