Your doctor needs a complete picture of you and your back pain before he or she can get to the bottom of the problem. During the telling of your story and a physical examination, any one fact may be the clue that solves the puzzle of your back pain. In fact, most diagnoses are established during the history portion of the examination. The rest of the process identifies the correct diagnosis from the variety of possibilities developed by your description of your back pain.
Your age and gender, naturally, are important to a correct diagnosis. For example, more herniated discs occur between the ages of twenty-five and forty-five. Conversely, approximately 80 percent of people with cancer of the spine are fifty or older. Men have back pain more frequently than women, some of which may be explained by occupational exposure to more physically strenuous work. Certain disorders occur exclusively or predominantly in women, such as back pain during pregnancy and osteoporosis. (Men are at risk for this thinning of the bones, too, but the risk is greater for postmenopausal women.)
The history you provide is the most important part of the diagnostic process. The more complete the information, the greater its value. Every subsequent step is used to confirm the ideas and even hunches developed during the medical history. The first part of your history, the chief complaint, is your description of what brought you to the doctor. In most circumstances, the chief complaint is “I have a pain in my back.” Another frequent chief complaint is “I have a pain in my back that runs down my leg to my foot.” Your description guides the doctor’s questions.
Telling your story allows you to describe those events that you believe are most important in explaining the evolution of your back pain. Your doctor may or may not ask questions as you progress with your narrative. A physician may interrupt to ask a question if a particular point is essential to differentiate between diagnostic possibilities. For example, you may be asked: “Did the pain that ran down your leg go to your big toe or small toe?”
Help yourself and your doctor by gathering your thoughts about your back pain and organizing the description of your symptoms and questions you want to ask. Perhaps you can store the information in your head, but writing it down may be more useful. By carefully thinking about your back pain, you will have organized information necessary to start the diagnostic process. Also, bring a list of your medicines—or the actual medicines—with you and the names and addresses of your other healthcare providers.
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QUESTIONS TO HELP YOU FIND THE CAUSE
When Did the Pain Begin?
Acute onset of back pain is most closely associated with a specific episode of trauma to the spine, such as lifting a heavy bag of groceries from the back seat of your car. In contrast, systemic illnesses cause pain that is gradual in onset. People with inflammatory arthritis of the spine (spondyloarthropathy) may have had back stiffness and pain for six months or longer when first evaluated for their spine symptoms.
How Long Does It Last and How Often Does It Occur?
The initial episodes of mechanical low back pain resolve over days. With successive episodes, the duration of pain increases to a week and then a month; episodes may be intermittent over time. The frequency of pain follows environmental exposure, such as shoveling snow in winter or several hours of weeding the garden in the summer.
For medical low back pain, the important characteristic is duration, not frequency. As opposed to the short duration of mechanical low back pain, medical low back pain is more persistent. It may last for months, with minimal variation in discomfort.
Where Is It Located and Where Else Do You Feel It?
Most low back pain is localized between the lower rib and buttocks, where the spinal curve (lordosis) is greatest. Frequently, the pain starts to one side of the spine and quickly spreads across the low back. The fleshy part of the back is more commonly affected than the bones themselves. Occasionally pain will be present on both sides of the spine, near the “dimples” just above the buttocks, over the sacroiliac joints. Sometimes the location and radiation of pain is very difficult to describe because it is referred pain, that is, it comes from somewhere else (see chapter 1). Pain can move side to side, or up and down the leg. However, the most important facts are where the pain first started and how far the pain has spread.
What Makes It Feel Worse or Better?
Mechanical low back pain disorders improve with rest and worsen with certain activities. Muscle injuries are aggravated with stretching and are relieved when the muscle is at rest and therefore shortened in length. This resting position allows healing to take place. For example, a thirty-two-year-old man who picked up a heavy box of papers experienced immediate onset of right-sided low back pain. His pain increased with any movement of his spine forward (flexed) or to the left side. These motions stretched the injured muscles on the right side of his spine, thereby intensifying the pain. He was most comfortable when resting in bed or standing with a tilt to the right side.
Anything that increases pressure on discs will also increase compression of spinal nerves. If you have a herniated disc, you have increased pain with sitting, sneezing, coughing, or having a bowel movement. Disc pressure is reduced when you are standing up.
If you have more back pain standing, then you could have arthritis of the back joints. You probably have less pain when you sit. When leg pain occurs with standing, spinal stenosis is the most common diagnosis. Walking for a distance may be associated with leg pain. If you sit down or rest against a structure with your spine bent forward, your leg pain decreases.
Alleviating and aggravating factors for medical low back pain are more complicated. Inflammatory arthritis can hurt more when you are not moving and hurt less with walking, bending, and stretching. Others with medical low back pain have severe low back pain unless they stay motionless. They may also have other signs of a serious illness such as fever, chills, or weight loss (remember those red flags).
What Time of Day or Night Does It Occur?
Systemic disorders, like inflammatory arthritis, are most symptomatic during sleep or in the early morning while getting out of bed. Stiffness and pain are improved with normal movement as the day progresses. Conversely, people with tumors of the spine have increased pain when lying flat in bed. They usually sit in a chair to sleep, or they may walk around to relieve their pain.
Mechanical disorders become more symptomatic with use, and the greatest pain occurs at the end of the day.
What Is the Quality and Intensity?
A wide variety of terms are used to describe pain. Skin disorders cause local burning pain on the surface of the body. Disorders of the bones, joints, muscles, and ligaments cause a deep, dull ache that is most intense over the involved site. A cramping pain is associated with reflex contraction of an injured muscle, or from a muscle chronically contracted to protect an injured portion of the lumbar spine, like a facet joint.
Pain from nerve compression (radicular pain) has a sharp, shooting, burning quality that follows the distribution of the compressed nerve. This kind of pain is associated with sciatica, compression of the sciatic nerve. Other forms of nerve pain occur with direct trauma to the nerve or secondary to changes in the metabolism of the nerve, a situation associated with diabetes. This form of pain has a tingling and crushing component that is unaffected by physical position of the body but is intensified by touching of the skin supplied by the nerve. The severity of the pain may continue even after the stimulus is gone.
Kidney stones cause a recurrent gripping pain that rises quickly to its greatest intensity in twenty to thirty seconds, lasts one to two minutes, and then quickly resolves. Throbbing pain is associated with disorders of blood vessels. A tearing sensation is a potential sign of blood vessel injury that may cause loss of blood flow to structures in the lower extremities.
Who Else in Your Family Has It?
Most disorders of the lumbar spine are not genetic. However, disc herniations and sciatica occurring in many family members suggests a relationship between your back and leg pain and family characteristics. The group of conditions known as inflammatory arthritis of the spine (spondyloarthropathies) has a genetic predisposition and a test could determine if you are at risk. Therefore, mention these disorders to your doctor as part of your family history.
How Does Your Work or Lifestyle Affect It?
Your profession can determine your risk for developing low back pain. Other risk factors aside, heavy lifting and carrying on the job add to the risk for developing mechanical low back pain. Onset of pain while at work has potential implications for qualifying for worker’s compensation. Be sure to tell your doctor if you see a relationship between your job and your back pain. If you sit all day at a computer, you may develop low back pain, and there’s been lots of talk lately about ergonomics, posture chairs, and mouse pads. (See my Back School FAQ for information about chairs.)
Smoking tobacco and drinking alcohol are implicated in osteoporosis; they weaken the bones in your spine. (Alcohol may also limit the use of certain medications used to control pain and inflammation.) Think about the way your back pain affects activities and relationships with the important people in your life. Perhaps you are unable to participate in your basketball or bowling league or swing dancing. Back pain often has a detrimental effect on sexual relationships. When any simple motion increases your pain it is difficult to enjoy sex. Discuss these social and personal difficulties honestly with your physician, so he or she can help you.
Past and Present Medical History
Your medical history necessarily deals with past and current illnesses. For example, a history of cancer may have great significance in the onset of new back pain. A previous injury, such as slipping and falling on ice, may be the initiating event in the development of a herniated disc. A history of diabetes increases risk for developing nerve irritation (neuropathy) that causes back and leg pain. Psoriasis and inflammatory bowel disease are associated with inflammatory arthritis of the spine. Eye inflammation may also be linked with back disorders. Illnesses such as hypertension may limit the use of certain medications because of side effects. Environmental or drug allergies should be mentioned as well.
From Back in Control by Dr. David Borenstein