Clinical assessment

An accurate history must be obtained including:

• Duration of symptoms, whether acute onset or deterioration of a chronic problem, any associated precipitating events such as a traumatic incident and factors that exacerbate or relieve the pain.

• Precise location of pain and whether there is any referred pain to the lower limbs.

Figure 22.36. Adolescent idiopathic scoliosis.

• Accurate systems review, particularly with regard to weight loss, fevers, sweats and a nocturnal component to the pain; genitourinary or gastrointestinal pathology or associated ocular symptoms.

• Sphincter disturbance and any neurological deficits in the lower limbs associated with back pain.

• Extent to which symptoms interfere with the patient's lifestyle, namely domestic and social duties, employment, sports and hobbies.

• Nature of any past treatment, be it conservative or operative, and how effective it has been. Has the patient's requirement for analgesics and anti-inflammatory agents increased recently?

• Whether the patient is a smoker.

• Family history of back problems or history of spinal deformity diagnosed in childhood and any treatment undertaken for this.

Although the vast majority of patients presenting to the orthopaedic clinic with symptoms of back pain generally have degenerative lumbosacral spine disease, vigilance is required to ensure symptoms representative of tumours or infections of the spine are not overlooked. These are comparatively uncommon but if the diagnosis is missed the consequences

Figure 22.37. Spondylyosis at L2/L3.

are catastrophic. The clinician should be wary of patients who present with back pain that falls in the following categories:

• Elderly patients who present with recent onset of back pain that has never been experienced before, especially when associated with systemic symptoms such as weight loss.

• Patients who are troubled by persistent severe nocturnal back pain.

• Patients with interscapula/midthoracic pain.

• Any patient with associated neurological deficit.

• Patients presenting with back pain with bilateral radicular pain referred to the lower limbs.

• Any patient with perianal sensory disturbance or loss of sphincter control.

• Any patient with a previous diagnosis of malignant disease involving other organ systems.

A thorough clinical examination is imperative and involves:

• Identification of the exact source of the pain if possible and also any referred pain pattern into the limbs. In those with diffuse thoracic and lumbar spinal pain, assessment of respiratory excursion is also important.

• Any limitation in the range of movement of the spine and paravertebral muscle spasm.

• Tender areas must be accurately identified, whether they be over the spinous process or interspinous ligaments. Any palpable defect or step in the spinous processes should also be recognized by careful palpation.

• Spinal deformity should be noted in both the coronal and sagittal planes.

• Accurate lower limb neurological examination, including assessment of perianal sensation and anal tone. Any neurological defects need to be elucidated, including performing a rectal examination.

• Careful abdominal examination to exclude any intraabdominal masses such as aortic aneurysms, pancreatic pseudocysts, retroperitoneal lymphadenopathy, bladder distension, secondary to neurogenic sphincter disturbance.

• General assessment for signs of generalized arthropathy and ocular, integumentary and cardiac manifestations that may accompany an inflammatory spondyloarthropathy.

0 0

Post a comment