Page 1 of 78
BACK PAIN COMPREHENSIVE EXAM LATEST VERSION
QUESTIONS AND ANSWERS 2026 EDITION
Back Pain Exam: 250 Practice Questions with Rationales
DOMAIN 1: CLINICAL HISTORY, CLASSIFICATION, AND DIFFERENTIAL DIAGNOSIS
(50 Questions)
1. The cornerstone of diagnosis and management in low back pain is:
A) MRI imaging
B) CT scanning
C) History-taking combined with physical examination
D) Laboratory testing (ESR, CRP)
Answer: C) History-taking combined with physical examination
Rationale: In evaluating low back pain (LBP), history-taking remains a cornerstone in
diagnosis and management. While the physical examination alone rarely provides
definitive answers, combining it with a detailed history significantly enhances diagnostic
accuracy. A structured and problem-oriented approach can derive precision in
diagnosis and reduce unnecessary tests .
2. What are the seven "must-not-miss" causes of back pain?
A) Muscle strain, ligament sprain, degenerative disk disease, facet arthropathy,
sacroiliitis, spinal stenosis, herniated disc
B) Osteomyelitis, metabolic bone disease, inflammatory spondylitis,
neoplasm/neurologic deficit, aortic dissection/abscess, unstable spine (fracture),
spinal cord disease
C) Arthritis, fibromyalgia, osteoporosis, scoliosis, kyphosis, spondylolisthesis,
radiculopathy
D) Pregnancy, obesity, poor posture, sedentary lifestyle, aging, smoking, occupational
hazards
Answer: B) Osteomyelitis, metabolic bone disease, inflammatory spondylitis,
neoplasm/neurologic deficit, aortic dissection/abscess, unstable spine (fracture),
spinal cord disease
, Page 2 of 78
Rationale: The seven causes of back pain you would least want to miss are:
osteomyelitis, metabolic bone disease, inflammatory spondylitis, neoplasm or
neurologic deficit, aortic dissection/abscess, unstable spine (fracture), and spinal cord
disease .
3. A 22-year-old patient presents with acute low back pain that began after lifting a
heavy box. Which of the following would be a RED FLAG for serious pathology?
A) Pain duration of 3 days
B) Pain with straight leg raise
C) New onset in patient over 50 years old
D) Pain relieved by rest
Answer: C) New onset in patient over 50 years old
Rationale: Red flags indicating high risk of serious disease include: new onset in patient
>50 years old or <20, pain in abdomen/flanks/hip/perineum/upper back, onset following
direct blow to the back or fall, progressive pain or neurological symptoms unrelieved by
bed rest, crossed straight leg raising sign, or exquisite pain on heel drop .
4. A patient with low back pain reports "saddle anesthesia" (numbness in the
perineal area). This symptom is a red flag for:
A) Lumbar strain
B) Cauda equina syndrome
C) Spinal stenosis
D) Sacroiliitis
Answer: B) Cauda equina syndrome
Rationale: Saddle area numbness, urinary incontinence/retention, fecal incontinence,
and bilateral true sciatica are red flag symptoms for cauda equina syndrome requiring
urgent action. Patients with these symptoms present on the day of attendance should
be immediately sent to the emergency department .
5. Imaging findings do not always correlate with patient symptoms. Which
statement best reflects this principle?
A) All disc herniations require immediate surgery
B) Many patients with disc herniations are asymptomatic
C) Normal imaging always rules out serious pathology
D) MRI is the gold standard for all back pain
, Page 3 of 78
Answer: B) Many patients with disc herniations are asymptomatic
Rationale: It is important to note that imaging findings do not always correlate with
patient symptoms. Evidence supports that many patients with disc herniations are
asymptomatic .
6. A 60-year-old farmer developed low back pain after lifting a toolbox. The pain has
persisted for 8 months and radiates to the right gluteal region. Examination reveals
limited ROM and bilateral positive straight leg raise with absent ankle jerks. What is
the most likely diagnosis?
A) Lumbar strain
B) Herniated disc
C) Spinal stenosis
D) Sacroiliitis
Answer: C) Spinal stenosis
Rationale: This case from the AAN Continuum exam describes a patient with features of
spinal stenosis: older age, chronic pain, bilateral symptoms, and absent ankle jerks
bilaterally. The imaging study most likely to reveal the cause would be a CT scan of the
lumbar spine with contrast .
7. Which of the following patient characteristics indicates LOW risk of serious
disease?
A) Age >50 years
B) History of cancer
C) Acute onset of pain <3 weeks duration with normal examination
D) Progressive neurological symptoms
Answer: C) Acute onset of pain <3 weeks duration with normal examination
Rationale: Low risk of serious disease with good prognosis includes patients age 20-40
with acute onset of duration <3 weeks, few previous episodes, relief by bed rest, no past
back surgery or neurological symptoms, and normal examination or muscle
spasm/tenderness only .
8. Red flags in back pain include all of the following EXCEPT:
A) Age >55 years
B) Unexplained weight loss
, Page 4 of 78
C) Pain worse at night
D) Pain relieved by sitting
Answer: D) Pain relieved by sitting
Rationale: Red flags include thoracic pain, fever, unexplained weight loss, bladder or
bowel dysfunction, history of carcinoma, progressive neurological deficit, disturbed gait,
saddle anesthesia, and age of onset <20 years or >55 years . Pain relieved by sitting is
not a red flag; in fact, this is often a feature of spinal stenosis.
9. A systems review is important in back pain evaluation. Which finding may be
associated with ankylosing spondylitis?
A) History of deafness
B) Optic neuritis
C) Iritis (in about 20% of patients)
D) Conjunctivitis
Answer: C) Iritis (in about 20% of patients)
Rationale: A history of optic neuritis may indicate multiple sclerosis, while iritis occurs in
about 20% of patients with ankylosing spondylitis. Reiter's syndrome often begins with
conjunctivitis as well as urethritis .
10. A patient with low back pain reports loss of appetite and unintentional weight
loss. This finding should raise suspicion for:
A) Muscular strain
B) Carcinoma
C) Disk herniation
D) Facet arthropathy
Answer: B) Carcinoma
Rationale: A loss of appetite or loss of weight not associated with dieting may suggest
carcinoma .
11. Bowel disturbance such as alternating diarrhea and constipation in a patient
with back pain may indicate:
A) Simple mechanical back pain
B) Late development in cauda equina lesions
BACK PAIN COMPREHENSIVE EXAM LATEST VERSION
QUESTIONS AND ANSWERS 2026 EDITION
Back Pain Exam: 250 Practice Questions with Rationales
DOMAIN 1: CLINICAL HISTORY, CLASSIFICATION, AND DIFFERENTIAL DIAGNOSIS
(50 Questions)
1. The cornerstone of diagnosis and management in low back pain is:
A) MRI imaging
B) CT scanning
C) History-taking combined with physical examination
D) Laboratory testing (ESR, CRP)
Answer: C) History-taking combined with physical examination
Rationale: In evaluating low back pain (LBP), history-taking remains a cornerstone in
diagnosis and management. While the physical examination alone rarely provides
definitive answers, combining it with a detailed history significantly enhances diagnostic
accuracy. A structured and problem-oriented approach can derive precision in
diagnosis and reduce unnecessary tests .
2. What are the seven "must-not-miss" causes of back pain?
A) Muscle strain, ligament sprain, degenerative disk disease, facet arthropathy,
sacroiliitis, spinal stenosis, herniated disc
B) Osteomyelitis, metabolic bone disease, inflammatory spondylitis,
neoplasm/neurologic deficit, aortic dissection/abscess, unstable spine (fracture),
spinal cord disease
C) Arthritis, fibromyalgia, osteoporosis, scoliosis, kyphosis, spondylolisthesis,
radiculopathy
D) Pregnancy, obesity, poor posture, sedentary lifestyle, aging, smoking, occupational
hazards
Answer: B) Osteomyelitis, metabolic bone disease, inflammatory spondylitis,
neoplasm/neurologic deficit, aortic dissection/abscess, unstable spine (fracture),
spinal cord disease
, Page 2 of 78
Rationale: The seven causes of back pain you would least want to miss are:
osteomyelitis, metabolic bone disease, inflammatory spondylitis, neoplasm or
neurologic deficit, aortic dissection/abscess, unstable spine (fracture), and spinal cord
disease .
3. A 22-year-old patient presents with acute low back pain that began after lifting a
heavy box. Which of the following would be a RED FLAG for serious pathology?
A) Pain duration of 3 days
B) Pain with straight leg raise
C) New onset in patient over 50 years old
D) Pain relieved by rest
Answer: C) New onset in patient over 50 years old
Rationale: Red flags indicating high risk of serious disease include: new onset in patient
>50 years old or <20, pain in abdomen/flanks/hip/perineum/upper back, onset following
direct blow to the back or fall, progressive pain or neurological symptoms unrelieved by
bed rest, crossed straight leg raising sign, or exquisite pain on heel drop .
4. A patient with low back pain reports "saddle anesthesia" (numbness in the
perineal area). This symptom is a red flag for:
A) Lumbar strain
B) Cauda equina syndrome
C) Spinal stenosis
D) Sacroiliitis
Answer: B) Cauda equina syndrome
Rationale: Saddle area numbness, urinary incontinence/retention, fecal incontinence,
and bilateral true sciatica are red flag symptoms for cauda equina syndrome requiring
urgent action. Patients with these symptoms present on the day of attendance should
be immediately sent to the emergency department .
5. Imaging findings do not always correlate with patient symptoms. Which
statement best reflects this principle?
A) All disc herniations require immediate surgery
B) Many patients with disc herniations are asymptomatic
C) Normal imaging always rules out serious pathology
D) MRI is the gold standard for all back pain
, Page 3 of 78
Answer: B) Many patients with disc herniations are asymptomatic
Rationale: It is important to note that imaging findings do not always correlate with
patient symptoms. Evidence supports that many patients with disc herniations are
asymptomatic .
6. A 60-year-old farmer developed low back pain after lifting a toolbox. The pain has
persisted for 8 months and radiates to the right gluteal region. Examination reveals
limited ROM and bilateral positive straight leg raise with absent ankle jerks. What is
the most likely diagnosis?
A) Lumbar strain
B) Herniated disc
C) Spinal stenosis
D) Sacroiliitis
Answer: C) Spinal stenosis
Rationale: This case from the AAN Continuum exam describes a patient with features of
spinal stenosis: older age, chronic pain, bilateral symptoms, and absent ankle jerks
bilaterally. The imaging study most likely to reveal the cause would be a CT scan of the
lumbar spine with contrast .
7. Which of the following patient characteristics indicates LOW risk of serious
disease?
A) Age >50 years
B) History of cancer
C) Acute onset of pain <3 weeks duration with normal examination
D) Progressive neurological symptoms
Answer: C) Acute onset of pain <3 weeks duration with normal examination
Rationale: Low risk of serious disease with good prognosis includes patients age 20-40
with acute onset of duration <3 weeks, few previous episodes, relief by bed rest, no past
back surgery or neurological symptoms, and normal examination or muscle
spasm/tenderness only .
8. Red flags in back pain include all of the following EXCEPT:
A) Age >55 years
B) Unexplained weight loss
, Page 4 of 78
C) Pain worse at night
D) Pain relieved by sitting
Answer: D) Pain relieved by sitting
Rationale: Red flags include thoracic pain, fever, unexplained weight loss, bladder or
bowel dysfunction, history of carcinoma, progressive neurological deficit, disturbed gait,
saddle anesthesia, and age of onset <20 years or >55 years . Pain relieved by sitting is
not a red flag; in fact, this is often a feature of spinal stenosis.
9. A systems review is important in back pain evaluation. Which finding may be
associated with ankylosing spondylitis?
A) History of deafness
B) Optic neuritis
C) Iritis (in about 20% of patients)
D) Conjunctivitis
Answer: C) Iritis (in about 20% of patients)
Rationale: A history of optic neuritis may indicate multiple sclerosis, while iritis occurs in
about 20% of patients with ankylosing spondylitis. Reiter's syndrome often begins with
conjunctivitis as well as urethritis .
10. A patient with low back pain reports loss of appetite and unintentional weight
loss. This finding should raise suspicion for:
A) Muscular strain
B) Carcinoma
C) Disk herniation
D) Facet arthropathy
Answer: B) Carcinoma
Rationale: A loss of appetite or loss of weight not associated with dieting may suggest
carcinoma .
11. Bowel disturbance such as alternating diarrhea and constipation in a patient
with back pain may indicate:
A) Simple mechanical back pain
B) Late development in cauda equina lesions
