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Back Pain

There is emerging data on test utility, especially in regard to expensive spinal imaging, which facilitates teaching rational, cost-effective test ordering. Back pain requires skillful management and patient education which facilitates the teaching of these competencies.



Describe and discuss:

  • the bony, soft tissue, vascular, and neuroanatomy of the spine
  • the dermatomes corresponding to spinal roots
  • the pathophysiology of strain, osteoporosis, disc degeneration, and spinal metastasis


  • basic physical examination of the spine
  • basic neurologic examination of the lower extremities
  • basic communication skills


Apply Medical Knowledge in the Clinical Encounter

1.     Describe the signs and symptoms that suggest back pain.

2.     Describe the clinical features that help to differentiate one etiology from another.

3.     Describe how neuroimaging studies would help in the evaluation of back pain, including their indications, limitations, and cost.

4.     Describe the natural history of important causes of back pain, especially those which require urgent attention (cauda equina syndrome, epidural abscess, spinal metastasis) and those which do not (strain, minor disc herniation).

5.     Describe how the various etiologies respond to different therapies.

6.     Describe approaches to limiting disability and chronicity.



1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including:

  • elicitation of key elements of the history helpful in establishing etiology
  • ruling out “must-not-miss” causes
  • determining degree of disability

2.     Perform a physical exam to establish the diagnosis and severity of disease, including detailed lower extremity neuro exam.

3.     Perform a mental status exam.

4.     Recommend when to order diagnostic laboratory and imaging studies, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and interpret the results (with consultation).

5.     Generate a differential diagnosis recognizing specific history and physical exam findings that suggest back pain.

6.     Identify the patient’s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients.

7.     Record, present, research, critique, and manage clinical information.


Develop a Management Plan

Make decisions about what to include from the following items and explain why each item selected should be included:

1.     Provide necessary patient education including preventive measures such as the proper use of bed rest and exercise, as well as the mechanics of lifting, standing, and sitting.

2.     Describe treatment measures such as the appropriate prescribing of analgesics and muscle relaxants as well as appropriate use of consultants and referral to specialists.

3.     Recommend for psychological support if indicated.

4.     Access and utilize appropriate information systems to ascertain information about health system and community resources.

5.     Plan for follow-up.

6.     Formulate a prognosis for the patient with back pain and communicate it to the patient in a caring and compassionate manner.

7.     Consider the cost-effectiveness of the management plan.


Differential Diagnosis

  • muscle strain
  • lumbar disc herniation
  • pyelonephritis
  • nephrolithiasis
  • vertebral compression fracture
  • spinal metastasis
  • spinal epidural abscess
  • osteomyelitis
  • aortic aneurysm
  • cauda equina syndrome
  • ankylosis spondylitis