Patient Care Assessment

Figure 6a.
S1 radicular-type pain illustrated on a patient pain diagram.
Legend: Ache ^ ^ ^ ^, Numbness o o o o, Pins & Needles = = = =, Burning X X X X, Stabbing / / / /

Figure 6b.
Patient-completed pain diagram indicating symptoms not likely to be spinal in origin.

A pain visual analog scale (VAS) allows the patient to rate their pain. Other health history details (past medical and surgical history, review of systems, allergies, medications, family, social and work history) are documented. Careful attention is paid to constitutional 'red flags' in the review of systems. Red flags may include fever, chills, night sweats, unplanned weight loss, and night pain that may indicate a metabolic or neoplastic process. Previous treatment for the spinal condition is ascertained, along with diagnostic tests performed, and the presence of any litigation related to the patient's symptoms.

The physical exam includes the techniques of inspection, palpation, assessment of range of motion, neurologic status, and vascular status. Inspection should include an evaluation of posture, symmetry, and the presence of atrophy, deconditioning or swelling. The presence of café-au-lait spots (birthmarks), with a positive family history, may be a sign of neurofibromatosis. Identification of painful areas is accomplished by palpation of the spine and related extremities. Spinal range of motion (flexion, extension, rotation, side bend) and range of motion of related extremities is assessed. Reproduction of the patient's pain complaints with the specific aggravating motion is noted.

It may be necessary to differentiate pain of non-spinal origin from spinal pain by carefully assessing the shoulder, pelvis, hip, or knee for reproduction of the patient's pain complaints. The patient's gait is assessed for ataxia, weakness, and antalgia. A careful neurologic exam includes evaluation of deep tendon reflexes, motor strength (Table 1), sensory status, neurotension signs, (straight leg raise, contralateral straight leg raise, femoral stretch test), and the presence of long tract signs that may indicate myelopathy (hyperreflexia, clonus, positive Babinski, positive Hoffman's, Lhermitte's sign).

Table 1:
Motor Strength Rating

Rating and Description
5 (Normal): Range of Motion (ROM) unimpaired against gravity with full resistance.
4 (Good): Complete ROM against gravity with some resistance.
3 (Fair): Complete ROM against gravity.
2 (Poor): Complete ROM with gravity elminated.
1 (Trace): No joint motion, slight evidence contractility.
0 (Zero): No evidence of muscle contraction.

Neurogenic claudication (leg pain from spinal stenosis) may need to be differentiated from leg pain from vascular causes. Therefore, accurate vascular assessment is essential. This includes palpation of pulses, inspection for edema or discoloration of skin, and assessment of extremity temperature.

Certain physical exam techniques can screen for non-organic physical signs. Referred to as Waddell's Non-organic Signs, these include:(108)

1) Tenderness that is superficial or non-anatomic
2) Overreaction
3) Regional (versus well-localized) sensory or motor disturbances
4) Disparate findings by using unobtrusive distraction tests
5) Simulated tests

Some authors have advised caution in interpreting the meaning of these exam techniques. In two prospective studies, the presence of positive non-organic signs was not correlated with long-term outcome of return to work. (109,110) Figure 6b (above) illustrates a patient pain diagram indicating symptoms not likely to be spinal in origin.