“My back’s killing me.”
That’s probably one of the most common complaints you’ll hear in general practice or emergency rooms.
But here’s the thing — while most cases are benign and self-limited, some hide dangerous causes that you definitely don’t want to miss.
So, how do we tell the difference?
What clues should we look for?
And how do we stay calm and systematic when the chief complaint is vague and broad?
Let’s start with a patient.
🚪 Doorway Information
- Age: 45
- Gender: Male
- Chief Complaint: “My lower back started hurting suddenly after lifting a heavy box yesterday.”
- Vital Signs: BP 128/76, HR 78, RR 16, Temp 36.8°C, SpO₂ 99%
This might sound familiar, right?
A patient walks in with sudden lower back pain after lifting something. No leg pain. No fever. No trauma. No known chronic conditions.
You might be thinking, “This is just a simple strain.”
Maybe it is.
But… what if it isn’t?
What if you miss spinal cord compression?
Or an epidural abscess?
Or even a leaking aortic aneurysm?
That’s why in this article, we’ll go back to the basics — and then build up a solid, clinically useful approach.
By the end, you’ll be able to take this vague presentation and start narrowing it down confidently, one step at a time.
🔍 Step 1: Think Anatomically
Let’s take a step back — literally.
Not all back pain actually comes from the back.
Here’s a simple way to break it down:
🔹 1. Primary spinal pathology
Problems directly involving the spine or its supporting structures:
- Musculoligamentous strain
- Degenerative changes (spondylosis)
- Herniated discs
- Spinal stenosis
- Compression fractures
🔹 2. Systemic disease
These are the ones we don’t want to miss:
- Infections like discitis or vertebral osteomyelitis
- Spinal metastases
- Inflammatory diseases like ankylosing spondylitis
🔹 3. Referred pain
Pain that feels like it’s from the back, but actually isn’t:
- Aortic aneurysm or dissection
- Pancreatitis
- Pyelonephritis or kidney stones
- Retroperitoneal hemorrhage
With this framework, you’re not just reacting to “back pain” —
you’re beginning to map it anatomically and prioritize causes that need action.
🔢 Step 2: Know the Big Five
Let’s go over the five most common types of lower back pain you’ll encounter. These are the heavy-hitters worth remembering:
1. Lumbosacral Strain
- Trigger: Overuse, lifting, twisting
- Pattern: Worse with movement, better with rest
- Exam: Diffuse tenderness, no radicular signs
- Imaging: Not necessary
2. Lumbar Disc Herniation
- Age: 30s–50s
- Pattern: Sudden onset, leg radiation (sciatica), worsens with sitting
- Exam: Dermatomal findings, ↓ reflexes, +SLR
- Imaging: MRI if symptoms persist or worsen
3. Spinal Stenosis
- Age: Older adults
- Pattern: Leg > back pain, worsens with walking, better with sitting/flexion
- Exam: Negative SLR, neurogenic claudication signs
- Imaging: MRI for confirmation
4. Inflammatory Back Pain
- Pattern: Morning stiffness >30 min, better with exercise
- History: Young adult, HLA-B27 association
- Exam: ↓ spinal mobility, SI joint tenderness
- Imaging: X-ray or MRI sacroiliac joints
5. Vertebral Compression Fracture
- Risk: Elderly, steroid use, trauma
- Pattern: Sudden pain after minimal trauma
- Exam: Midline bony tenderness, possible kyphosis
- Imaging: Plain X-ray of spine
🚩 Step 3: Red Flags
When do you need to worry? Red flags help identify serious pathology needing urgent workup:
- Age > 50 with new-onset pain
- History of cancer
- Unexplained weight loss
- Fever, IV drug use, immunosuppression
- Neurologic symptoms (weakness, numbness, bowel/bladder changes)
🧠 Step 4: History & Physical Examination
Ask the right questions, perform a focused yet thorough exam:
OPQRST Highlights
- O: Onset — sudden or gradual? related to activity?
- P: Provocation — what worsens or relieves it?
- Q: Quality — dull, sharp, radiating?
- R: Radiation — does it go to legs?
- S: Severity — pain score
- T: Timing — constant or intermittent?
Key Physicals
- Inspection: posture, scoliosis, gait
- Palpation: midline vs paraspinal tenderness
- SLR: assess for sciatica
- Neuro exam: strength, reflexes, sensation
🔄 Let’s revisit our patient
Now that we have a structured framework, let’s go back to our initial case:
- Acute back pain after lifting
- No red flags
- Localized pain, no radiation
Putting it all together, this is most consistent with a lumbosacral strain.
No imaging needed. Conservative treatment, watchful waiting, and clear return precautions are enough for now.
🗣️ Useful Expressions for History Taking
- “Can you point to exactly where it hurts?”
- “Does the pain travel down your legs?”
- “Is the pain worse in the morning, or after activity?”
- “Have you noticed any weakness, numbness, or trouble controlling your bladder?”
📌 Take-Home Messages
- Not all back pain is spinal — think anatomically
- Use “The Big Five” to organize your differentials
- Red flags help prioritize serious conditions
- Most cases don’t need imaging right away
- Anchor your approach in history and physical exam
Move on to mock cases practice:
🌳Standard
🔥Challenging (coming soon…)
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