Return to:   An Evidence-based Diagnostic Classification System For Low Back Pain

Table 1:

Low Back Pain Diagnostic Categories and Key Information.

CategoryDefinitionKey FindingsDiagnostic Standard UsedPerformance Statistics9References
ScreeningFindings indicating recent injury, special testing, referral or need for emergent evaluationEvidence of possible fracture, progressive neurologic deficit, infection, tumor…N/A1N/A1Chou 2007
Dagenais, 2010
Hawk, 2010
Murphy, 2007
NociceptivePain from noxious stimulation (inflammation, compression, injury) of peripheral tissues
DiscogenicPain from the posterior annulus and near the endplate
  1. Centralization with repeated end-range loading
  2. Any two: Centralization with repeated motion, vulnerable/apprehensive when stooped, lumbar extension loss
Lumbar discography
  1. +LR 6.9
  2. +LR 6.7
Sacroiliac Joint (SI-joint)Pain from the sacroiliac joint and/or supporting ligamentsSI-joint area pain with 3 or more of: L & R Gaenslen’s2, Thigh Thrust3, Sacral Thrust4, Iliac Comp5, Distraction6Flouroscopically-guided, controlled anesthetic block+LR 4.3 for 3 or more positive testsLaslett, 2005
Zygapophyseal Joint (Z-joint)Pain from Z-joint structures including the joint capsule and subchondral bone3 or more: > Age 50, relief by walking, relief by sitting, paraspinal onset, positive extension-rotation testFlouroscopically-guided, controlled anesthetic block+LR 9.7Laslett, 2006
MyofascialPain from muscles, tendons, and/or fascial tissue in the low backPain with use of involved muscle and trigger pointsNoneN/A1Bennett, 2007
NeuropathicPain from peripheral or central nervous system tissues
Compressive RadiculopathyPain from compression and inflammation of a nerve root
  1. Absent ankle/knee reflex
  2. Pain worse in lower extremity than in back
  3. Dermatome distribution (cough, sneeze, straining)
  4. Paresis (extremity motor strength loss)
  5. Finger to floor distance > 25 cm
  6. LANSS7 score > 12
1.– 5. Clinical findings in individuals with nerve root compression confirmed by Magnetic Resonance Imaging
6. Expert opinion
  1. OR 2.4
  2. OR 5.5
  3. OR 3.8
  4. OR 5.2
  5. OR 2.4
  6. PPV = 86-100
1–5. Vroomen, 2002
Bennett, 2001
Non-compressive RadiculopathyPain from compression, stretch and/or inflammation of peripheral nerve structures
  1. LANSS7 score > 12
  2. Compressive Radiculopathy criteria are not met
  1. Expert opinion
  2. N/A1
  1. PPV = 86–100
  2. N/A
Neurogenic ClaudicationPain from ischemia/compression of individual nerve roots, the cauda equina or spinal cord
  1. Age > 60
  2. Activity induced lower extremity pain with relief upon forward bending, or rest
  3. Symptoms worsened by standing or extension
  4. Urinaryincontinence
  5. NegativeABI
1.– 4. Expert opinion
5. Doppler Ultrasound
1.–4. +LR 3.9 for a score of ? 7 on clinical prediction rule (see appendix for scoring)
5. Sensitivity71
??Specificity 91
1.–4. Sugioka, 2008
5. Carmo, 2008
CentralPain from a lesion or dysfunction within the central nervous system
  1. Disproportionatepain,
  2. Unpredictable symptom aggravation and relief,
  3. Maladaptive psychosocial factors
  4. Non-anatomicdistribution
Expert opinion
  1. +LR 15.19
  2. +LR 30.69
  3. +LR 7.65
  4. +LR 27.57
Smart, 2012
Functional InstabilityDisruption of neuromuscular control of a spinal joint neutral zone during normal physiologic demand
  1. Positive prone passive lumbar extension8
  2. Hypermobile lumbar segment(s)
  3. Absence of hypomobile lumbar segment
Radiographic measurements of intervertebral motion
  1. +LR 8.8
  2. +LR 2.4
  3. +LR 9.0
Other DiagnosesDiagnoses not categorized aboveDependent on suspected conditionN/A1N/A1N/A1
1.N/A: Not applicable or not available;
2.Patient lies supine at the edge of a table with one leg hanging off. The examiner applies downward pressure to the knee of the hanging leg while pressing the opposite knee (flexed) toward the patient’s chest.
3.Patient lies supine with hip flexed to 90 degrees. With one hand, the examiner cups the sacrum and holds the comfortably flexed knee with the other. Pressure is applied along the femur shaft.
4.Patient lies prone while examiner manually applies an anterior pressure on the sacrum.
5.Patient is side-lying with hips and knees flexed to 90 degrees. The examiner applies medially oriented pressure on the upper iliac crest.
6.Patient lies supine while examiner manually presses posteriorly on the anterior superior iliac spines.
7.Leeds Assessment for Neuropathic Symptoms and Signs
8.With patient in prone position, both lower extremities are passively elevated 30 cm with knees extended. Positive test causes LBP.
9.+LR = (Positive Likelihood Ratio) Probability of the finding in patients with condition divided by the probability of the finding in patients without condition. Greater than 1 indicates test is associated with condition. Higher numbers indicate greater probability of association. PPV = (Positive Predictive Value) The number of true positives divided by the sum of true and false positives, indicating the probability that a positive test is truly positive for a condition. Higher numbers indicate greater diagnostic strength or accuracy. OR = (Odds Ratio or Diagnostic Odds Ratio [DOR]) A ratio measuring effectiveness of a diagnostic test. OR greater than 1 indicates ability to predict diagnosis. Higher numbers indicate greater diagnostic strength or accuracy. Sensitivity = percentage of individuals with a condition who test positive for that condition. Specificity = percentage of individuals who do not have a condition are identified as negative by the test
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