Diagnostic Triage

Diagnosis is the foundation of management and is based on clinical assessment1

Waddell 1998

Many texts provide the reader with comprehensive lists of different causes for back pain.  All of them are clinically important in their right but many are rare and will never be seen in everyday practice, especially by the non-specialist.

This is an impractical approach to back pain and leads to confusion on the physicians’ part and in turn misleading investigations.  Essentially this results in poor management.

The diagnostic triage approach, first described by Waddell for the assessment of back pain, is a more simple and practical approach.  It is not concerned with making a specific diagnosis immediately but to catergorise patients into groups according to the immediate need and priority for further investigation and treatment.

The three main categories include:

  • Ordinary Backache
  • Nerve Root Pain
  • Serious Spinal Pathology


Presenting Symptoms:

  • Back pain
  • Leg pain
  • Neurological symptoms
  • Spinal deformity


Table 1.  Red Flags for serious spinal pathology2

Table 1. Red flags for serious spinal pathology

Onset of pain <20 or >55 years old


History of trauma  
Thoracic pain  
Non-mechanical pain  
Previous history of: (i.e:  Malignancy / Steroid use / Drug abuse / HIV)
Constitutional symptoms: (i.e:  Weight loss)
Prolonged restriction of lumbar spine flexion  
Structural spinal deformity  
Evidence of neurological signs  
Investigations (if indicated): (i.e:  ESR > 25mm / Plain X-ray abnormality)















1.  Waddell G. 2004. The back pain revolution. 2nd Ed.  London: Churchill Livingstone.

2.  Greenhalgh S, Selfe J.  Red Flags: A Guide to Identifying Serious Pathology of the Spine. Elsevier Health Sciences (Scotland) 2006.