musculoskeletal and connective tissue disorders
Evaluation of Neck and Back Pain
Evaluation of Neck and Back Pain
Because the cause of neck or back pain is often multifactorial, a definitive diagnosis cannot be established in many patients. However, clinicians should determine the following if possible: Whether pain has a spinal or extraspinal cause Whether the cause is a serious disorder If serious causes have been ruled out, back pain is sometimes classified as follows: Nonspecific neck or low back pain Neck or low back pain with radicular symptoms Lumbar spinal stenosis with claudication (neurogenic) or cervical stenosis with myelopathy Neck or low back pain associated with another spinal cause should include quality, onset, duration, severity, location, radiation, time course of pain, and alleviating and exacerbating factors such as rest, activity, changes in position, weight bearing, and time of day (eg, at night, when awakening). Accompanying symptoms to note include stiffness, numbness, paresthesias, weakness, Urinary Retention , should note symptoms suggesting a cause, including fever, sweats, and chills (infection); weight loss and poor appetite (infection or cancer); worsening of neck pain during swallowing (esophageal disorders); anorexia, nausea, vomiting, melena or hematochezia, and change in bowel function or stool (gastrointestinal disorders); urinary symptoms and flank pain (urinary tract disorders), especially if intermittent, colicky, and recurrent ( Urinary Calculi ); cough, dyspnea, and worsening during inspiration (pulmonary disorders); vaginal bleeding or discharge and pain related to menstrual cycle phase (pelvic disorders); fatigue, depressive symptoms, and headaches (multifactorial mechanical neck or back pain). includes known neck or back disorders (including Osteoporosis , Temperature and general appearance are noted. When possible, patients should be dressed in a gown and observed as they move into the examination room, walk, balance on one leg, and climb onto the table to assess gait and balance. The examination focuses on the spine and the neurologic examination. If no mechanical spinal source of pain is obvious, patients are checked for sources of localized or referred pain. In thespinal examination,the back and neck are inspected for any visible deformity, area of erythema, or vesicular rash. The spine and paravertebral muscles are palpated for tenderness, and change in muscle tone. Gross range of motion is tested. In patients with neck pain, the shoulders are examined. In patients with low back pain, the hips are examined. should assess function of the entire spinal cord. Strength, sensation, and Deep tendon reflexes are tested. Reflex tests are among the most reliable physical tests for confirming normal spinal cord function. Corticospinal tract dysfunction is indicated by upgoing great toes with the plantar response and by the Hoffman sign, most often with hyperreflexia. To test for the Hoffman sign, clinicians tap the nail or flick the volar surface of the 3rd finger; if the distal phalanx of the thumb flexes, the test is positive, usually indicating corticospinal tract dysfunction caused by stenosis of the cervical cord or a brain lesion. Sensory findings are subjective and may be unreliable. The straight leg raise test helps confirm Sciatica . The patient is supine with both knees extended and the ankles dorsiflexed. The clinician slowly raises the affected leg, keeping the knee extended. If sciatica is present, 10 to 60° of elevation typically causes symptoms. Although the knee is often palpated from behind to assess for sciatica, it is probably not a valid test for this. For the crossed straight leg raise test, the unaffected leg is raised; the test is positive if sciatica occurs in the affected leg. A positive straight leg test is sensitive but not specific for Cervical Herniated Nucleus Pulposus ; the crossed straight leg raise test is less sensitive but 90% specific. The seated straight leg raise test is done while patients are seated with the hip joint flexed at 90°; the lower leg is slowly raised until the knee is fully extended. If sciatica is present, the pain in the spine (and often the radicular symptoms) occurs as the leg is extended. The slump test is similar to the straight leg raise test in applying traction on spinal nerve roots but is done with the patient "slumping" (with the thoracic and lumbar spines flexed) and the neck flexed while the patient is seated. The slump test is more sensitive, but less specific, for disk herniation than the straight leg raise test. 55, a pulsatile mass (which suggests Abdominal Aortic Aneurysms (AAA) ). With a fist, clinicians percuss the costovertebral angle for tenderness, suggesting including stool testing for occult blood and, in men, prostate examination, is done. Rectal tone and reflexes are assessed. In women with symptoms suggesting a pelvic disorder or with unexplained fever, Physical Examination is done. Lower-extremity pulses are checked. The following findings are of particular concern: Abdominal aorta that is > 5 cm (particularly if tender) or lower-extremity pulse deficits Acute, tearing upper and midback pain Cancer, diagnosed or suspected Neurologic deficit Fever or chills Gastrointestinal findings such as localized abdominal tenderness, peritoneal signs, melena, or hematochezia Infection risk factors (eg, immunosuppression; IV drug use; recent surgery, penetrating trauma, or bacterial infection) Meningismus Severe nocturnal or disabling pain Unexplained weight loss Although serious extraspinal disorders (eg, cancers, Abdominal Aortic Aneurysms (AAA) , epidural abscesses, Red flag findings should heighten suspicion of a serious cause (see table). Other findings are also helpful. Worsening of pain with flexion is consistent with intervertebral disk disease; worsening with extension suggests Lumbar Spinal Stenosis or arthritis affecting the facet joints. Tenderness over certain specific trigger points suggests muscle pain caused by a spinal disorder. Generalized tenderness and nonlocalized allodynia suggests a central pain disorder. 