The initial assessment: An overview
Derived from federal guidelines as published by the Agency for Healthcare Research and Quality (AHRQ), formerly Agency for Healthcare Policy and Research (AHCPR).
Primary care assessment
Institute for Clinical Systems Improvement, www.icsi.org
- Obtain a pertinent spinal history.
- Perform a focused examination to rule out serious secondary causes of spinal pain. The information below provides a basis for the history and physical exam.
For more information:
- Managing non-specific spinal pain
- Managing acute disc herniations
- Philosophical approaches to managing spinal pain
HISTORY: Patient History form
- Does onset have cause/effect relationship; fall, lifting/twisting injury?
- What are main symptoms: pain, numbness, weakness, extremity pain, other radiations, bowel/bladder complaints?
- Is pain constant vs. intermittent?
- How limiting are the symptoms: difficulty walking, sitting, sleeping, working, and doing sports/household activities?
- What is the duration of symptoms; acute vs. chronic recurrent vs. long term chronic?
- Are there any prior treatments – how effective were they?
- What are patient goals of this medical visit?
- Constitutional questions: fever, chills, night sweats, H/O Ca, weight loss…
HISTORICAL RED FLAGS:
- H/O unexplained, concurrent fever, chills, night sweats, weight loss
- H/O malignancy
- Retention/loss of bowel bladder control (cauda equina?)
- H/O severe pain that wakes patient from sleep and not relieved by position change
- H/O progressive motor deficit
- Severe acute pain with unexplained onset; i.e. no injury, fall, etc.
- Athletic injury, especially in adolescents
- Throbbing, unrelenting LBP with H/O ASCVD; i.e. aneurysm
- Unexplained spinal pain in the elderly, alcoholic, steroid user
- Osteoporosis
PHYSICAL EXAM: focused on spinal/extremity complaints but modified
based on history, i.e. abdominal/peripheral pulses, clonus, cerebellar functions,
lymphadenopathy,…
1. General Observation And Regional Back Exam:
- Note general appearance of patient; can’t sit, severe pain look, bent over, gait, etc.
- Assess general range of motion; spasm/tilted or twisted posture.
- Palpate affected region of spine, midline, paravertebral, CVA, SI joints, scapular area or other areas of pain complaints.
- Observe for any unusual skin appearances; spina bifida, café au lait spots
2. Neurologic Assessment: see the nerve root syndrome illutstrations. As more than 90% of lumbar nerve root complaints come from the L3-L4 disc (L4 nerve root), the L4-L5 disc (L5 nerve root) or the L5-S1 disc (S1 nerve root) these are explained below.
- L5-S1 disc level (S1 nerve root):
- Motor: screen by toe walking strength, general foot/toe plantar flexion strength (or 10 rapid single leg toe raises)
- Sensory: lateral foot
- Reflex: ankle jerk
- L4-L5 disc level (L5 nerve root):
- Motor: screen by heel walk, extensor hallicus longes (EHL) is most specific – great toe dorsiflexion strength, also general foot dorsiflexion strength
- Sensory: dorsum of foot, 1st (great toe) web space very specific
- Reflex: NONE
- L3-L4 disc level (L4 nerve root):
- Motor: screen by doing squat and rise (quad strength) – mainly L4
- Sensory: medial foot
- Reflex: knee jerk
- Nerve Tension Signs:
- Straight leg raising (SLR) should be done with the patient in the supine position. While the patient has his or her knee locked, explain that you will gently raise the leg.
- Pain below the knee in a radicular location reproduced with the leg elevated less than 70 degrees from the table and aggravated by foot dorsiflexion/relieved by foot plantar flexion suggest L5 or S1 nerve root tension.
- Reproducing low back pain alone does not indicate nerve root tension. Crossover SLR positivity (raising non-affected leg reproduces pain below the knee on the affected side) is highly suggestive of nerve root compression. The reverse straight leg raising test or femorel stretch also causes root tension at L2, L3 and L4.
- For cervical and higher lumbar nerve root syndromes: see the nerve root syndrome illutstrations.
3. Inconsistent Findings: document pain behaviors such as excessive groaning, laughing while describing severe pain, amplified grimacing, excessive rubbing of affected body part.
- Waddell signs- Psychosocial Screening and Assessment Tools - when linked, scroll down to pages 23 - 25, should be assessed in patients with potential secondary gain issues:
- Axial head compression reproduces severe lumbar complaints
- Trunk twisting reproduces severe lumbar complaints
- Cogwheeling (give away) strength testing
- Non-dermatomal sensory loss; global leg deficits, unusual locations of loss
- Discrepancies between sitting and supine SLR testing
- Non-anatomic pain locations; alar wings, lateral hip areas, etc.
- Light touch to the area produces extreme pain
- Light pinch over affected area results in deep pain complaints
4. Broadened Physical Exam: Your exam of spinal complaints should be broadened
based on the your need to rule out specific secondary causes of spinal/extremity
complaints.
EXAM RED FLAGS:
- Profound/progressive motor loss
- Unexplainable neurologic deficits
- Decreased sphincter tone/saddle anesthesia with fears of cauda equina
- Severe pinpoint vertebral pain
- Upper motor neuron findings i.e. clonus, + Babinski, etc.
- Myelopathy with general weakness
- Ataxia gait