Making Sense of Low Back Pain

Hamilton Hall, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Yoga Raja Rampersaud, MD, FRCSC,3

1Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.


Abstract: In 1987, the Quebec Taskforce noted, "Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment." Identifying these patterns begins with the patient's history: "Where is your pain the worst?" "Is your pain constant or intermittent?" "Has there been any change in your bowel or bladder function?" This questioning establishes the mechanical nature of the pain, and a physical examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A failure of the results to fit into one of four syndromes—two back dominant and two leg dominant—suggests a non-mechanical or more complex problem.
Key Words:patterns of back pain, pain location, pain characteristics, history, physical examination.

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90% of Low Back Pain is not related to serious pathology and does not require surgical intervention.
Mechanical Low Back Pain can be categorized to patterns that are identified in history and confirmed in the physical examination.
Findings on radiological imaging including x-ray, CT scan and MRI have not been found to correlate to pain-generating pathology, can increase patient anxiety and detract from successful recovery.
A concise history starts with two questions: "Where is your pain the worst?" and "Is your pain constant or intermittent?"
The goal of physical examination is to verify or refute the diagnostic assumptions made on the basis of the history.
Managing low back pain is not a one-time event. Low back pain is a chronic condition that demands ongoing care and follow-up.
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