Discussion
The need for a systematic approach to back pain has long been acknowledged in the field of primary care.8,72Underwood has discussed the poor performance of the red flags approach due to the high prevalence of at least one red flag in back pain patients and the rarity of severe pathology. Instead, he proposed focusing upon a select number of disorders that need to be diagnosed early: cauda equina syndrome, major intra-abdominal pathology, focal infections, and fractures. For other causes of back pain, he proposed that diagnosis can be made over a period of time and with several observations, because reasonable delay would not endanger the patient and it would not affect the initial treatment in many cases.7
Singleton and Edlow have also suggested a systematic approach for risk stratification and diagnosis of severe spinal pathology in emergency departments.1 Our approach is somewhat similar to theirs by adopting a mental framework that includes benign self-limited musculoskeletal pathologies, spinal pathologies that cause neurologic disability due to cord or cauda damage, and non-spinal (abdominal or retroperitoneal) causes of low back pain.
Bardin et al proposed a “diagnostic triage” for low back pain, starting with exclusion of non‐spinal causes and continuing with allocation of patients to one of 3 broad categories: specific spinal pathology (<1% of cases), radicular syndrome (5–10% of cases), and non‐specific low back pain (90–95% of cases), with the latter being diagnosed by exclusion of the former two.11
We find the above diagnostic approaches to back pain useful and effective guides for the workup of low back pain. They are focused upon not missing an important pathology in a patient with low back pain. The originality and the relative advantage of this article is an inclusive overview of spinal pathologic conditions from the cervical to the sacral spine. This, as previously stated, would educate the reader to have a more wide view of the spinal pathology. Extending the number of pain syndromes (7 instead of 3 or 41,11) makes this review useful for non-emergency settings. We believe that using the list of the above 7 syndromes will guide any physician that is concerned with diagnosis of axial pain to wisely and cost-effectively diagnose the underlying pathology with the minimum number of diagnostic tests and referrals.