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Patient History and Physical Examination:
SECTION
12
CHAPTER
Caring for patients with spine disorders can be extremely
challenging for clinicians because of the complexities of spinal
anatomy and pathophysiology as well as the multifactorial
nature of pain. Despite extensive advances in imaging of and
interventions for the spine, a massive medical and social
problem related to spinal pain and disability remains. To
address the needs of patients with spine disorders and to select
appropriate patients for whom specic care may be benecial,
clinicians need to identify the true nature of a patient’s
problem. Frequently, the patient’s problem may extend well
beyond any anatomic derangement that can be identied on
imaging studies and involve numerous psychosocial factors in
the patient’s life. rough the history and physical examination, clinicians are able to identify not only the physical manifestations of a spine disorder but also the root causes of a
patient’s distress, suering, and disability, all of which ultimately need to be addressed if a successful outcome is to be
achieved.
A thorough history and physical examination of a patient
with a spine disorder has several aims. From a strictly medical
perspective, the examiner must be aware of the full medical
context of the patient’s complaints and how the complaints
may relate to the overall health of the patient. It is imperative
to ascertain the presence of an emergent medical problem
promptly and to identify patients who need more urgent (or
emergent) assessment and care. Clinicians must also identify
any secondary medical issues that may directly aect the care
of spine-related problems or may be associated with broader
health concerns. In a more focused sense, the history and
physical examination should allow an examiner to identify
relevant spine problems that have led to the issue for which
the patient is seeking care (e.g., the source of pain or neurologic loss, anatomic derangements). e history and physical
examination also allow the practitioner to understand the
level of function and impairment that is associated with the
patient’s presentation.
Moving beyond the strictly medical context, identication
of the factors associated with the patient’s pain and disability
that pose the dominant barriers to optimal functional recovery
is an important goal of the history and physical examination.
To decide on the appropriate intervention for a patient, it is
imperative to understand what exactly is being treated. Despite
Cervical, Thoracic, and Lumbar
Christopher J. Standaert
Stanley A. Herring
J. David Sinclair
all the attention paid to pain, frequently the patient’s sense of
suering is the real problem, particularly in patients with
chronic pain. e only way to identify the issues behind the
presentation of many patients is by asking the right questions.
is chapter addresses relevant issues in the history and
physical examination in patients with spine disorders, particularly as these issues relate to the assessment of patients seen
commonly in clinical practice, and provides information on
how to identify patients at risk for ongoing pain despite what
seems to be appropriate care for their structural problems.
Dierential Diagnosis
e dierential diagnosis of spinal pain or related symptoms
is enormous when considered in a general sense. Numerous
anatomic structures may be associated with pain, multiple
local or systemic disease processes can aect the spine, and
numerous non–spine-related structures or conditions can
result in back or neck pain or mimic syndromes related to
spine disorders.
can produce ongoing pain and disability. e ability to process
all of the available possibilities and to develop a relatively short
list of diagnostic options depends heavily on the ability to
obtain a thorough history and physical examination. It is
helpful to begin with an understanding of structures in the
spine that can be associated with pain and their patterns of
pain referral.
From an anatomic perspective, a structure must be innervated to cause pain. In the spine, the list of discrete anatomic
structures with sensory innervation (i.e., potential pain generators) includes muscles, tendons, ligaments, fascia, anulus of
the intervertebral discs, bone, zygapophyseal joints, dura
mater, nerve roots and dorsal root ganglia, and vascular ele-
1,2
ments.
origin tend to refer pain in very similar patterns, and the
pattern of pain is determined by the nerve supply to the
structure.1 e end result is that there is substantial overlap
between the referral patterns for anatomic structures of the
same spinal level, such as intervertebral discs and zygapophyseal joints, and dermatomal, myotomal, and sclerotomal
referral patterns at many spinal levels (Fig. 12.1). e location
1–5
In addition, numerous psychosocial factors
All structures of common embryologic segmental
II
183
184 DIAGNOSIS
C6
C2–C3
Dermatomes
PosteriorAnterior
Myotomes
Sclerotomes
FIG. 12.1 Dermatome, myotome, and sclerotome of C6 level showing
substantial overlap in distribution. (From Bland JH. Disorders of the Cervical
Spine: Diagnosis and Medical Management. 2nd ed. Philadelphia: WB
Saunders; 1994.)
PosteriorAnterior
PosteriorAnterior
of pain or radiating symptoms can oen be a useful feature in
the identication of an aected spinal level, although the loca-
tion of pain alone does not indicate which particular anatomic
structure is the source of the specic symptom.
e zygapophyseal joints are one of the best-studied structures in terms of pain referral patterns and relative prevalence
in patients with spinal pain. In the cervical spine, the pattern
C3–C4
C5–C6
FIG. 12.2 Map of characteristic areas of pain referred from the cervical
zygapophyseal joints (C2–C3 to C6–C7). (From Dwyer A, Aprill C, Bogduk N.
Cervical zygapophyseal joint pain patterns I: a study in normal volunteers.
Spine. 1990;15:453–457.)
C4–C5
C6–C7
of pain distribution from the stimulation of specic zygapophyseal joints has been described (Fig. 12.2).6 ose results
were subsequently validated in a study of patients with cervical
complaints based on pain distribution and response to diagnostic blocks.7 Another study using a double-block protocol
on patients with persisting symptoms aer whiplash injury
found that the prevalence of C2–C3 zygapophyseal joint pain
in patients with headache was 50%; in patients without C2–C3
zygapophyseal joint pain, the prevalence of symptoms related
to the lower cervical zygapophyseal joints was 49%.8 Although
there is far less clinical information on pain associated with
thoracic zygapophyseal joints, a similar map of referral patterns has been identied (Fig. 12.3).
9
In the lumbar spine, there has also been a great deal of
attention directed to the zygapophyseal joints as potential
sources of pain, although the relative frequency with which
they seem to be primary pain generators is less than for cervical zygapophyseal joints causing pain in patients with chronic
whiplash. A more recent study noted a 15% overall prevalence
of zygapophyseal pain in a group of 176 patients with chronic
low back pain using a diagnostic double-block protocol.10
Although pain associated with lumbar zygapophyseal joints is
generally described as occurring with lumbar extension and
rotation, the authors of that study did not nd any consistent
clinical features that were associated with the presence of a
positive diagnostic response to injections.10 Stimulation of
lumbar zygapophyseal joints can result in either local axial or,
far less frequently, radiating pain, and pain referral patterns
have been documented.
11
Multiple authors have addressed the distribution of pain
associated with intervertebral discs. Cloward12 rst described
cervical discography and noted that pain that seemed to be
emanating from irritation of the anulus resulted in radiating
pain into the thoracic or scapular regions in distinct patterns
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 185
T4–T5
T6–T7
T8–T9
T10–T11
T9–T10
B
C4
C6
T1
T3–T4
T5–T6
T7–T8
L5
FIG. 12.3 Map of characteristic areas of pain referred from thoracic
zygapophyseal joints (T3–T4 to T10–T11). (From Dreyfuss P, Tibiletti C, Dreyer
S. Thoracic zygapophyseal joint pain patterns: a study in normal volunteers.
Spine. 1994;19:807–811.)
Other pain referral patterns that should be recognized by
all physicians treating patients with spine disorders include
patterns related to neurologic injury. ese patterns are discussed further later in the section on the neurologic examination, but identifying the dermatomal pattern of pain is central
to the assessment of individuals with potential nerve root
pathology (Fig. 12.5). Nerve root symptoms include paresthesias, burning, hyperalgesia, aching, analgesia, or pain. e
ability to identify a dermatomal pattern to the symptoms can
help localize the area of spine involvement.
e clinical utility of pain provocation is uncertain because
there are inherent problems with this approach owing to the
complex nature of pain perception.
1,14–18
e identication of
a “pain generator” in individuals with chronic spinal pain can
be dicult. In contrast to cutaneous sensation, nociceptive
signals from deep somatic structures—such as joint capsules,
fascia, and periosteum—are carried by relatively few primary
aerent bers, resulting in only vague localization of pain.16
Additionally, there is the issue of convergence, in which a
single dorsal horn cell may receive synaptic input from aerent bers that innervate many structures and can result in
multiple structures producing similar patterns of pain perception. is convergence makes it extremely dicult to validate
a single entity as the cause of an individual’s pain because the
stimulation of any one of numerous structures may result in
identical perceptions of pain.16 ese issues become even
more complex when additional potential neurologic and
psychological changes that can occur with chronic pain are
involved.
SECTION
II
25
B-D
20
B-D
A
C5
FIG. 12.4 Pain referral pattern from (A) posterolateral and (B) central discs.
(From Cloward RB. Cervical discography: a contribution to the etiology and
mechanism of neck, shoulder and arm pain. Ann Surg. 1959;150:1052–1064.)
(Fig. 12.4). Similar ndings were more recently described by
others.13 As mentioned previously, pain referral patterns are
similar to patterns noted for cervical zygapophyseal joints,
with the level of spine pathology, rather than the actual structure involved, aecting the pain referral pattern.
Biomedical Factors and the Medical History
It is essential to obtain a thorough and appropriate medical
history from patients presenting with spine disorders or
related complaints. e identication of potentially serious
problems is one of the most important functions of obtaining
a good medical history. Ideally, the medical history also should
help the clinician establish a reasonable dierential diagnosis
that can direct further diagnostic or therapeutic steps. Given
the scope and complexities of spine disorders, it can be useful
to break down some aspects of the clinical presentation into
broad categories. is categorization may allow clinicians to
focus their thought process and subsequent eorts more
eectively. Useful categories to consider relate to the presence
or absence of radiating pain and specic demographic factors.
e following categories can help in obtaining a concise
medical history.
Red Flags: What Not to Miss
It is essential to identify all conditions that pose a substantial,
imminent risk for further harm to the patient. Many authors
have identied specic red ags in the history of patients with
low back complaints that indicate the presence of such a
condition; these include infection, tumor, fracture, cauda
equina injury, and progressive neurologic injury, such as
motor loss or myelopathy (Table 12.1).
19–22
Red ags for the
186 DIAGNOSIS
C8
S1
S3
C6
C5
Palm
C2
C3
C4
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1 L1
C2
T2T2
C5
C3
C4
T1T1
C6
Palm
L2
C6
C7
L4 L4
L5
FIG. 12.5 Dermatomal distribution and key sensory points. (From American Spinal Injury Association.
International Standards for Neurological Classication of Spinal Cord Injury [reprint]. Chicago: American Spinal
Injury Association; 2008.)
L2
L3L3
L5
S1S1
S1
possibility of cancer include age older than 50 years, previous
cancer history, unexplained weight loss, pain not relieved by
bed rest, duration of pain for more than 1 month, and failure
of conservative therapy aer 1 month.22 Although widely used
clinically, systematic reviews have found limited data to
support the use of any individual red ags in the identication
of patients with malignancy, with a Cochrane review noting
particularly high false-positive rates for factors such as insidious onset of pain, persistence of pain for greater than 1 month,
and age greater than 50 years.
23,24
A history of malignancy
seems to exhibit the strongest posttest probability for detecting spinal malignancy.
24
Spine infections—including discitis, osteomyelitis, and epidural abscess—are usually blood-borne from other regions.22
Important risk factors for infection include the use of illicit
S4–5
C8
C6
C7
DorsumDorsum
intravenous drugs, active or recent infection elsewhere (e.g.,
L2 L2
L3 L3
S2 S2
L4 L4
L5
S1
L5
urinary tract, pulmonary, skin, dental), and immunosuppression (owing to either medications or illness aecting
the immune system).
19,22
Additional risk factors for infection
include diabetes and history of tuberculosis or exposure to a
region endemic for tuberculosis.
e risk of fracture is elevated in patients older than 50
years, particularly patients older than 70 years.22 Patients
with a history of corticosteroid use or known osteopenia or
osteoporosis are also at increased risk for fracture. A study
of 669 patients greater than 55 years of age presenting to
their primary physician identied four patients (1%) with
malignancy and 33 (5%) with a fracture, 30 of which were
associated with osteoporosis.25 Trauma, osteoporosis, pain
greater than 7 out of 10, and thoracic pain were all associated
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 187
TABLE 12.1 “Red Flags”: Emergent or Urgent Medical Conditions That
Need to Be Identied Promptly in All Patients Presenting With Possible
Issues Related to the Spine
Possible
Symptom or Finding
History of cancer Cancer
Unexplained weight loss
50 y
Age >
Failure to respond to >1 mo of conservative care
Duration of pain >1 mo
No pain relief with bed rest
Night pain
History of smoking
Known osteopenia or osteoporosis Fracture
History of corticosteroid use
50 y
Age >
DISH or ankylosing spondylitis
Trauma (major in younger individual, minor in
older individual)
Fever Infection
Illicit use of intravenous or percutaneously
injected drugs
Recent or known infection
Immunosuppressive illness
Use of immunosuppressive medications
Tuberculosis exposure
Progressive weakness in limbs Cauda equina
Progressive balance decit or loss of coordination
Bowel or bladder dysfunction or urinary retention
Sexual dysfunction
Numbness or paresthesias in perineum or saddle
anesthesia
Signicant weakness of major muscle group or
progressive motor loss in limb
DISH, diuse idiopathic skeletal hyperostosis.
Signicance
or spinal cord
injury
Severe or
progressive
radiculopathy
with the identication of a fracture, with a history of trauma
having the strongest predictive value.25 Trauma and fracture
risk are discussed further elsewhere in this book.
Signicant neurologic injuries include cauda equina
syndrome, progressive radiculopathy, or myelopathy. Cauda
equina syndrome should be considered in a patient with
saddle anesthesia; bowel, bladder, or sexual dysfunction; or
signicant lower extremity pain and weakness, particularly
if bilateral.
19,22
Progressive neurologic loss from nerve root
compression is an indication for urgent surgical intervention,
thus needs to be identied promptly. Myelopathy can present
in various ways, including hand paresthesias or decreased ne
motor control; lower extremity weakness or gait instability;
sensory alterations in the trunk or extremities; or changes in
bowel, bladder, or sexual function.
26
Historical Features of the Presenting Complaint
Specifying the exact nature of the patient’s chief complaint and
provocative and palliative factors is an extremely important
part of the diagnostic assessment. e examiner must identify
the nature, onset, duration, and course of the primary complaint; history of previous injury; character and distribution
of symptoms; prior diagnostic testing and treatment; other
circumstances surrounding an injury (e.g., perceived fault, the
presence of workers’ compensation or litigation status); and
the degree of pain and disability perceived by the patient. All
of these factors are important in establishing an appropriate
dierential diagnosis and identifying some of the potential
barriers to recovery.
Axial Versus Radicular Pain
e distinction between axial and radicular pain is fundamental in assessing a patient with a potentially neurogenic problem.
Axial pain in the cervical, thoracic, or lumbar region suggests
a dierent etiology, evaluation, diagnosis, and potentially
treatment than radicular pain. For all levels of the spine,
pathology involving the musculotendinous and ligamentous
structures, zygapophyseal joints, vertebrae, and anulus of the
intervertebral discs tends to cause axial pain. Other structures
in the cervical and thoracic regions that can result in axial pain
include so tissue structures in the neck; vascular structures
(e.g., aorta or carotid arteries); portions of the brachial plexus,
such as the long thoracic or suprascapular nerves; the proximal
portion of the ribs; costovertebral or costotransverse articulations; various structures within the shoulder; and various
visceral structures, including the pancreas, gallbladder, lung
and pleura, and stomach or duodenum (Fig. 12.6).
Radicular pain radiating into the upper extremities gener-
ally has a dierent etiology. If related to spine pathology,
radicular pain implies neural compression from many potential causes, including disc herniation, spinal canal or neuroforaminal stenosis, or intrinsic disease of the spinal cord or
nerve roots (e.g., herpes zoster). Radicular pain in the thoracic
region can result in a bandlike distribution on one or both
sides of the chest wall or abdominal region. Additional structures that can result in radiating upper extremity pain include
peripheral nerves, such as the median nerve (e.g., carpal
tunnel syndrome); ulnar nerve; portions of the brachial plexus
(e.g., lower trunk plexopathies related to true neurogenic
thoracic outlet syndrome or a Pancoast tumor); vascular
structures; the shoulder; the heart; and musculotendinous,
ligamentous, or bony structures in the upper extremities.
For the lumbar spine, the hip and pelvic structures must be
considered as potential sources of low back, buttocks, or
posterolateral hip pain. Particular sources of low back or
buttock pain related to the bony pelvis include the sacroiliac
joints, the sacrum (e.g., stress fractures), the ilia, and the hip
joints. Other structures and processes that can result in low
back pain include the kidneys and ureters; the pancreas;
gastric ulcers; vascular abnormalities (e.g., aortic aneurysm);
and retroperitoneal processes such as hematoma, endometriosis, or lymphadenopathy associated with malignancy.
27
SECTION
II
188 DIAGNOSIS
Temporomandibular
or without perforation
Gallbladder
Lesions of mediastinum
Pancreas
As with upper extremity pain, lower extremity radicular
pain oen has dierent etiologies and generally implies
involvement of the lumbosacral nerve roots, the conus medullaris, or the spinal cord. e lumbar zygapophyseal joints and
the sacroiliac joints also may occasionally be associated with
radicular leg pain.
may arise from intraarticular hip pathology; greater trochanteric bursitis; vascular pathology (e.g., vascular claudication);
peripheral nerve injuries; compartment syndrome; local
musculotendinous, ligamentous, or bony structures; and
pelvic causes, such as endometriosis. Whatever the cause, the
presence of leg pain with low back pain appears to increase
the overall severity of the clinical state. Compared with those
who have axial lumbar pain alone, patients with associated
radicular pain experience a lower quality of life, require more
resources, and have higher levels of pain and disability.29 Given
this, eorts to identify and appropriately treat the cause of leg
symptoms have particular importance.
Patient Demographics
Demographic characteristics—such as age, gender, educational
background, occupation, and cultural milieu—are important
factors that must be considered in the history of a patient with
a spine problem. Age is a primary determinant in establishing
a dierential diagnosis. Dierent spine problems appear at
dierent frequencies at dierent ages. e social and psycho-
logical issues of individuals can also be quite distinct at dierent ages.
Growth and development have a profound impact on the
approach to various processes, such as spondylolisthesis,
scoliosis, and Scheuermann kyphosis. In contrast to the adult
spine, the developing bony spine is relatively more prone to
injury than some so tissue structures. In a study by Micheli
and Wood,30 47% of adolescents presenting to a pediatric
sports medicine clinic were diagnosed with spondylolysis and
only 11% had disc abnormalities compared with 48% of adults
presenting to a low back pain clinic who were thought to have
disc pathology. Generally, symptomatic isthmic spondylolysis
is almost entirely seen in older children, adolescents, or young
Cystic duct stone
Pancreatic disease
Esophageal hernia
Gastric ulcer
Gallbladder disease
Hiatal hernia
Duodenal ulcer with
Gastric ulcer
Tail of pancreas
FIG. 12.6 Posterior referral sites from distant visceral or somatic structures. (From Nakano KK. Neck pain. In:
Kelley WN, Harris ED Jr., Ruddy S, et al, eds. Textbook of Rheumatology. 4th ed. Philadelphia: WB Saunders; 1993.)
joint
Gallbladder:
common duct stone
and lung
Perforated peptic ulcer
involving pancreas
Duodenal ulcer
Head of pancreas
Gallbladder
adults, and the rate of pars defects identied in the general
population does not change substantially between the ages of
20 and 80 years.
31,32
Although 50% or more of children may
be aected by low back pain by age 15 years,
spinal pain in children is uncommon and should raise concern
11,28
Distal lower extremity symptoms also
for the presence of serious medical pathology.
neoplasm, rheumatologic conditions such as ankylosing
spondylitis and juvenile rheumatoid arthritis, and other nonspine sources of pain may be more common in children and
adolescents than in adults.
35,36
In adults, the frequency of certain spine conditions varies
by age group. Disc herniations are most frequent during the
4th and 5th decades, although they can aect individuals in
their 50s and 60s or children and young adults.37 Degenerative
spinal stenosis and degenerative spondylolisthesis tend to
present later in life. As mentioned previously, some medical
conditions, including ankylosing spondylitis, spondylitis
associated with inammatory bowel disease, and tumors such
as osteoid osteoma and osteoblastoma, tend to manifest in
younger adults (20s and 30s). Other conditions—such as
osteoporosis, polymyalgia rheumatica, metastatic cancer, or
multiple myeloma—tend to occur in older adults (40s and 50s
or older; Fig. 12.7).
3,38
Gender is a factor in many spine pathologies. Osteoporosis
is more common in women than in men, and osteoporotic
fractures are more common in women. Neck pain also has
been noted to be more prevalent in women than in men.
Rheumatoid arthritis, polymyalgia rheumatica, and endocrine
disorders also tend to occur more frequently in women.38
Spondyloarthropathies, infections, and various spine tumors—
such as multiple myeloma, lymphoma, osteoblastoma, and
eosinophilic granuloma—occur more frequently in men.
Demographic factors—such as race, ethnicity, and cultural
milieu—may also play a role in the prevalence of some spine
disorders, but are less well studied. Whites tend to have higher
rates of osteoporosis than some other races, and metabolic
conditions such as Gaucher disease can be associated with
certain ethnic groups.3 Whites have a higher rate of spondylolysis than African Americans.31 e prevalence of low
back pain also varies in dierent parts of the world, with
33,34
signicant
35,36
Infection,
39,40
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 189
20 30 40 50 60 70
20 30 40 50 60 70
Ankylosing spondylitis
Aneurysmal bone cyst
Inflammatory bowel disease
Herpes zoster
Lymphoma
Osteoid osteoma
Sickle cell anemia
Vertebral sarcoidosis
Genetic disorders
Reiter syndrome
Osteoblastoma
Giant cell tumor
Eosinophilic granuloma
Osteochondroma
Rheumatoid arthritis
Lyme disease
Herniated nucleus pulposus
Muscle strain
Subacute bacterial endocarditis
Pituitary disease
Fibromyalgia
Intraspinal neoplasms
Ochronosis
Psoriatic spondylitis
Hemangioma
Microcrystalline disease
Osteoarthritis
DISH
Paget disease
Osteomyelitis
Chondrosarcoma
Chordoma
Osteoporosis
Metastases
Polymyalgia rheumatica
Spinal stenosis
SECTION
II
Cervical angina
Neuropathy (Charcot's joint)
Multiple myeloma
Parathyroid disease
FIG. 12.7 Age at peak incidence of neck pain associated with various disorders. DISH, diuse idiopathic
skeletal hyperostosis. (From Borenstein DG, Wiesel SW, Boden SD. Neck Pain: Medical Diagnosis and
Comprehensive Management. Philadelphia, WB Saunders; 1996.)
industrialized regions reporting a higher prevalence of low
back complaints than rural, low-income areas.41 Pain perception, disability, and other eects of pain on individuals vary
widely and depend on many cultural and social factors.
Past Medical History
In addition to identifying prior surgical procedures, it is
important to identify all past and current medical conditions
because many medical problems can be associated with spine
issues and can aect care of a patient with a spine disorder.
As noted previously, a history of cancer, recent infection, or
disease processes that aect the immune system or may require
immunosuppressive medications can be associated with sig-
nicant spine problems. Other medical conditions—such as
osteoporosis, ankylosing spondylitis, and diuse idiopathic
skeletal hyperostosis—may place patients at increased risk for
spine fracture.42 Some congenital or genetic syndromes, such
as Marfan syndrome and Down syndrome, can be associated
with spine anomalies that must be identied. Vascular disease,
190 DIAGNOSIS
such as vascular claudication or aortic aneurysm, can produce
symptoms that mimic spine pathology. Other disorders—
including cardiac or pulmonary disease, renal disorders, skin
conditions, gastric ulcers, diabetes, and hepatic disorder—
may have an impact on potential treatment options and may
preclude certain therapies. Clinicians need to be aware of all
facets of a patient’s medical history and the potential inuence
that medical issues may have on the care of the patient.
An additional aspect that must be considered in a patient
with a spine disorder is a history of prior injury. Previous spine
problems, trauma, and surgery may have important implications for the care of the patient. Details about the type and
severity of injury and the type of treatment (including surgery),
as well as the patient’s response to it, are important historical
features. Whenever possible, prior operative reports should be
obtained. Short-term and long-term problems potentially can
develop aer surgery, and it is important to understand the
nature of any prior surgery. Such adverse events include
adjacent-segment degeneration or instability aer a fusion,
epidural brosis, infection, hardware-related problems, such
as loosening, and recurrent disc herniation. A history of
multiple or prolonged periods of pain or disability aer prior
treatments should raise concerns about the chances for success
with future treatments.
Family History
e family history is a necessary component of a complete
medical history. Although back pain and many other spinal
conditions are common in the general population, data
suggest possible genetic risk factors for lumbar degenerative
disc disease.43 A family history of rheumatologic diseases,
particularly conditions associated with HLA B-27 (such as
ankylosing spondylitis, Reiter syndrome, and inamma-
tory bowel disease) can suggest a tendency for, or risk of,
developing a similar process.
including certain neuromuscular diseases, may be associated
with progressive spinal deformity, and patients with a genetic
predisposition for certain medical conditions (e.g., vascular
disease, specic cancers) may also present additional diag-
nostic considerations.
Obtaining a thorough family history may also allow a clinician to understand potentially complicated or delicate psychosocial aspects of a patient’s life. Identifying signicant disability
in a family member or altered family dynamics from a spine
issue may provide useful insight into a patient’s expectations,
fears, or other psychological features that could have a strong
bearing on outcome. By asking about family members and
parents, one can begin to understand the nature of family
dynamics that may be inuencing the presentation of a patient
with spinal pain. A history of abuse, the presence of a disruptive home environment, and a history of poor parenting or
alcoholism in the family may have a signicant future impact
on the psychological makeup of an individual. Anger, unmet
dependency needs, and problems with trust in authority
gures are some of the issues that could result in chronic pain
issues. Probing these issues in taking a family history may
provide valuable insight into potential barriers to recovery.
3,44
Other inheritable diseases,
Yellow Flags: Predictors of Poor Outcome in the Patient’s History
Numerous factors in a patient’s history have been identied as
potential predictors of poor outcome in the treatment of
spinal pain. ese factors are known as yellow ags (Box
12.1).45 e presence of more than one of these factors in a
patient is a strong predictor of poor outcome and chronic pain
and disability.45 ese yellow ags include issues related to the
nature of the patient’s injury and general medical health,
occupational and social issues, and psychological factors. It is
imperative to identify these factors, if present, early in the
course of evaluation and treatment of patients with spinal pain
because they have been shown to be more powerful predictors
of outcome than other biomedical issues.
Patients who report more widespread symptoms of neck
or back pain, who have more severe pain or disability at the
onset of their injury, or who have higher rates of concurrent comorbidities tend to have a higher risk of developing
protracted pain complaints or disability.
pain specically, dominant medical factors associated with
the development of protracted pain or disability seem to be
the presence of severe leg pain and a history of prior episodes
of low back pain.
47,49,51
In the setting of whiplash, more severe
pain or disability, the immediate onset of neck pain, low
back pain or headache, and a history of neck pain all predict
more protracted problems aer the injury, as do less strictly
event-related factors, such as a high level of catastrophizing
BOX 12.1 Yellow Flags: Potential Predictors of Poor Outcomes or
Persisting Pain and Disability, Particularly When More Than One Is
Present
Biomedical Factors
Widespread pain
High levels of comorbidity
Prior episodes of spinal pain (particularly if associated with disability)
Severe radiating limb pain
Poor sleep
Occupational Factors
Poor job satisfaction
Perceived poor-quality work environment
Absence of light-duty alternatives
Short time at current position
Low level of education
Physically demanding work
Extensive time o from work
Psychosocial or Cognitive Factors
Fear-avoidance beliefs
Catastrophizing
Passive coping style
Depression
Anxiety
Somatization
Psychological distress
History of abuse
Self-perceived poor health
Social withdrawal
History of substance abuse
From Gaunt AM. Caring for patients who have acute and subacute low back pain.
CME Bull. 2008;7:1–7.
44–48
47–50
For low back
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 191
and a low educational level (less than a secondary education).
Interestingly, accident-related details, including a rear-end
mechanism and accident severity, are not predictive of worse
outcomes.52 Some distinct occupational factors that have
been shown to be related to the development of chronic pain
include heavy physical workload, unavailability of light duties
on return to work, perceived poor working environment or
job dissatisfaction, a low level of education, and a short time of
employment on the job.
47–49,51,53
e amount of time o work
from an injury also has a negative correlation with return to
work rates.
54,55
As noted previously, psychological factors seem to play a
substantial role in the development of chronic spinal pain. In
a review on this topic, Linton46 noted that psychological
variables are clearly linked to the transition from acute to
chronic pain and generally have a stronger impact on chronicity than medical or biomechanical factors. Pertinent emotional
factors cited include depression, anxiety, distress, and selfperceived poor health. Cognitive and behavioral factors also
apparently play a key role in the development of a chronic pain
state; these include a passive coping style, catastrophizing, and
fear-avoidance beliefs (beliefs that certain activities should be
avoided owing to fear of injury). A history of sexual or physical
abuse also may be related to chronic pain and disability.46 A
systematic review of psychosocial factors found that psychological distress, depressed mood, and somatization were
associated with the transition to chronic low back pain.
56
Despite the high prevalence of psychopathology in patients
with chronic pain, there does not seem to be a premorbid “painprone” personality; the depressive features of chronic spinal
pain generally seem to arise more as a consequence, rather than
a cause, of the pain state.
46,57,58
One study did identify premorbid
depression, however, as an independent, robust risk factor for
the onset of an episode of troublesome neck or low back pain.
59
From a strictly surgical perspective, the outcomes of lumbar
surgical procedures are inuenced by numerous factors com-
pletely unrelated to the anatomy or pathophysiology of the
spine. e results of lumbar discography are inuenced by
psychosocial variables to such a large degree that there are
concerns about the validity of the procedure.15 Factors identi-
ed as predictors of poor outcome from surgical intervention
in the lumbar spine include low level of education, low income
at the time of injury, the presence of pending litigation, the
presence of an industrial injury, anxiety, neuroticism, and
depression.
60–65
Surgical outcomes have also been found to be
worse in geographic regions with higher rates of surgical
intervention.66 From a clinical standpoint, it is important to
identify predictors of poor outcome or chronicity to provide
appropriate care to address these issues and to avoid invasive
care that is highly unlikely to be helpful and could contribute
to the perpetuation of chronic pain and disability.
Obtaining a Psychosocial History
Obtaining information necessary for successful decisions
about care requires the spine specialist to evaluate a patient
with chronic pain dierently from a patient with an acute
injury. It is particularly true in treating the patient with chronic
pain that the foundation for good decision making is having
a good knowledge of the person with a back disorder; the spine
itself is less important. In other words, it is more important to
know about the patient who has the disease than to know
about the disease the patient has. is is well borne out in the
data presented earlier on prognostic and predictive factors,
which generally have much more to do with the psychological
state or approach of the aected individual than they do with
the actual injury.
It is dangerous to assume that a patient’s presenting
symptoms are solely the result of the injury that led to the
consultation. Patients in whom disability greatly exceeds that
expected on the basis of objective ndings have been shown
to be much more likely to have encountered childhood abuse
and conict, parental job stress, or a dicult divorce. Pain is
an experience that is inuenced by everything that is currently
occurring in the life of the patient. Equally or sometimes more
important is everything that has gone on in the patient’s life
in the past. In a study of more than 25,000 subjects in 14
countries, the World Health Organization found that physical
disability is more closely associated with psychological factors
than with medical diagnosis.67 Regardless of the presence
of anatomic pathology, it is important to understand that a
family member, a stressful circumstance, regular use of opioid
analgesics, money issues related to compensation or litigation, and other factors can contribute to a patient’s ongoing
pain and disability. is comment should not be construed as
indicating that the pain is “all in the patient’s head,” and it is
not intended to suggest that the patient is malingering or that
the patient’s pain is invalid or trivial. Pain and the disability it
may produce are complex and multidimensional.
It has been estimated that approximately 50% of patients
with chronic pain in rehabilitation and family practice settings have a personality disorder, as documented through
structured interviews and psychological testing.68 orough
evaluation of patients with back pain needs to include some
form of psychological testing because psychological factors
play a critical role in patient recovery from illness or injury
and the response to surgery or other medical interventions.
Ignoring either the physical or the psychological components
of pain in diagnosis and treatment is a prescription for failure,
disappointment, and dissatisfaction. Several psychological test
instruments are available for this purpose.
Additional Assessment Tools
Although there is no substitute for a concise, yet thorough,
history, there are some tools that can improve eciency.
Preprinted questionnaires can be used to obtain details of a
patient’s history. Including some questions about the psychological issues noted previously can facilitate the ecient
acquisition of a large pool of information. Other vehicles—
such as pain drawings, pain scales, and functional outcome
measures—can also be used.
Pain drawings have been used since the 1940s, and research
into their signicance has provided mixed results.69 Although
SECTION
II
192 DIAGNOSIS
B
Left
Right
there are data supporting an association between psychological distress and widespread, nonanatomic markings on the
pain drawing, there is contradictory evidence in other studies.
Data are also contradictory on the usefulness of pain drawings
in predicting surgical outcomes.69 Pain drawings have been
assessed using various means and have been shown to have
relatively high repeatability.
69,70
Although the presence of
widespread or nonanatomic patterns of pain on these drawings may be of some use in identifying pain intensity and the
presence of depression or psychological distress, one systematic review did not nd evidence to support their use as a
formal psychological assessment tool (Fig. 12.8).
69,71,72
A variety of pain scales may be used in patient assessment.
Various visual analog scales have been reported. e Million
Visual Analog Scale has been shown to have good reliability,
Left
Right
Left
A
Right
RightLeft
validity, and responsiveness.73 e McGill Pain Questionnaire
has also been widely used and is well validated. is questionnaire provides a quantitative assessment using numerous
descriptors of pain over three separate domains that are
identied by the test taker and scored.73 Other scales identify-
ing the “bothersomeness” of pain and the bodily pain item in
the Medical Outcomes Study 36-item Short Form Health
Survey (SF-36) have also been applied in the assessment of
patients with spine disorders.
74
Numerous functional scales exist, including the Oswestry
Low Back Pain Disability Questionnaire, the modied Roland
scale, the Neck Disability Index, the Sickness Impact Prole
and the related Disability Questionnaire, and the SF-36.
73–77
e Oswestry questionnaire, which uses self-rated functional
impairment in numerous activities of daily living, has been
shown to be valid and responsive, and is generally easy to
administer and score.
73,75
e modied Roland scale, which
consists of 24 “yes” or “no” questions regarding the functional
impact of back pain, was originally derived from the Sickness
Impact Prole, has been well validated, has a high responsiveness, and is very easy to score.
73,74
Several brief psychological scales are also useful. e
presence of fear-avoidance beliefs and catastrophizing are
particularly important in the development and maintenance
of chronic pain and disability. e Fear-Avoidance Beliefs
Questionnaire78 and the Pain Catastrophizing Scale79 are
validated assessment tools that can be used to quantify these
factors.
e Battery for Health Improvement-2 is a self-report
multiple-choice instrument designed for assessment of
medical patients. It is intended to provide one source of
clinical hypotheses that professionals can use to explore
the interrelationships between a patient’s psychological and
medical conditions. e information can be particularly
useful in helping to determine factors that may be inuencing
an inexplicable delay in recovery of an injured patient. e
Opioid Risk Tool is clinically relevant and easily employed
during the interview.
80
e Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) is a set of publicly available measures
to evaluate patient-reported outcomes through the assessment
of physical, social, and emotional health. ere is a wide range
of measures that have been developed and validated, including
a number for pain, emotional distress, alcohol use, and other
issues that may be related to chronic spinal pain. ere are
several composite scales available, including the PROMIS-29,
which covers the domains of anxiety, depression, fatigue, pain
interference, physical function, sleep, and social functioning.81
e PROMIS measures have been studied in a vast array of
medical conditions, and are likely to play an important role in
research and clinical care in the chronic pain population.
Physical Examination
FIG. 12.8 Pain drawings by patients. (A) The patient had radiating pain in
an L3 pattern related to intraforaminal disc herniation at L3–L4. (B) The
patient had long-standing, widespread pain in nonanatomic distribution.
Aer obtaining a complete history, a focused examination can
be performed to establish a baseline functional and neurologic
assessment, identify pertinent positive and negative ndings