3
The Supremacy of the Clinical Evaluation

Roberto Chapa Sosa and Neil N. Patel

■ Introduction

A comprehensive clinical history and physical examination is imperative to enable physicians to thoroughly and accurately assess patient with back pain, a complaint that may be complex and multifactorial. Clinical history should include time of onset of symptoms (acute < 12 weeks vs. chronic ≥ 12 weeks),¹ quality and intensity of pain, aggravating and alleviating factors, and any concerning red flag symptoms (bowel or bladder dysfunction, fevers, night sweats, unexpected weight loss, progressive weakness, etc.). Physical examination should assess for point tenderness and location of pain, aggravation or alleviation with flexion and extension of the lumbar spine, and a complete neurologic exam. The clinical history and physical examination in conjunction with appropriate imaging and possible lab work may help to tease out the true etiology of the patient’s back pain.2

At times, history and physical examination are not completely performed and advanced imaging tests (computed tomography [CT] or magnetic resonance imaging [MRI]) are ordered early in the diagnostic process. This can be misleading and can incorrectly diagnose the etiology of the patient’s symptoms. Boden et al. performed a study that suggested that MRI finding can be highly misleading if used alone.³

This study prospectively reviewed 67 patients with no lumbar spine symptoms and found a lumbar spine abnormality on MRI in 20% of study subjects less than the age of 60 and 57% of study subjects 60 years or older. This suggests that if the diagnostic process is rushed and treatment is highly reliant on imaging without correlative clinical history and physical exam, the treatment may be misguided and consequently unsuccessful.^4–6

■ Clinical History

The diagnostic process begins with a complete clinical history which can help physicians identify the etiology of the patient’s symptoms. Especially in the setting of back pain, which can be vague and ambiguous, certain clinical clues can help narrow differential diagnoses. For example, back pain in a slender, postmenopausal woman can prompt a physician to evaluate for osteoporotic compression fractures, especially in the setting of previous osteoporotic fractures, chronic steroid use, or history of osteoporosis. Overall, the clinical history should include specifics regarding onset of symptoms, quality and intensity of pain, aggravating and alleviating factors, and any concerning red flag symptoms (bowel or bladder dysfunction, fevers, night sweats, unexpected weight loss, progressive weakness, etc.). Along with that, the history should include other medical diagnoses, previous surgeries, current and previous medications, social history, psychosocial status, and employment status.

One key aspect of successful management of back pain is analysis of response to previous treatments, which may include anti inflammatory medications, physical therapy, diagnostic and therapeutic injections, chiropractic care, and acupuncture. Specifically, diagnostic and therapeutic injections can be useful to determine the cause of the patient’s symptoms, especially if successful response with relief is noted with targeted injections.

As discussed, the location and quality of pain can give clues to its etiology (Fig. 3.1). For example, if pain is more paraspinal and cramping, a muscular cause can be inferred. However, if the pain follows a dermatomal distribution and is worse with flexion, a disc related neurologic compression should be high on the differential diagnosis. In an over simplified general manner of thinking, back pain worse with flexion is likely diskogenic, where as back pain worse with extension is likely related to the posterior elements (facet arthropathy, pars fracture, etc.). A thorough understanding of spine anatomy, biomechanics, and load distribution is essential in the diagnostic process.¹

Fig. 3.1 Diagrams on which the patient can indicate the site of the pain.

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