History

Analysing the history invariably guides the clinician to the diagnosis. The pain patterns have to be carefully evaluated and it is helpful to map the diurnal variations of pain to facilitate the diagnosis (Fig 33.3).

It is especially important to note the intensity of the pain and its relation to rest and activity. In particular, ask whether the pain is present during the night, whether it wakes the patient, is present on rising or whether it is associated with stiffness.

Continuous pain present day and night is suggestive of neoplasia or infection. Pain on waking also suggests inflammation or depressive illness. Pain provoked by activity and relieved by rest suggests mechanical dysfunction while pain worse at rest and relieved by moderate activity is typical of inflammation. In some patients the coexistence of mechanical and inflammatory causes complicates the pattern.

Pain aggravated by standing or walking that is relieved by sitting is suggestive of spondylolisthesis. Pain aggravated by sitting (usually) and improved with standing indicates a discogenic problem. Pain of the calf that travels proximally with walking indicates vascular claudication; pain in the buttock that descends with walking indicates neurogenic claudication. This latter problem is encountered more frequently in older people who have a tendency to spinal canal stenosis associated with spondylosis.

A i rflaT nation

A = Activity ft mechanical Ft = Rest

Fig. 33.3 Typical daily patterns of pain for conditions causing back pain. Note conditions that can wake patients from sleep and also the combined mechanical and inflammatory patterns

Fig. 33.3 Typical daily patterns of pain for conditions causing back pain. Note conditions that can wake patients from sleep and also the combined mechanical and inflammatory patterns

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