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Low back pain (Diagnosis)

How the diagnosis of low back pain is made?

The doctor would start with a medical history followed by physical examination and tests which may include some blood investigations and imaging tests.

I. Clinical history:

The doctor would enquire about the onset, location, duration and severity of pain. He will also ask about any limitation of movement and history of any previous episode of pain or disease.

II. Physical examination:

• Inspection: where the doctor just sees the spine for any abnormality of the curvature. He would ask to stand straight and then bend forward. Normal curvature of spine should be slightly forward (anterior) in lower back region and slightly backward (posterior) in upper back region.

• Palpation: the doctor would mild press on the spine and adjacent region to detect the source of pain and to check for any palpable pathology.

The doctor would examine the back by performing certain maneuvers and examinations.

• Straight Leg Test

• Straight Leg Test Variant

• Tripod Sign

• Femoral Stretch Test (L2-4)

Neurological tests for lower limbs

These tests are usually done in cases where there is severe and long standing pain with possibility of nerve involvement. These tests involve following examinations to check for proper functioning of the nerves supplying lower limbs:

• Motor exam

• Sensory exam

• Reflex exam

Know more about clinical examination

III. Imaging and blood tests:

Imaging tests are not necessary in most of the cases. However, if there is a suspicion of specific condition causing back pain such as spinal stenosis or tumor, the doctor would like to get some investigations done. These tests may include the following:

1. X-ray: is usually the first imaging technique done. It is done to look for any abnormality of the curvature of spine, any abnormal shape of bones or any obvious fracture or dislocation of the bones.
Soft tissues such as muscles, spinal cord, ligaments, or bulging discs could not be seen on plain x-rays.

2. Computerized tomography (CT): uses X-rays to produce high quality 2D and 3D images of bones and muscles. It is very sensitive in detecting fractures and dislocation. It is not as good as MRI in detecting soft tissue abnormalities especially of the spinal cord.

3. Magnetic resonance imaging (MRI): this test is highly sensitive in detecting the abnormalities of soft tissue. It is the most sensitive and comprehensive test in detecting pathologies related to spine. It can very well detect abnormalities of IV discs, muscles, ligaments, spinal cord and nerves along with bony abnormalities. It is useful in detection of abnormalities such as disc herniation, spinal canal stenosis, radiculopathies, infection, tumor, inflammation etc.

4. Nerve studies: tests done measure electrical activity of the nerves and muscle response. It is done to confirm nerve compression.
The procedures include:, and studies.

• Electromyography (EMG): assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles.

• Nerve conduction studies (NCS): NCSs are often performed along with EMG to exclude conditions that can mimic radiculopathy.

• Evoked potential (EP): record the speed of nerve signal transmissions to the brain.

5. Bone scan: rarely the doctor might advise a bone scan to look for bone tumors or compression fractures caused by osteoporosis. It uses a small amount of radioactive material that is injected into the bloodstream which will collect in the areas of abnormality.

6. Blood tests: may be ordered to look for suggestion of infection, inflammation, or arthritis. The following tests may be ordered according to clinical suspicion:

• Complete blood count (CBC)

• Erythrocyte sedimentation rate (ESR)

• C-reactive protein

• HLA-B27 blood test: is done to check for ankylosing spondylitis or reactive arthritis associated with infection in another part of the body.


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