Clues To Your Back Pain Diagnosis

Excerpt By Bruce Freundlich, MD, University of Pennsylvania, Philadelphia Healthology,
Special to ABCNEWS.com

Not all back pain is treated equally. How do you know if your problem is in your muscles or your discs?

Each year more than twelve million Americans go to their doctors with back pain complaints. Not all back pain is treated equally, however, and making a specific diagnosis allows us to create a more customized and effective treatment. Below are a series of ten questions I ask my patients. The answers help us get closer to the right diagnosis, and treatment.

1) Is the pain mechanical (due to abnormal stretching of muscles, tendons, and ligaments) or a disc problem?

I like to know if you lifted something heavier than usual or reached to get a package while in an awkward position, like pulling a shopping bag from the trunk of a car. Did you lift by bending straight over (the wrong way) or by bending your knees first and using your legs (the correct way)? Were you playing a sport when it happened? Any new type of exercise is always a good clue, even if you think it was mild and don't believe it had anything to do with the current problem. I always like to know what type of work you do, what your leisure activities are, and how you spend your day in general in order to uncover potential moments of extra physical exertion.

2) Is there the possibility of a bulging or ruptured disc?

As these injuries are extremely common, I want to know if this is a muscle and tendon problem or if there is the possibility of a bulging or ruptured vertebral disc. Although both these types of injuries can cause immediate pain that ranges from mild to severe, disc pain has some telltale characteristics. One common symptom, known as sciatica, is lower back pain associated with pain shooting down the back of one or both legs. Other signs that a nerve may be pinched are tingling or a burning sensation anywhere in the buttocks or legs, a sensation of numbness, or a feeling that part of the leg or foot is "asleep."

More serious signs that demand immediate medical attention include weakness in the lower extremities or loss of bladder or bowel control. If any of these are present, the odds are greater that pieces of a ruptured disc may be pushing on either individual nerves or the spinal cord itself.

3) What position makes the pain worse?

For each different cause of back pain, there are particular positions that will be most uncomfortable. This is an important clue in diagnosing the problem.

4) How old is the person?

Disc injury is more probable in those under fifty with acute back pain. The above-fifty population is more likely to have back pain from osteoarthritis, a common condition that effects the joints. Patients over sixty may experience spinal stenosis, a condition in which the spinal canal, which contains and protects the spinal cord and nerve roots, narrows and pinches the spinal cord and nerves. Patients complain of pain that radiates into the buttocks and thighs when they begin to walk. At first, this may occur after a few blocks but over time it may occur after less than half a block of walking.

5) Is the pain acute or chronic?

Knowing whether the pain is acute or chronic can help to get us closer to a diagnosis. Acute pain occurs for at most a few weeks, and is more likely to be mechanical in nature. Chronic pain may also be mechanically induced initially from an injury that was never properly rested and therefore never fully healed.

6) Is there an inflammatory condition?

Although inflammatory conditions of the back are uncommon, they are not rare, and are frequently misdiagnosed as mechanical back pain and therefore treated incorrectly. Symptoms of inflammatory back pain to look out for are: morning stiffness in the back that improves as the day goes on, pain that is worse in bed, and a psoriasis skin rash. There are a number of conditions associated with inflammation, and it is important to identify them, since treatment is markedly different than for the far more common mechanical conditions.

7) Does the back feel as if it is "going out," often with the same motion?

In young patients who may have hurt themselves playing sports, this sensation may be the sign of an unstable back with structural problems in the bones or soft tissues.

8) Is there pain in the buttock that is worse with sitting but also lying down?

This symptom may indicate gluteal bursitis. A bursitis is a small inflamed sack of fluid lodged between muscles. Although patients with disc problems may also complain of buttock pain that gets worse while sitting, they usually feel better lying down, when pressure is off the disc, and worse when they get up and move around, when pressure on the disc is greater.

9) Is there a sleep disturbance with pain in many other parts of the body besides the back?

Fibromyalgia, a common problem, particularly for young to middle-aged women, can result in back pain. It is characterized by poor sleep and generalized muscle aches accompanied by tender areas in the physical examination. This is an important syndrome to differentiate from other causes of back pain because patients tend to respond well to sleep medications.

10) Is there fever, more than ten percent body weight loss, muscle weakness, loss of bowel or bladder control, blood in the urine, or excruciating pain?

Though very rare, serious conditions do occur in the back or are manifested as lower back pain. These conditions include some tumors, abdominal aneurysms, kidney stones, and infections.

Conclusion

Using this approach, I can begin to distinguish the various causes of lower back pain in order to tailor treatments appropriately. The most important thing to remember is that all back pain, whether it is acute or long standing, is not the same. Patients' histories often offer simple and excellent clues to the most specific diagnoses.

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