Fady Y. Hijji, Ankur S. Narain, Junyoung Ahn, Philip K. Louie, Daniel D. Bohl, and Kern Singh

8.1 Spinal History

8.1.1 Background

• Obtaining an accurate clinical history is the most important aspect of evaluation:

– Physical examination.

– Diagnostic imaging.

– Urgency of spinal pathology.

– Therapeutic modalities.

8.1.2 History

• Age:

– Younger than 40 years: isthmic spondylolisthesis, disk herniation, congenital deformities.

– Older than 40 years: degenerative disk disease, spinal stenosis, disk herniation.

• Pain:

– Character:

∘ Axial versus radicular:

▪ Axial: more diffuse/generalized.

▪ Radicular (extremities): pain associated with paresthesias, numbness, weakness in a dermatomal distribution.

∘ Mechanical versus nonmechanical:

▪ Mechanical: worse with activity, progresses over the day, relief with rest.

▪ Nonmechanical: independent of activity or rest, worse at night.

– Location:

∘ Determine anatomic location (neck, back, upper or lower extremity) and presence of radiation:

▪ Must distinguish pain due to radiation versus referred pain:

❖ Radiating: pain pattern not localizable to a specific dermatome.

❖ Referred pain:

◊ Shoulder pain referred form cervical spine.

◊ Buttocks/posterior thigh pain referred from lumbar spine.

∘ Determine unilateral versus bilateral nature.

∘ Acute: associated with lumbar muscle strain, disk herniation, spondylolisthesis.

∘ Progressive: spondylosis, spondylolisthesis, tumor.

∘ Night pain: associated with space-occupying lesions (tumors) and infections.

– Alleviating and exacerbating factors:

∘ Can distinguish spinal stenosis (neurogenic claudication), disk herniation:

▪ Spinal stenosis improves with sitting, leaning forward:

❖ Vascular claudication differs in that pain is exacerbated by physical activity, pain relief occurs with rest, and weakness is not typically present.

▪ Herniation pain improves with lumbar extension, worse with flexion.

• Mechanism of injury:

– Trauma: assess airway, breathing, circulation.

– Activity: often associated with sports.

– Progressive/atraumatic: common with degenerative conditions.

• Neurologic symptoms:

– Radiculopathy or neuropathy: paresthesias, numbness, weakness in a dermatomal pattern.

– Myelopathy: broad-based gait, clumsiness, inability to perform fine motor activities, pain in a nondermatomal pattern.

• Constitutional symptoms:

– Accompanying fevers, chills, night sweats, and significant weight loss may be consistent with infectious or oncologic etiologies.

• Patient factors that may be associated with spinal pathology:

– Past medical history:

∘ Previous infections, diagnosed tumors, childhood illnesses, neurological diseases.

∘ Mental disorders (depression, anxiety) may be associated with low back pain.

∘ Underlying systemic illnesses.

– Family history:

∘ Previous history of spinal pathology, spinal tumors, and other cancers.

– Social history:

∘ Inquire about occupation, job satisfaction, previous workers’ compensation–related injuries.

∘ Recreational activities.

∘ Smoking, illicit drug use.

8.2 Physical Examination

8.2.1 Background

• Physical examination is crucial for narrowing differential diagnoses to identify spine pathology:

– Must be individualized to patient’s presentation:

∘ History.

∘ Imaging findings.

• Physical examination includes five main components:

– General:

∘ Inspection.

∘ Palpation.

∘ Range of motion.

∘ Walking gait.

– Sensory.

– Motor.

– Reflexes.

– Special maneuvers.

8.2.2 General Physical Examination

• Inspection:

– Skin:

∘ Must disrobe patient adequately for appropriate assessment.

∘ Inspect for any unique growths or lesions:

▪ Café au lait spots:

❖ Neurofibromatosis.

▪ Hair tufts in lumbar region:

❖ Spina bifida.

– Muscle tone/bulk:

∘ Inspect for muscle size or abnormal contractions:

▪ Atrophy:

❖ Chronic neuropathy consequently decreasing muscle fiber innervation and usage.

▪ Fasciculations:

❖ Neuropathy causing limited innervation of muscle fibers:

◊ Inability to stimulate full muscle contraction.

▪ Contractures:

❖ Chronic upper motor neuron pathology causing long-term immobilization and spasticity:

◊ Reorganization of collagen fibers leads to muscles being held in shortened position for extended periods of time.

– Posture and alignment:

∘ Inspect spinal alignment, abnormal bony prominences, and upright position of patient:

▪ Malalignment:

❖ Forward-bending test:

❖ Can be associated with abnormal rib and iliac crest prominences.

▪ Neck or pelvic tilting:

❖ Paraspinal muscle spasms:

◊ Consider torticollis in severe neck tilting with pediatric patients or patients taking dopamine antagonist medications.

• Palpation:

– Soft tissue:

∘ Firm palpation of paraspinal muscles to assess for tenderness:

▪ Paraspinal muscle tenderness:

❖ Can indicate paraspinal muscle spasm, trauma, or myofascial nodes.

– Bony structures:

∘ Firm palpation of spinous processes, sacrum, and coccyx:

▪ Spinous process tenderness:

❖ Can indicate spinous process fracture.

▪ Coccygeal tenderness:

❖ Possible fracture or contusion.

• Range of motion:

– Cervical:

∘ Flexion/extension:

▪ Chin to chest and occiput to back.

▪ Normal flexion: 45 degrees or within 3 to 4 cm of touching chest.

▪ Normal extension: 70 degrees.

∘ Lateral flexion:

▪ Bending ear to shoulder.

▪ Normal: 30 to 40 degrees in each direction.

∘ Rotation:

▪ Turning head in either direction with stationary shoulders.

▪ Normal: 70 degrees in each direction.

– Lumbar:

∘ Flexion/extension:

▪ Toe touch with straight legs and leaning backward.

▪ Normal flexion: 45 to 60 degrees.

▪ Normal extension: 20 to 30 degrees.

∘ Lateral flexion:

▪ Bend at waist to either side.

▪ Normal: 10 to 20 degrees in each direction.

∘ Rotation:

▪ Rotating at the waist with hips stationary.

▪ Normal: 5 to 15 degrees.

– Patient walks across examination room.

– Inspect for abnormal movements or postures:

∘ Wide-based gait:

▪ Late finding in myelopathy, usually involving the posterior columns of the spinal cord.

∘ Leaning forward:

▪ Often indicates spinal stenosis.

▪ Spinal flexion increases space within spinal canal.