Overview of Lumbar Spine Assessment

Original Editor - Shala Cunningham Top Contributors - Jess Bell and Stacy Schiurring

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Introduction

Low back pain is the leading cause of disability in most countries, with a point prevalence of 11.9%. Years lived with disability caused by low back pain are continuing to increase, and the socioeconomic burden of low back pain is high. Around half of all individuals with low back pain seek care, and it is estimated that around 60 percent of patients presenting to a primary care physician have a complaint of low back pain. It is, therefore, important that rehabilitation providers have a comprehensive understanding of the lumbar spine evaluation. This page provides an overview of this evaluation and includes links for more information.

History

When assessing patients with low back pain, age can help us formulate hypothetical diagnoses about the potential pathoanatomical cause of pain:

• individuals aged less than 20 years old: low back pain is rare (apart from muscle sprains), so check for anomalies (e.g. spondylolisthesis)
• individuals aged between 20 and 50 years: more likely a disc pathology, muscle strain or instability
• individuals aged more than 50 years: more likely associated with degeneration, so consider conditions such as arthritis or spondylosis

The mnemonic L-M-N-O-P-Q-R-S-T is used to cover the key aspects you should consider when taking a patient’s history.

L: location of symptoms and level of functional impairment

We want to know the exact location of pain - is it general or localised. Does it radiate or move? It is important to fill in a body chart to determine exactly where a patient does and does NOT have symptoms.

M: medical factors (medications) and mechanism of injury

We need to find out what medications the patient is taking (including those prescribed by physicians or other healthcare providers or supplements) and what co-morbidities they may have.

We also want to determine when and how the injury occurred. For low back pain, consider the following questions:

• Was the patient lifting something?
• Did they fall?
• What happened when they first noticed their low back pain?
• If they have experienced a traumatic injury (e.g. a fall / motor vehicle accident), do they have any neurological symptoms

Red flags: no incident / accident with sudden onset of severe pain AND neurological symptoms following a trauma

N: neurological symptoms

Neurological symptoms include numbness, tingling, burning, and electrifying pain. When neurological symptoms are present, we need to determine if they are constant or intermittent and if they follow a dermatomal or a peripheral nerve pattern. Consider also if symptoms are related to the position of the patient’s back (i.e. certain activities make certain symptoms worse).

Subjective red flag symptoms related to cauda equina are loss of sensation in the saddle / perineal region, urinary retention/overflow incontinence and faecal incontinence.

O: occupation, including limitations

Are there any work- or activity-related factors that are relevant?

P: palliating and provocating symptoms

Find out from the patient exactly what makes their symptoms better or worse. It is important to ask how long it takes for symptoms to calm down once they are irritated / increased.

Red flag symptom: symptoms that are constant and unrelenting.

Q: quality of symptoms/pain

For the low back, consider if there is numbness, tingling, unusual sensations (e.g. ants crawling on skin) etc.

R: radiation of symptoms

Questions to consider for radiating symptoms are:

• Where do the symptoms radiate?
• Are radiating symptoms provoked by activities or position?
• How long do symptoms last?

Red flag symptom: radiating symptoms down multiple dermatomes (ruling out peripheral nerve distributions first).

S: severity of symptoms

It can be helpful to use scales such as the Visual Analogue Scale or the Numeric Pain Rating Scale, but also consider how symptoms affect function and activities.

Red flag symptom: sudden onset of severe pain without incident or accident.

T: timing of symptoms

Consider the sequence of symptoms and the progression fo symptoms throughout the day.

Red flag symptom: pain that interrupts sleep or is worse at night (this pain isn’t related to sleeping position) AND constant pain

Red Flags Specific to Low Back Pain

Despite a lack of consensus, red flags are still considered the most reliable clinical indicator of potential serious pathology. In the lumbar spine, we use red flags to help detect pathologies such as fracture, infection and cancer. Common red flags in the back are:

• aged over 50 years
• history of trauma
• immunosuppression
• night pain / pain at rest
• lower extremity neurological deficits
• history of cancer
• saddle anaesthesia
• bladder / bowel dysfunction
• fever / chills
• night sweats
• weight loss
• recent infection

Self-Assessment Questionnaires for Low Back Pain

• Oswestry Disability Index / Modified Oswestry Disability Questionnaire
• Roland-Morris Disability Questionnaire
• Patient Specific Functional Scale
• Fear Avoidance Belief Questionnaire
• Pain Catastrophizing Scale