History-taking
CPSA · Focused history · Musculoskeletal
Back pain
Most back pain is mechanical, but the job of the history is to exclude the serious causes — cauda equina, malignancy, infection and fracture — via the red flags.
Focused questions
Characterise (SOCRATES)
- Site, onset (trauma?), character, radiation (down the leg = sciatica), timing (worse at night?), aggravating/relieving, severity
Red-flag screen (must ask)
- Cauda equina: saddle anaesthesia, bladder/bowel dysfunction, bilateral leg weakness
- Malignancy: age >50, weight loss, history of cancer, night pain
- Infection: fever, IV drug use, immunosuppression
- Fracture: trauma, osteoporosis, steroids
Function & context
- Impact on function/work, mood, prior episodes, occupation
Differentials to screen
Mechanical / non-specific back painMovement-related, no red flags, improves with activity
Sciatica (radiculopathy)Radiating leg pain in a dermatome, positive straight-leg raise
Cauda equina syndromeSaddle anaesthesia, urinary retention/incontinence, bilateral weakness — emergency
Malignancy / metastasesAge >50, weight loss, night pain, cancer history
Vertebral fracture / discitisTrauma/osteoporosis, or fever/IVDU with focal tenderness
Red flags — exclude these
- Saddle anaesthesia, bladder/bowel dysfunction, bilateral leg weakness (cauda equina — emergency MRI)
- Weight loss / history of cancer / night pain (malignancy)
- Fever / IV drug use / immunosuppression (infection)
- Significant trauma or age <20 / >55 with new pain
OSCE tips
- Explicitly ask the cauda equina questions in every back-pain history — it’s a can’t-miss emergency.
- Red flags drive imaging; without them, most back pain is managed conservatively.
- Night pain + weight loss + cancer history should raise malignancy.