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The different flag systems are useful tools to support the diagnostic triage. Simple standardized assessment tools may be used to aid diagnosis and assess patient progress.
Introduction Back pain is the third most common symptom presented to general practitioners after headache and fatigue. While most patients with back pain seen in primary care will have ‘simple mechanical back pain’, there is a long list of potential diagnoses, some of them serious and life threatening. The concept of diagnostic triage has been developed to facilitate the efficient and effective diagnosis and management of patients presenting with back pain in primary and secondary care. Diagnostic triage When we are talking to patients and colleagues it is important to make sure that we are using words in the same way. Confusion frequently arises because of simple misunderstandings (Box 1.1). The clinical assessment should aim to place the patient into one of three diagnostic groups. When taking the history, be alert for flag features (Box 1.2). Box 1.1 Some important definitions Where is the back? From the point of view of diagnostic triage ‘the back’ means ‘the low back’ or lumbosacral region, defined as the area on the dorsal ABC of Spinal Disorders. Edited by Andrew Clarke, Alwyn Jones, Michael O’Malley and Robert McLaren.  2010 by Blackwell Publishing, ISBN: 978-1-4051-7069-7. surface of the body from the bottom of the 12th rib to the gluteal folds (Figure 1.1).
Where is the leg? In common parlance ‘the leg’ is frequently used to mean ‘the lower limb’ but this is anatomically incorrect. In relation to referred and nerve root pain, the leg is the structure between the knee and the ankle; between the hip and the knee is the thigh. There is an analogous situation in the upper limb; the arm is between the shoulder and the elbow, and the forearm is between the elbow and the wrist. Where is the hip? Patients frequently refer to the buttock, lateral pelvic area or lateral upper thigh region as ‘the hip’. In fact, pain here is often referred back pain. It is instructive to ask the patient to point with a finger to the painful area. Genuine hip pain is usually experienced in the groin and anterior thigh. What is sciatica? Sciatica is a misnomer. The pain that we now know to originate from the lumbar nerve roots was originally thought to be due to pressure on the sciatic nerve. The name ‘sciatica’ persists, even though the pain has nothing to do with the sciatic nerve. What is pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
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