General Medical History. A conventional medical history includes: family history; personal habits (diet, sleep, medications, supplement use, etc.); social history (relationships, work, etc.); review of systems (other relevant medical issues such as heart disease, diabetes, other areas of pain, pelvic/genital/urinary problems, intestinal disorders, neurologic, hormonal, musculoskeletal, infectious, auto-immune or other chronic inflammatory conditions.)
Specific Pain-Related History. The specific evaluation for pain includes detailed description of the characteristics of pain, including: the onset of pain, its location, duration, severity and quality (shooting, stabbing, dull ache, throbbing, etc.), when it occurs, factors that relieve (ameliorate) or enhance (aggravate) pain (such as stress, trauma, disease, etc.), interference with daily function, treatments tried to date, the meaning of the pain to the patient, and other symptoms associated with the pain.
The integrative approach takes particular effort to obtain an expansive medical history. Particular attention is paid to the psychosocial history. Time is spent talking with the patient in order to gain an understanding of emotional factors, beliefs and attitudes, social and family relationships, past or current stressful life events, nutrition, occupational issues, activity level and spiritual concerns that may be contributing to the symptom of back pain. Such factors as depression, anxiety, stress, insomnia, feelings of helplessness, fear, and misconceptions about back pain are very important to explore.
The physical examination for low back pain begins with taking vital signs (including pulse rate, blood pressure and temperature). The gait (how a person walks) and station (how a person sits and stands) are evaluated. Hands-on palpation will include examination of the spine (for pain, curvature, etc) and abdomen (to rule out referred pain from internal abnormalities). The examination will also include a detailed analysis of abnormal movements of the back, soft tissue abnormalities, restricted range of motion in the back, hips or legs, or the presence of muscle tenderness and trigger points. A neurologic exam of the spine, trunk, and lower body will look at strength, sensation (ability to perceive pain, light touch, vibratory sense, two-point discrimination, proprioception), reflexes, and coordination.
Diagnostic tests may be needed in selected patients. Occasionally, an evaluation for a systemic illness is appropriate, and may involve testing of the blood and urine. More often, low back pain is evaluated with imaging studies and/or electrodiagnostic testing.
- X-rays: These are the most basic imaging study. They are very good for looking at bony structures-for arthritis, narrowing of the nerve outlet (foramen) as it leaves the spine, bone spurs, narrowing of the disc space, osteoporosis, and spinal misalignment. It is less capable of identifying soft tissues, nerves and discs.
- Computerized Axial Tomography (CT or CAT) scans: A form of X-ray that takes "fine cuts" of the low back (or any other area). It is much more precise than an X-ray---providing a better image of the disc, internal spine and soft tissues, and finer resolution of all structures. With intravenous dye added it is also able to image the circulation in the imaged area.
- Magnetic Resonance Imaging (MRI) scans: This technique applies a magnetic field to the area---aligning all cells north-south. When the field is turned off, the cells assume their normal alignment and give off energy that the machine detects, providing a detailed image of the area. This technique is similar to CT scan in the definition of bones and discs, but is better at imaging the nerves and soft tissues (ligaments, tendons and muscles). Its use, versus the CT, depends on the combination of tissues that the clinician needs to look at. Like the CT, an MRI can be done with intravenous contrast to highlight the circulation.
- Myelogram: This technique is seldom used anymore with the advent of CTs and MRIs. It consists of injecting a contrast medium (dye) into the fluid of the spine to light up abnormalities within the canal. It is still used occasionally by spine surgeons preoperatively to better assess abnormal areas in the spine.
- Electrodiagnostic testing: An electromyogram (also called an EMG) evaluates the integrity of the muscle and the nerves that supply it. Nerve conduction tests evaluate the integrity of the larger nerves. These two tests can provide information about the extent to which a spinal disorder has involved nerve roots or nerves. The EMG involves the insertion of needles into specific muscles. The needles are connected by wires to a machine that detects electrical activity.