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.