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Chapter 1 
 
History and Physical Examination after Red Flag Evaluation                              
Author's Example         
   
Panel findings and recommendations: 
  -   Information about the patient's age, the duration and description of symptoms, the impact of symptoms on activity, and the response to previous therapy are important in the care of back problems.  (Strength of Evidence = B.) 
  -   Inquiries about history of cancer, unexplained weight loss, immuno-suppression, intravenous drug use, history of urinary infection, pain increased by rest, and presence of fever are recommended to elicit Red Flags for possible cancer or infection.  Such inquiries are especially important in patients over age 50.  (Strength of Evidence = B.) 
  -   Inquiries about signs and symptoms of cauda equina syndrome, such as a bladder dysfunction and saddle anesthesia in addition to major limb motor weakness, are recommended to elicit red flags for severe neurologic risk to the patient.  (Strength of Evidence = C.) 
  -   Inquiries about history of significant trauma relative to age (for example, a fall from height or motor vehicle accident in a young adult or a minor fall or heavy lift in a potentially osteoporotic or older patient) are recommended to avoid delays in diagnosing fracture. (Strength of Evidence = C.) 
  -   Attention to psychological and socioeconomic problems in the individual's life is recommended since such nonphysical factors can complicate both assessment and treatment.  Strength of Evidence = C.) 
  -   Use of instruments such as a pain drawing or visual analog scale is an option to augment the history.  (Strength of Evidence = D.) 
  -   Recording the results of straight leg raising (SLR) is recommended in the assessment of sciatica in young adults.  In older patients with spinal stenosis, SLR may be normal.  (Strength of Evidence = B.) 
-   A neurologic examination emphasizing ankle and knee reflexes, ankle and great toe dorsiflexion strength, and distribution of sensory complaints is recommended to document the presence of neurologic deficits. (Strength of Evidence = B.)  
 
  The initial assessment (Attachment A1) of a patient with activity intolerance due to low back symptoms consists of a focused medical history, a physical examination, and related decisions.  A careful medical history and physical examination are critical.  The primary purpose is to seek medical history responses or physical examination findings suggesting a serious underlying condition such as fracture, tumor, infection, or cauda equina syndrome.  These responses or findings are referred to as red flags.  They alert clinicians to the possibility that low back symptoms may be related to a dangerous condition.  However, serious conditions presenting as low back problems are relatively rare. 
 
  The initial assessment categorizes back symptoms without red flags as either primarily back (non-neurologic) or sciatic (neurologic) and defines the duration of these symptoms to guide both what type of special studies may be considered and when they should be considered.  In the absence of red flags, special tests are not usually required in the first month of low back symptoms because most patients recover from their activity limitations within 1 month. 
 
  The initial assessment also provides an opportunity for the clinician to establish rapport with the patient, to find out patient expectations, and to become aware of potential psychological and socioeconomic factors that can alter response to care. 
 
Assessment Literature Reviewed 
  Of the 214 articles screened for this topic, 34 met the article selection criteria for efficacy.20, 21, 22, 23 ,24 ,25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53  
 
  The important points in these articles are well summarized in review articles by Deyo, Rainville, and Kent54 and Waddell, Main, Morris, et al.55  Both reviews elaborate on the reproducibility and accuracy of specific medical history findings (Table 1) and physical examination findings (Table 2) for assessing low back problems.  Other articles not meeting selection criteria are cited where appropriate since they contain information used in formulating recommendations.56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66 
 
Evidence on Efficacy of Assessment Methods 
 
Medical History__________________        Author's Example 
  A few key questions on the medical history can help ensure that a serious underlying condition, such as cancer26 or spinal infection, will not be missed.  These questions include: age, history of cancer, unexplained weight loss, immunosuppression, duration of symptoms, responsiveness to previous therapy, pain that is worse at rest, history of intravenous drug use, and urinary or other infection. 
 
  Symptoms of sciatica (leg pain) or neurogenic claudication (walking limitations due to leg pain) suggest possible neurologic involvement.  Pain radiating below the knee is more likely to indicate a true radiculopathy than pain radiating only to the posterior thigh.  A history of persistent numbness or weakness in the leg(s) further increases the likelihood of neurologic involvement.  
 
  A typical sciatica history of back and leg pain in a typical lumbar nerve root distribution is reasonably sensitivity but of uncertain specificity for symptoms being related to disk herniated (Van den Hoogen et al.`95, Vroomen et al.`99). The L4/L5 and L5/S1 levels make up over 90% of the symptomatic lumbar herniations. This allows a focused exam to include straight leg raise testing, then evaluation of the nerve roots including L4 by testing knee strength and reflexes, L5 for contributions to great toe and foot dorsiflexion strength , S1 in foot plantar-flexion and ankle reflexes, and sensory distribution of complaints to assess nerve root dysfunction. Positive straight leg raise test defined as reproduction of the patientís sciatica between 30 and 70 degrees of leg elevation (Deyo et al.`92). As noted below, straight leg rais has relatively high sensitivity (0.91, 95% CI 0.82 to 0.94) but modest specificity (0.26, 95% CI 0.16 to 0.38) for diagnosing herniated disc (Devillé et al.`00). By contrast, the crossed straight leg raise is more specific (0.88, 95% CI 0.86 to 0.90) but less sensitive (0.29, 95% CI 0.24 to 0.34).  
  The evidence for history and examination identifying lumbar spinal stenosis relies upon 7 clinical and 2 special diagnostic articles according to a review by de Graaf et al.`06. Higher-quality studies found factors associated with high sensitivity to be inversely related to specificity (low), except for a modest or poor predictive values (1.2 for pseudoclaudication and 2.2 for radiating leg pain) (de Graaf et al.`06). Symptoms impacted by downhill treadmill testing are associated with the highest positive predictive value (3.1). Age over 65 years had a positive predictive value of 2.5 but had a negative predictive value of 0.33 in one lower-quality study (Katz et al.`95). Predictability of pain relieved by sitting is reported from poor to high (de Graaf et al.`06). No other factors have significant predictive value except in studies of questionable reliability in lower quality for predicting lumbar spinal stenosis. 
The articles indicate that cauda equina syndrome can be ruled out with a medical history that ascertains the absence of bladder dysfunction (usually urinary retention or overflow incontinence), saddle anesthesia, and unilateral or bilateral leg pain and weakness. 
__________________________________________ 
 
Table 1.  Estimated accuracy of medical history in diagnosis of spine diseases causing low back problems  
References
Disease 
to be 
detected
Medical History 
red flags
True- positive rate (sensitivity)
True- negative rate (specificity)
Deyo and Diehi26
Cancer
Age>50
0.77 
0.71
 
 
Previous cancer history
0.31
0.98
 
 
Unexplained weight loss
0.15
0.94
 
 
Failure to improve with  
1 month of therapy
0.31
0.90
 
 
Bed rest no relief
>0.90
0.46
 
 
Duration of pain >1 month
0.50
0.81
 
 
Age >50 or history of 
cancer or unexplained 
weight loss or failure of 
conservative therapy.
1.00
0.60
Waldvogel and Vassey64
Spinal osteomyelitis
Intravenous drug abuse, UTI, or skin infection
0.40
NA
Unpublished dataa
Compession fracture
Age > 50
0.84
0.61
 
 
Age > 70
0.22
0.96
 
 
Trauma
0.30
0.85
 
 
Corticosteroid use
0.06
0.995
Deyo and 
Tsui-Wu59 
Spangfort63
Herniated disc
Sciatica
0.95
0.88
Turner, Ersek, 
Herron, et al.66
Spinal stenosis
Pseudoclaudication
0.60
NA
 
 
Age > 50
0.90b
0.70
Gran60
Ankylosing 
Spondylitis
Positive responses 4 out of 5
0.23
0.82
 
 
Age at onset < 40
1.00
0.07
 
 
Pain not relieved in supine position
0.80
0.49
 
 
Morning back stiffness
0.64
0.59
 
 
Duration of pain > 3 months
0.71
0.54
a From 833 patients with back pain at a walk-in clinic as reported in Deyo, Rainville, and Kent.54 All received plain lumbar roentgenograms.  
b Author's estimate.Table 1.  Estimated accuracy of medical history in diagnosis of spine diseases causing low back problems  
 
__________________________________________ 
 
Table 2.  Estimated accuracy of physical examination for lumbar disc herniation among patients with sciatica  
 
 
 
 
References
Test
True- positive  
rate (sensitivity)
True- negative rate (specificity)
Comments
Hakelius 
Hindmarsh61 
Kosteljanetz 
Espersen 
Halaburt, et al.37
Ipsilateral 
SLR
0.80
0.40
Positive result:        leg pain at <60 
Hakelius and 
Hindmarsh61
Spangfort63
Crossed SLR
0.25
0.70
Positive result: reproduction of contralateral pain
Hakelius and 
Hindmarsh61
Spangfort63
Ankle dorsiflexion weakness
0.35
0.70
HNP usually at   L4-L5 (80%)
Hakelius and 
Hindmarsh61
Kortelaainen, 
Puranenn, 
Koivisto, et al.35
Great toe extensor weakness
0.50
0.70
HNP usually at   L5-S1 (60%) or 
L4-L5  (30%)
Hakelius and 
Hindmarsh61
Spangfort63
Impaired ankle reflex
0.50
0.60
HNP usually at  
L5-S1; absent reflex increase specificity
Kortelainen, 
Puranen, 
Koivisto, et al.35
Kosteljanetz, 
Espersen, 
Halaburt, et al. 37
Sensory loss
0.50
0.50
Area loss poor predictor of HNP level
Aronson and 
Dunsmore56
Patellar reflex
0.50
NA
For upper lumbar HNP only
Hakelius and 
Hindmarsh61
Ankle plantar flexion weakness
0.06
0.95
__
Hakelius and 
Hindmarsh61
Quadriceps weakness
<0.01
0.99
__
Note: Sensitivity and specificity were calculated by Deyo, Rainville, and Kent.54 Values represent rounded averages where multiple references were available.  All results are from surgical case series.  HNP = herniated nucleus pulposous.  SLR = straight leg raising. 
__________________________________________ 
 
  Patients' reports of symptoms and treatment outcomes may be influenced by psychological or socioeconomic factors.  Several studies have reported a variety of such factors for patients with low back problems.  These factors include work status, typical job tasks, educational level, pending litigation, worker's compensation or disability issues, failed previous treatments, substance abuse, and depression.23,38,39,41,43,50,58 
 
  Clinicians are urged by some authors to augment the medical history with pain drawings and visual analog pain rating scales to document the distribution of pain and intensity of symptoms (Attachment B). 40,45,46,52,53 
 
Physical Examination _________________________        Author's Example 
  The physical examination supplements the information obtained in the medical history in seeking an underlying serious condition or possible neurologic compromise.  The basic elements of a physical examination are inspection, palpation, observation including range of motion testing, and a specialized neuromuscular evaluation.  This evaluation emphasizes ankle and knee reflexes, ankle and great toe dorsiflexion strength, and distribution of sensory complaints.  For patients presenting with low back problems and no limb complaints, a more elaborate neurologic evaluation is usually not necessary. 
 
  The physical examination is less useful than the history in searching for underlying serious conditions such as cancer, but may be helpful in detecting spinal infections.  Fever, vertebral tenderness, and very limited spinal range of motion suggest the possibility of spinal infections, but these are also common findings in patients without infection.  Otherwise, evaluation of spinal range of motion has been found to be of limited diagnostic value,62 although some clinicians consider it helpful in planning and monitoring treatment. 
 
  Findings from both the history and physical examination provide useful information in the search for possible neurologic compromise.  For example, sciatica has such a high true-positive rate for lumbar nerve root compression that its absence makes a clinically important lumbar disc herniation related to neural compression unlikely.  In addition, leg pain usually overshadows back pain when such a clinically significant radiculopathy is present.  Finally, crossed straight leg raising is such a highly specific test that a positive finding makes neurologic compromise due to herniated lumbar disc very likely, but this is not a sensitive test since discomfort upon crossed straight leg raising may be absent in many patients with neurologic compression. 31,34,61,63 
 
  Deyo, Rainville, and Kent's summary54 of available data suggests that in the primary care setting for patients with leg symptoms, the neurologic examination can safely be limited to a few tests.  These are: (1) testing of dorsiflexion strength of the ankle and the great toe, with weakness suggesting L5 and some L4 root dysfunction; (2) testing of ankle reflexes to evaluate S1 root dysfunction; (3) testing of light touch sensation in the medial (L4), dorsal (L5), and lateral (S1) aspects of the foot; and (4) the straight leg raising (SLR) test. 
 
  This abbreviated neurologic examination of the lower extremities will allow detection of most clinically significant nerve root compromise due to L4-L5 or L5-S1 disc herniations, which together make up over 90 percent of all clinically significant radiculopathy due to lumbar disc herniations. 35,37,56,61,63  Although this limited examination might miss the much less common L2-L3 or L3-L4 disc herniations, these conditions are more difficult to diagnose on physical examination.  Moreover, if such patients have not improved by 1 month, this guideline suggests a further diagnostic workup or consultation (Chapter 3), which may clarify the diagnosis.  For over 95 percent of patients with low back problems, no special interventions or diagnostic tests would be required within the first month of symptoms. 
 
Potential Harms and Costs of Assessment Methods 
  Potential harms and costs are considered low for both the medical history and the physical examination. 
 
Summary of Findings 
  Positive answers to key medical history questions, in addition to positive findings on physical examination and/or simple lab tests, are Red Flags that suggest the possibility of a serious underlying condition as the cause of low back problems. 
 
  For cancer or infection, red flags are: history of cancer, unexplained weight loss, immunosuppression, urinary infection, intravenous drug use, prolonged use of corticosteroids, back pain not improved with rest, and age of patient over 50
 
  For spinal fracture, Red Flags are: history of significant trauma (for example, a fall from a height, motor vehicle accident, or direct blow to the back for a young adult, or a minor fall or heavy lift in a potentially osteoporotic or elderly individual), prolonged use of steroids, and age over 70. 
 
  For cauda equina syndrome or severe neurologic compromise, red flags are: medical history or physical examination findings of acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, saddle anesthesia (about the anus, perineum, and genitals), and global or progressive motor weakness in the lower limbs. 
 
  There are indications in the literature that psychological or socioeconomic factors may affect a patient's report of symptoms and response to treatment. 
 
  Simple laboratory tests, including complete blood count (CBC) and erythrocyte sedimentation rate (ESR), are sufficiently inexpensive and efficacious for use as initial tests when there is suspicion of back-related tumor or infection. 
 
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