Diagnostic Process in Chronic Low Back Pain

In failed back patients, looking back often reveals important lacks in the diagnostic process. Anatomical and radiological observations do not focus on the mechanism of pain and often conclusions are drawn only from history taking and physical examination.

Patient's History

Although no physician would deny patient's history is essential, there is no evidence to support that this helps in establishing a correct diagnosis, moreover, the best method of history taking in chronic low back pain has neither been defined nor validated. History must assess the patient in a bio-psycho-social context, particularly in FBSS (Guzman et al., 2001). Psycho-social ''red flags'', called yellow flags must be searched and a complete evaluation of the patient is mandatory if they are present (Deyo et al., 1992). Moreover, we recommend an interdisciplary approach for these patients.

After unsuccessful surgery, with or without added pain, all history must be reviewed even before the operation because unfortunately often FBSS means failed diagnostic. From the biological point of view, the localisation and quality of the pain must be established.

Localisation: The origin of the main pain should be clearly defined, is the pain coming truly from the back? Couldn't it be buttock pain or loin pain? If it is back pain, is lumbar spinal, sacral-spinal or lumbo-sacral spinal pain (Merskey et al., 1994). This precision is important since each condition suggests different diagnostics. If more than one pain is present, a link between them should not be presumed before a clear history has been drawn for each of them. If pain is clearly in the leg, could it be so matic referred pain? In order this question the quality of the pain will help in this regard.

Quality: somatic pain is characterized by deep, dull pressure-like pain and it must be differentiated from radicular neurogenic shooting or lancinating pain. Neurogenic pain will lead to a different diagnostic strategy and probably to another treatment (Fukui et al, 1997).

The other elements of history are all indicative without being essential.

The mode of onset is not diagnostic. Spontaneous or explosive start is more alarming and serious conditions as infection, fracture and tumour must be ruled out, but in chronic low back pain these pathologies have usually already been eliminated, especially if the patient had spinal surgery.

The initial clinical presentation of the pain helps dividing patients with predominant low back versus leg pain and this may influence the diagnostic strategy which differs between the two groups.

Intensity of the pain is not a good indicator of the severity of the disease, but a comparison to baseline Visual Analog Scores (VAS) is useful to follow the patient along the treatment course.

Duration of pain is a more complex issue. For patients with chronic pain unlike acute pain, a multidisciplinary approach is essential.

An exhaustive list of therapeutic and diagnostic procedures that have been performed is mandatory. Not only must the individual procedures be listed but also the order in which they were performed.

Precipitating, aggravating and relieving factors have not been shown to have an important diagnostic value. Difficult social or psychological conditions must be evaluated and in the case of failed-back, interdisciplinary evaluation may raise crucial pitfalls. Most chronic pain patients have to some extent psycho-social distress. This may be only an aggravating factor or a more causal disorder. If not all pain patients need a psychosocial evaluation, failed back patients are probably good candidates for such an approach. In these patients, suffering and distress may be severe, and social context is most of the time disturbed as a consequence of the disease and the loss of self-esteem (Guzman et al., 2001).

Physical Examination

The reliability of a clinical sign is usually evaluated using a K score. K score measures the agreement between two individual observers and is always less than or equal to 1.0 (Cohen, 1960). In rare situations, K can be negative and this is the sign that two observers agree less than it would be expected just by chance. K scores inferior to 0.2 signs a poor agreement; between 0.2 and 0.4 slight agreement, 0.4 to 0.6 moderate agreements, 0.6 to 0.8 good agreement and 0.8 to 1.0 very good agreement. In low back pain evaluation, K scores range from 0.1 to 0.6. Compared to the neuro-

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