Physical and Neurological Examination

Taking a Medical History

A surgeon’s ability to efficiently obtain a thorough history by being a good listener is foundational. Validating the impact of patients pain or disability on their quality of life or ability to function facilitates building rapport. Communicating a genuine willingness to offer both surgical and nonsurgical treatment is of paramount importance. By using open-ended questions early in the interview, the physician encourages patients to articulate their specific goals for restored function or pain relief and empowers the patient as a partner to help set treatment goals. Subsequent physician-generated focused questions will elicit the necessary information to formulate a preliminary differential diagnosis. At the end of the encounter, patients gain greater confidence in the physician when pertinent elements of the history and findings on the examination are used to explain the management plan.

The patient’s medical history should be used to help determine if the source of symptoms is likely coming from injury to the nervous system or injury to nonneurological structures. Nervous system involvement occurs in patterns. For example, motor or sensory symptoms that affect one side of the body, including the arm and leg, most often arise from the CNS. Sensory symptoms that envelop an entire limb or one side of the body also suggest a central etiology, given the number of individual dermatomes that would need to be involved on a nerve root or nerve basis. Patchy motor or sensory involvement of a limb suggests peripheral nervous system involvement.

The initial evaluation should include an assessment of risk factors by history that increase the index of suspicion for an urgent underlying etiology. These risk factors include a prior history of cancer, pain at rest or that awakens the patient from sleep, prior head or spine trauma, chronic steroid use, intravenous drug use, new urinary incontinence, or history of a new and rapidly progressive neurological deficit. Other concurrent medical illnesses that may influence diagnosis or management, such as diabetes, peripheral vascular disease, inflammatory arthropathies, neoplastic disorders, focal neuropathies in the limbs, tobacco use, and limb or limb joint pathology, should be collected routinely. Smoking history is important, because smoking has been demonstrated to increase the incidence of pseudoarthrosis. The history of a chronic pain syndrome (e.g., fibromyalgia or reflex sympathetic dystrophy) or a psychiatric disorder helps to inform the likely range of patient reactions to pain, disability, or therapeutic interventions.

Taking a good pain history is essential. Local pain in the back, neck, or limbs is commonly because of pathology in the skin, joints, or muscles. Nonneurological pain-sensitive structures of the spine include the facet and sacroiliac (SI) joints, vertebral periosteum, dura, connective tissue, and blood vessels. Combined back or neck pain with limb pain can be caused by nerve tissue injury or reflect referred pain from pain-sensitive spine structures, such as facet joints. The presence of a burning or electrical component to the pain affecting a patch of skin is more suggestive for nerve tissue injury than other pain quality descriptions. Radicular pain tends to occur in the distribution of the affected nerve root, whereas nonneurological sources of pain often cross multiple nerve or nerve root dermatomes. Limb pain caused by focal nerve injury occurs in the distribution of the nerve. Mechanical back pain resulting from injury to pain-sensitive structures of the spine tends to be worse with movement and relieved with rest.

There are several other common patterns of pain: (1) exertional calf pain triggered by walking, relieved by sitting, and absent when using a stationary bike or leaning over a shopping cart is often due to severe lumbar spinal stenosis that improves in the sitting position; (2) paresthesias in the hands that awaken the patient at night and are relieved by shaking the hands suggests median nerve entrapment at the wrist (carpal tunnel syndrome); and (3) pain or paresthesia radiating to the arms and associated with medial scapular pain may be radicular in origin or caused by brachial neuritis.

General Physical Examination

Although a comprehensive general physical examination may not be feasible in every patient, the medical history can serve as an initial guide to performing a focused examination of other organ systems. Vital signs should be recorded. Unexplained, documented fever or weight loss are risk factors for a cause of spine pain requiring prompt attention, such as metastatic tumor or infection. A history or examination revealing cardiorespiratory, abdominopelvic, or limb symptoms or examination findings can significantly inform the diagnosis and operative risk in a patient.

Specific general examination findings should be sought. For example, gallbladder disease or abdominal aortic aneurysm (AAA) may present with back rather than abdominal or pelvic pain. Palpation of the abdomen may reveal right upper quadrant tenderness (gallbladder) or a midline pulsatile mass (AAA). Nephrolithiasis can be mistaken for an upper lumbar radiculopathy and may be screened for by gentle percussion over the lumbar paraspinal musculature. In patients with symptoms of claudication, the peripheral pulses are palpated. The skin of the legs is inspected for edema, skin ulceration, loss of hair, and other signs of peripheral vascular disease or polyneuropathy. The skin should be inspected for café au lait spots and other sequelae of neurofibromatosis.

Spine Examination

The entire spine should be inspected for scars from old trauma or prior surgery. The dorsal midline skin should be carefully inspected for a sinus tract, dimpling, abnormal pigmentation, fatty masses, or tufts of hair, all of which could signal an underlying congenital spinal anomaly.