Diagnostic triage for low back pain: a practical approach for primary care

Abstract

Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP - informed by a focused history and clinical examination - is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral. The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (< 1% of cases), radicular syndrome (∼ 5-10% of cases) or non-specific LBP (NSLBP), which represents 90-95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis. Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category. A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care. Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.

Primary care management of non‐specific low back pain: key messages from recent clinical guidelines

“…Imaging is still not indicated for non‐specific LBP. The complete diagnostic triage process for LBP in primary care has been comprehensively described by Bardin and colleagues in a recent article in the MJA 12 …”

“…Examples of red flags with limited diagnostic accuracy include thoracic pain, night pain and age over 50 years to screen for cancer 13 . The contemporary approach relies on a smaller set of red flags than previously and emphasises the use of clusters of red flags along with clinical expertise to guide decision making 12 …”

“…Although this approach appears to be simple, a survey of Australian general practice care using Bettering the Evaluation and Care of Health (BEACH) data revealed that only 20% of patients with LBP are provided with education and advice 23 . GPs should review patients' progress at 1–2 weeks to make sure they have recovered 12 …”

“…The complete diagnostic triage process for LBP in primary care has been comprehensively described by Bardin and colleagues in a recent article in the MJA. 12 What is new in recent guidelines is a warning on the limited diagnostic accuracy of some individual red flags that were previously endorsed. 7,9 Examples of red flags with limited diagnostic accuracy include thoracic pain, night pain and age over 50 years to screen for cancer.…”

The association between the weight of schoolbags and low back pain among schoolchildren: A systematic review, meta‐analysis and individual patient data meta‐analysis

“…Common low back pain (LBP) is defined as pain between the costal margins and the inferior gluteal folds, which is usually accompanied by painful limitation of movement, may be associated with pain referred down to the leg, and is not related to fracture, direct trauma or systemic diseases, such as neoplastic, infectious, vascular, metabolic or endocrine‐related processes (Bardin, King, & Maher, ; Hoy et al, ; Maher, Underwood, & Buchbinder, ).…”