Clinical Evaluation

• A careful history is the first part of a clinical evaluation as this is where most diagnoses are made.
• Primary disorders of the spine as well possible systemic processes which affect the spine (metastatic disease or spondyloarthropathies) must be considered
• Location, quality, chronicity, prior surgery, exacerbating or relieving factors should all be sought.
• Spine disorders can manifest with back or neck symptoms, leg or arm symptoms or combinations of spine and extremity symptoms.
• Associated neurologic signs and symptoms such as sensory or motor changes should be elucidated.
• Disturbance of bowel or bladder function in the absence of upper motor neuron signs and symptoms should prompt an evaluation for cauda equina syndrome (see below).

History or Present Illness & Review of Systems:

• The back pain of disc herniation is worse when the patient is sitting probably from increased intradiscal pressure in a relatively static posture.
• Neurogenic claudication from spinal stenosis is characterized by diffuse back and leg pain symptoms that are relieved by sitting or leaning forward
• Secondary gain issues in the way of workers’ compensation claims need to be noted because treatment results, particularly surgical ones, are uniformly worse in this population.
• Age is important when considering a diagnosis. Disk herniation is common in adults younger than 55, and spinal stenosis is far more common in those older than 60 years old.
• Constant unremitting pain is suggestive of tumor or infection. Night pain is classically thought of as a symptom of these “red flag” diagnoses. Other symptoms such as malaise, fever, or unintended weight loss may be present. Pyogenic vertebral osteomyelitis is seen more often in older, debilitated patients and intravenous drug abusers.
• Inflammatory arthritides (such as rheumatoid arthritis) are more common in the axial skeleton and may lead to pain or stiffness complaints. This pain is usually worst in the morning and improves throughout the day. Cervical spine involvement is common in rheumatoid arthritis. Low back pain is seen less commonly in rheumatoid arthritis but is often seen in the seronegative spondyloarthropathies.
• Visceral sources of referred back pain include peptic ulcers, cholecystitis, pancreatitis, appendicitis, abdominal aneurysms, endometriosis or prostate disease.
• Psychiatric status is also important and may contribute to signs or symptoms of spinal disorders and predictability of outcomes of treatment.
• Patients who have numerous spine operations are particularly hard to evaluate and are sometimes referred to as “failed back” patients.
• The objective is to identify those patients with a surgically correctable, mechanical lesion such as a recurrent herniated disc, spinal instability or stenosis.
• Patients with scar tissue causing arachnoiditis or epidural fibrosis and psychological instability are best treated by nonsurgical means.
• Pain unchanged by surgery implies lack of adequate decompression, exploration of the wrong level, or possibly the wrong choice of a patient.
• Pain that begins six to 12 months after surgery suggests the possibility of a recurrent disk herniation at the same or different level.
• A pain-free interval of between one and six months with gradual onset of pain is consistent with scar tissue formation. Scar and recurrent disk herniation are best differentiated with a gadolinium enhanced MRI scan. Scar which is vascular, enhances markedly whereas disk, which is avascular, does not.

Physical Examination:

After a thorough history, examination of tenderness, range of motion, neurological evaluation and provocative testing should be performed.

Cervical Spine:

• In the trauma patient, posterior tenderness suggests ligamentous injury or a spinous process fracture.
• Generalized posterior paraspinal tenderness may also signify simple muscle strain.
• Tenderness over the spinous processes is more indicative of a bony injury
• A lateral shift may indicate a unilateral facet dislocation.
• Tenderness over the trapezius may be related to direct trauma, spasm, or referred pain from an underlying cervical condition such as tumor or infection.
• Active range of motion: the normal patient is capable of touching chin to chest in flexion and bringing the occiput within three to four fingerbreadths of the dorsal spine in extension. Rotation approximates 90 degrees while lateral bending should approach a 45 degree bend.
• Neurologic evaluation is an essential part of the clinical evaluation. Motor, sensory and reflex activity, if appropriate, are checked at each cervical level.