History and exam

Key diagnostic factors

common

obesity, stress, and psychiatric comorbidities

There is a statistically significant association between overweight/obesity and increased risk for lower back pain.[25][26][27]

Presence of a psychiatric comorbidity (e.g., depression) may predict, or be associated with, disabling low back pain.[34][35]​ Patients may report depression, anxiety, family or work stressors, or fear-avoidance behaviors.

history of prior lower back pain

Prior lower back pain episodes are related to the current episode to diagnose recurrent lower back pain.

Estimates of recurrence of lower back pain at 1 year (including transformation of acute lower back pain into either recurrent or chronic pain) range from 24% to 80%.[8][15][16]

History of any previous therapies should be obtained, including physical therapy, acupuncture, massage, transcutaneous electrical nerve stimulation, medications, injections, spinal manipulation, or surgery.

pain radiation does not extend beyond the knee

Typically, musculoskeletal lower back pain does not radiate to the legs. If it does, it does not travel beyond the knee.

If pain is located below the knee, it cannot solely be attributed to musculoskeletal lower back pain, and the differential broadens to include pathology such as radiculopathy, spinal stenosis, peripheral neuropathy, vascular claudication, and pathology of the lower extremities.[3]

absence of red-flag symptoms

The presumptive diagnosis is nonspecific lower back pain if red flags are absent or imaging is unremarkable on follow-up.

Imaging studies and additional investigations are needed for patients presenting with red flags: recent significant trauma; unexplained weight loss; immunosuppression; history of cancer; intravenous drug use; prolonged use of corticosteroids; minor fall or heavy lift in a potentially osteoporotic or elderly person; urinary tract infection; focal neurologic deficit with progressive or disabling symptoms; acute onset of urinary retention or overflow incontinence; loss of anal sphincter tone or fecal incontinence; saddle anesthesia; global or progressive motor weakness in the lower limbs; or duration of lower back pain >6 weeks.[3][4]

absence of fever, fluctuance, exquisite tenderness to palpation

Absence of these signs does not rule out infection. If infection is suspected based on history, then imaging must be obtained.

sensory, motor, and deep-tendon reflex exams within normal limits

Some examinations have greater specificity than sensitivity; thus, a normal exam does not exclude neurologic involvement: ankle plantar flexor weakness (sensitivity 47%, specificity 76%); quadriceps weakness (sensitivity 40%, specificity 89%); abnormal ankle deep-tendon reflex (sensitivity 47%, specificity 90%); abnormal lower extremity sensation (sensitivity 50%, specificity 62%).[71]

negative straight- or crossed straight-leg raise test

The straight-leg raise (SLR) test has a sensitivity of 91% and specificity of 26%. The crossed straight-leg raise (CSLR) test has a sensitivity of 29% and specificity of 88%.[72]

To perform the SLR test, the supine patient's leg is raised with the knee extended. Test is positive when radiating leg pain travels distal to the knee ipsilateral to the lesion, indicating a radiculopathy.

For CSLR testing, pain occurs on raising the leg contralateral to the radicular lesion.

Other diagnostic factors

common

dull, gnawing, tearing, burning, or electric pain associated with muscle spasms

Patient is asked to describe the nature of their pain, including dull, gnawing, tearing, burning, electric, associated with muscle spasms. Nonspecific lower back pain can be described as any of these.

The type of pain may also lead to consideration of another pathology (e.g., a burning paresthesia in a dermatomal pattern along the low back, flank, and abdomen may suggest shingles).

lack of pain on flexion or relief on extension

Can suggest a particular subtype of nonspecific lower back pain, although evidence is lacking.

Pain on flexion and relief on extension may suggest disk disease or other anterior element pathology. Pain on extension and relief on flexion may suggest spinal stenosis, facet arthropathy, or other posterior element pathology.

uncommon

scoliosis or kyphosis

Can be observed in either standing or forward flexion positions. Usually, mild degrees of spine curvature do not contribute to pain but severe cases may be painful and warrant surgical consultation.

negative FABER, Gaenslen, or Schober testing

Tenderness to palpation at the sacroiliac joint and positive result for the FABER (flexion, abduction, and external rotation) and Gaenslen (maximal hip flexion plus contralateral hip extension) tests may suggest sacroiliac joint dysfunction; a positive Schober test indicates reduced lumbar flexion.

Risk factors

strong

obesity

There is a statistically significant association between overweight/obesity and increased risk for lower back pain.[25][26][27]​​

The greater mechanical stresses placed on spinal structures with increased body weight may explain this trend.

family history of degenerative disk disease

Genetics has been identified as an important risk factor in degenerative disk disease (DDD), as shown through twin studies.[28][29]

There is a strong association between certain collagen gene polymorphisms and lumbar DDD.[30][31]

poor musculotendinous flexibility and abnormal posture

Meta-analyses report an association between reduced lumbar lordosis and increased risk of developing lower back pain due to disk herniation or degeneration.[32][33]

stress and psychiatric comorbidities

Presence of a psychiatric comorbidity (e.g., depression or psychological stress) may predict, or be associated with, disabling low back pain.[34][35]​ Risk factors for poorest outcomes at 1 year are: maladaptive pain-coping behavior; nonorganic signs; functional impairment; general health status; and the presence of psychiatric comorbidities.[34]

A multivariate analysis reported an odds ratio of 2.52 for lower back pain incidence in those with psychological distress.[36] Depression was the single greatest baseline predictor of incident lower back pain, with a hazard ratio of 2.3 in an initially asymptomatic Veterans Affairs cohort.[10]

weak

increasing age

Lower back pain prevalence appears to peak between 40 and 69 years, and progressively decline thereafter.[12]

Decreased prevalence of benign back pain (following a peak in the sixth decade) was reported in an earlier systematic review.[37] However, severe back pain prevalence continued to increase with age.

Increased prevalence of lower back pain with age can be explained by cumulative wear and tear, degenerative changes such as loss of disk height, or osteoarthritic changes of facet joints.

female sex

Some studies suggest an increased prevalence of lower back pain among women.[12][38][39] However, other studies do not replicate this finding.[40][41]

Higher prevalence of low back pain in women may, in part, be attributable to increased prevalence of osteoporosis.

heavy physical and occupational activities

A prospective, longitudinal study in the UK revealed that lifting objects heavier than 11.4 kg (25 lb), pushing/pulling heavy objects, and prolonged periods of standing or walking were associated with a higher incidence of lower back pain, especially among female workers.[42]

These occupational activities result in lower back pain because of both acute injuries and cumulative stresses to the spinal anatomy.[43]

tobacco use

A large British cohort study suggested a positive association, but a Danish twin-control study failed to demonstrate a significant association between smoking and lower back pain.[36][44]

Potential mechanisms include strain from frequent coughing, osteoporotic changes attributed to tobacco, and disk malnutrition due to lower blood oxygenation.[45]

prolonged standing

Static standing is associated with an increased risk for developing lower back pain.[46][47]

Clinically relevant levels of low back symptoms may occur after prolonged standing (>40 minutes).[46]

Increased intervertebral disk compressive force when standing may contribute to development of low back pain.[48]

vitamin D levels

One meta-analysis found that vitamin D deficiency is associated with lower back pain severity, with stronger associations observed in younger women and those with severe levels of deficiency.[49]

Causality between low vitamin D levels and the onset of lower back pain was not demonstrated.[49]

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