Spinal Pain

Assessment and
Diagnosis
Sanjeeva Gupta
MD; DNB; FRCA; FIPP; FFPMRCA

Consultant in Pain Medicine

Bradford Teaching Hospitals NHS
Trust

Spinal Pain
Assessment and Diagnosis
Pain in Cervical, lumbar and SIJ
History
Red Flags
Cauda Equina

Clinical Examination
Investigations
Diagnosis
Management

History
Age and gender of the patient
How did the spinal pain start?
History of Trauma or road traffic
accident
Aggravating and relieving factors
Character of pain nociceptive
and/or neuropathic pain

History
Family history of spinal pain and inflammatory
conditions
Family history of infective diseases like
tuberculosis
Previous and current treatment for spinal pain
History of co-morbidities: respiratory, cardiac,
central nervous system, gastrointestinal,
renal, hepatic, etc, as can influence choice of
pharmacotherapy
Drug allergies

History - Red Flags

History

Previous history malignancy

Age >16 or >50 with NEW onset
pain
Weight loss (unexplained)
Previous longstanding steroid use
Recent serious illness
Recent significant infection

History - Red Flags

Symptoms
Non-mechanical pain (worse at
rest)
Thoracic pain
Fevers/ rigors
General malaise
Urinary retention
Faecal incontinence

Red Flags (Examination )

Signs
Saddle anaesthesia
Loss of anal tone
Multilevel sensory-motor
deficits

Cauda Equina
Symptoms
Urinary retention
Faecal incontinence

Signs
Saddle anaesthesia
Loss of anal tone
Multilevel sensory-motor deficits

History
Medications

Examination
Neurological examination
Rule out red flags
Any neurological signs to confirm radicular
/neuropathic pain?
Midline pain in younger patients, worse on
flexion may be discogenic pain
Paraspinal pain worse on lumbar spine
extension and rotation may be of facet joint
origin
Lower back pain in a multiparous female
patient, most severe below L5 spinal level is
more likely to be sacroiliac joint mediated

Investigations
Blood tests for inflammatory markers
Role of X-Ray is limited, unless history of
trauma
CT Scan helpful when bone related
causes are suspected
Role of Ultrasound is limited unless to
rule out other abdominal causes of LBP
MRI scan is helpful when planning
injection therapy or surgery to define the
target level
Nerve conduction studies
Precision Diagnostic injections /

Diagnosis
Pain from
Facet joints
Discs
Sacroiliac Joints
Muscles
Ligaments
Abdominal organs
Pelvic Organs
Thoracic organs
Predominant radicular pain i.e. sciatica
Inflammatory conditions i.e. Rheumatoid
Arthritis, Ankylosing spondylitis
Low Back Pain not a diagnosis but a condition

Management

Advice/self management
Pharmacotherapy
Consider and treat neuropathic pain
Complementary therapy
Physical therapy
Referral to specialist centre if pain
is not improving or the patient has
radicular pain not improving with
pharmacotherapy

Role of Family Physician

Rule out red flags
Reassure and educate patients who
present with acute low back pain as often
the pain is likely to settle with
conservative management
Treat pain aggressively to prevent
chronicity i.e. frequent follow up to review
progress
If pain not getting better reassess in two
weeks of initial presentation
Early referral to physical therapy

Role of Family Physician

Advice regarding healthy living, smoking
cessation as evidence suggest poor
outcome and recovery in smokers
Identify if patient has radicular pain as
treatment is different
Explain to the patient the cause of pain and
its management, shared decision making
will help to develop a management plan
that both the patient and clinician support
Refer to specialist centre if pain not
controlled

Summary
Assessment
History
Examination
Investigations

Diagnosis
Management

Thank You