Low Back Pain Evaluation | Step-by-Step Clinical Approach by Dr. Debjyoti Dutta (Asian Pain Academy)

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Low back pain is one of the most widespread musculoskeletal conditions worldwide and a leading cause of disability across all age groups. A systematic Low Back Pain Evaluation ensures accurate diagnosis, prevents unnecessary imaging, and guides appropriate treatment.

Dr. Debjyoti Dutta, MD FIPP, Faculty – Asian Pain Academy, delivered a focused lecture on clinical evaluation of low back pain during OSPCON 2025, Bhubaneswar. The lecture PPT and full video recording are available on the Asian Pain Academy blog.

What is Low Back Pain?

In the majority of cases, low back pain resolves within a few weeks with conservative care. However, a small proportion of patients continue to experience persistent pain, leading to functional limitation and requiring a structured diagnostic approach.

Low Back Pain Evaluation: Red Flag Symptoms

Red flags indicate serious underlying spinal pathology and require urgent evaluation:

• Recent major trauma

• Possible tumor involvement

• Symptoms of infection

• Suspected vertebral fracture

• Motor, sensory, or autonomic neurological deficits

If any red flag is present, advanced imaging and specialist intervention are mandatory.

Diagnostic Challenges in Low Back Pain Evaluation

• In many cases, MRI or CT does not reveal a definite source of pain

• Imaging abnormalities may not correspond with symptoms

• Pain may be influenced by central sensitization and psychological factors

Therefore, clinical assessment remains the foundation of accurate diagnosis.

Pain Generators Considered During Low Back Pain Evaluation

Common contributors to low back pain include:

• Facet joint arthropathy

• Degenerative disc disease or internal disc disruption

• Sacroiliac joint dysfunction

• Disc prolapse or nerve compression

• Myofascial pain syndrome or CRPS

Identifying the specific pain generator is key to planning management.

Step-by-Step Clinical Approach to Low Back Pain Evaluation

Dr. Dutta highlights a four-step clinical method.

Step 1: History Taking

Detailed history should include:

• Chief complaints and pain characteristics

• Onset, duration, and progression

• Aggravating and relieving factors

• Day versus night pattern

• Occupation, lifestyle, and previous treatments

• Any systemic or neurological symptoms

A well-taken history often provides the strongest diagnostic clues.

Step 2: Physical Examination

Assessment includes:

1. Inspection – posture, gait, spine alignment, deformity

2. Palpation – tenderness over muscle, joints, and ligaments

3. Range of motion – spine mobility in all planes

4. Neurological assessment – motor strength, sensations, reflexes

5. Special tests – based on suspected diagnosis

Common special tests:

• Straight Leg Raise Test: nerve root irritation

• Kemp and Stoop Tests: lumbar spinal stenosis

• FABER and Gaenslen Tests: sacroiliac joint involvement

Step 3: Imaging and Laboratory Tests

Indicated when:

• Red flags are present

• Pain persists beyond expected healing time

• Neurological symptoms progress

Investigations may include X-ray, MRI, CT, and relevant blood tests.

Step 4: Diagnostic Pain Interventions

Used when clinical examination suggests a pain origin but imaging is inconclusive:

• Facet joint blocks

• Sacroiliac joint blocks

• Selective nerve root blocks

• Provocative discography

• Epidurogram or spinal endoscopy

These procedures confirm the anatomical pain source and guide targeted treatment.

Clinical Pattern Recognition in Low Back Pain Evaluation

Pattern	Likely Diagnosis
Predominant axial low back pain, worse in extension	Facet joint pathology
Leg pain worse than back pain, dermatomal distribution	Disc prolapse with radiculopathy
Buttock pain radiating to the thigh, worsened by sitting/standing	Sacroiliac joint dysfunction
Pain on walking, relieved by sitting or bending forward	Lumbar canal stenosis

Pattern-based assessment improves diagnostic efficiency.

Conclusion

Low Back Pain Evaluation should always begin with red flag screening, followed by history-driven clinical examination. Imaging and diagnostic interventions are reserved when necessary. This systematic approach ensures precise identification of pain generators and helps avoid unnecessary surgical referrals.

Dr. Debjyoti Dutta’s evaluation strategy is practical, evidence-based, and highly applicable in both primary care and pain clinic settings.

Download PPT

Evaluation_&_Approach_to_a_patient_with_low_back_pain_Updated_2025.pdf

Download PDF • 3.81MB

The full lecture slides and recorded video talk are available exclusively at: Asian Pain Academy YouTube Channel