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PART2.EXE
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EXAM.TXT
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1992-12-04
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BACK PAIN EXAMINATION AND DIAGNOSIS
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A visit to the doctor's office is an event filled with anxiety.
The fact that the visit is in connection with your back pain
makes it even more troublesome. Could it be cancer? Is a disc
ruptured? Could I have meningitis or tuberculosis of the spine?
What will happen to my job and work schedule if I have to go
into the hospital?
The good news, however, is that the diagnosis and treatment of
back pain has been significantly advanced in recent years by a
variety of new imaging methods and diagnostic tools which can
determine the source of your back pain quickly and reliably.
Unlike an obscure tropical disease, back pain today is usually
diagnosed quickly and accurately. But the first step is always
an examination by a physician.
Although the format of an office exam varies depending on the
doctor, the content remains roughly similar with some parts of
the following "ideal" exam omitted by the clinician and other
parts added or enhanced. The state of medical technology and the
pattern of arriving at a logical medical diagnosis varies from
patient to patient so do not be concerned about the exact
sequence of events which are outlined below.
Typically the physician will consider the following methods to
arrive at a diagnosis of your specific back pain 1) a physical
exam to determine normal back movement and limits 2) circulatory
exam 3) neurological exam 4) X rays 5) exam of reproductive
system if warranted 6) advanced imaging methods and diagnostic
tests if warranted.
The first step prior to the examination is for you to assemble
prior patient records, X rays and lab tests which have been done
to assess your back pain. Perhaps your family physician has
previously ordered chest and back X rays and done a limited
orthopedic examination and then referred you to a specialist.
Maybe members of your family have a history of ruptured discs or
back injuries. The more information and background you can
assemble before the examination, the more quickly and accurately
the physician can arrive at a diagnosis.
Also take the time to jot down the history and description of
the back pain. Did it begin on the job? Is it a chronic problem?
How long has the pain been with you? Does it worsen when you
stand, exercise, bend or lie down? Do weather or temperature
changes affect the pain? Does warmth or cold relieve the pain?
Do you drive long distances or sit at a desk all day? What types
of exercise and sports do you engage in? Is your exercise
regular or weekend in frequency? What medications do you take?
Use words like sharp, dull, burning or stabbing to describe the
pain. Do you smoke or drink alcohol? How would you describe your
family and home life? How would you describe your current level
of stress and emotional state? Is the backache or pain getting
better or worse?
Did you have meningitis as a child? Any other childhood
diseases? Are the pains localized in your back, legs, neck or
combinations of the above? Do the pains shoot into your legs and
what movement or position causes the pain to move into your
legs? Have you visited a chiropractor, physical therapist,
acupuncture specialist?
Have you had previous back operations? What home remedies have
you tried? Do you have any infectious diseases such as
tuberculosis? What is your job and how do you move your back
during the day as you perform that job?
Take a moment to assemble the answers to these questions before
the office visit. Surprisingly the answers to these questions
may lead the physician to immediately consider the exact range
of tests which will confirm the source of the pain.
After these preliminaries, the physical examination takes place.
Normally the patient wears only a gown and may be asked to
perform various movements either partially or fully unclothed so
that the physician can note the movements and relative positions
of your legs, back, neck and torso. Many physicians ask the
patient to initially perform various movements and changes in
posture without touching the patient. After this initial phase a
"hands on" exam at the examination table usually follows.
As you stand quietly before the physician he or she may begin by
looking for clues. Is the posture and lordosis (curve of the
lower back) within normal limits? Is the spine straight or
curved? Are there any bends laterally to the side (a diagnostic
hint of scoliosis?) Do the legs seem of nearly identical length?
Are the shoulders stooped or straight? Any malformation of
muscles?
Next, usually without touching the patient, the physician
requests a series of motions or activities to be undertaken. You
may be asked to walk normally forwards and backwards. In
addition you may be asked to walk on your tiptoes and then again
on the heels. Do you have fallen arches/flat feet? Can you hop
on one leg then the other? Can you twist and bend forwards,
backwards and side to side? Can you bend and touch your toes
without pain? You may be asked to maintain the position(s) in
certain cases. The physician may ask you to comment on the
presence or absence of pain during some of these simple
exercises and movements. Information is now flowing to the
physician and he is beginning to eliminate a some possible
causes and consider others.
Muscle spasm, vertebral disc status and nerve compression or
irritation can be inferred from results of these simple tests.
For example, a ruptured disc may cause pain when bending from
side to side. Compounding the problem can be an overlap of
symptoms among patients having both arthritis and disc ruptures.
The next stop is usually to sit on examination table for a brief
test of reflexes - tapping knees and ankles with a rubber
hammer. This can reveal quite a bit about nerve compression and
health in some back injuries.
Next you may be asked to lie down on your back on the exam table
for leg, calf, thigh and buttock comparative measurements. The
reason for this is that damaged muscles which are infrequently
used due to pain can atrophy, shrink or lose tone when a single
muscle is compared to its "twin companion" muscle on the other
side of the body.
Some physicians may follow these tests with nerve checks by
lightly touching or probing the skin of the leg, foot or calf
with a pin or pointed object. The reason for this is that nerve
roots which pass through the lumbar region of the lower back
serve these extremities and if the nerve has been pinched or
damaged in the vicinity of the spine, loss of sensation may be
apparent in areas of the body served by those nerves.
An adjunct to these nerve tests are related tests of muscle
strength and tone. For example, the physician may ask you to
lift, extend or pull a leg, foot or toe in a specific direction
while he attempts to keep it in position. Conversely he may try
to move a toe, leg or foot while he asks you to resist. This
will tell the doctor about the condition of a nerve which passes
through the lower back and the muscle tone of the extremity in
question. Frequently the knees, ankles, and hips are tested for
any sign of nerve damage by extension and retraction with
resistance offered by the hand of the doctor.
Routine blood circulation tests are also performed by checking
skin color in the legs, back and buttocks. Pulse is checked in
these regions. Blockage of blood flow in the leg may give rise
to back and upper leg pain especially in the elderly.
Still lying on your back, the doctor will probably instruct you
to keep your knee straight as he slowly lifts your leg and foot
from the table. A high angle of leg elevation in this position
indicates healthy hamstrings and, if little pain is present,
little likelihood of sciatic nerve pressure and ruptured disc
injury as the cause of back pain.
Conversely, tight hamstrings and pain in the lower back and
buttocks are usually consistent with the possibility of disc
injury. By the way, tight hamstrings are associated with back
problems in general which speaks to the positive effect of an
exercise program in preventing backaches.
The doctor may next bring one or both knees and thighs close to
your chest. For most people this should not be painful, but some
types of back injuries can cause additional pain in this
position and the doctor will note this. Hip joints are usually
rotated in and out and extended to assess any painful positions
and potential nerve or hip damage. Older patients are more prone
to hip injuries and fractures - sometimes both back and hip
injuries are found together in these patients.
You will usually be asked to lie on your stomach while still on
the exam table as the doctor directly feels along the length of
your spine, kidneys and rib cage. He may press or tap and note
both sound and sensation along the length of the spine. The
kidneys will be probed and examined. Kidney pain is often
confused with spinal pain in many patients.
The pelvis will be felt and examined for pain. Ligaments, facets
of the vertebrae and muscles along the spine are usually
palpated (probed) by hand for tenderness or sign of injury. The
doctor may ask you to tense or clench your buttocks. In some
cases of nerve damage or pain, one of the two buttock muscles
may be smaller or softer then the other during this maneuver and
the difference between the two will be noted. Disc ruptures and
nerve damage are sometimes suspected by loss of muscle tone
localized on one side of the body - a valuable clue to a medical
professional.
A gynecologic exam may be requested for women, and this is
usually performed by the woman's gynecologist rather than the
orthopedic specialist or internist. For men a prostate exam done
manually with the gloved physician's hand and/or also by newer
ultrasound methods may be requested. Infections, tumors and
other abnormalities of the reproductive organs sometimes are
manifested in lower back pain.
Laboratory blood tests are not normally done for the majority of
back pain patients since muscle, bone and disc problems are
usually the source of most back pains. However arthritis,
infections and some tumors can be detected with blood tests. If
a physician suspects one of these conditions, a blood chemistry
profile group, blood count and ESR sedimentation test may be
ordered.
A blood count simply measures the number and concentration of
white and red blood cells. If white cells are increased the
patient may have an infection. If red cells are decreased, the
patient may be suffering from anemia. The blood chemistry
profile checks uric acid, phosphorous and calcium levels.
Results of this test can reveal significant data about overall
metabolism, possibility of gout as the cause of back pain and
other indicators. The ESR sedimentation test reveals the general
state of the body's immune system and the presence of
unidentified infections. In addition, other blood tests can
reveal the presence of certain forms of arthritis which can
affect the spine.
Most back pain patient will undergo a routine X ray of the
spine. These standard X rays are normally used to reveal shape
and curvature of the spine, compression of intervertebral discs,
suggestions of arthritis, spondylosis and congenital
abnormalities such as spina bifida. By themselves, X rays are
not useful for conclusive diagnosis of soft tissue damage such
as disc rupture. Similarly, the narrowing of space between two
vertebrae may suggest the collapse of a disc, but the X ray does
not produce an image of the soft tissue disc itself.
A more specialized type of X ray image, the MRI (magnetic
resonance image) also known as NMR (nuclear magnetic resonance)
may be ordered to provide high resolution images of soft tissue
structures such as the discs and spinal cord. NMR does not
involve X ray radiation, but instead relys on high level
magnetic and radio frequency pulses to produce a soft tissue
cross section image of the area of study. This test is
relatively expensive and only available at larger hospitals or
special imaging centers. A computer processes the pulses of
energy from the magnetic field and radio frequency beams as they
pass through the patient to produce remarkably clear images of
soft tissue.
Another test which may be ordered is a CT (computerized
tomography) also known as CAT scan which likewise produces
images of a cross-sectional area of the body. Unlike NMR it uses
X ray beams and is useful for imaging ruptured discs, vertebrae
and the spinal canal. However it is limited in resolution and
because of its X ray imaging method produces better images of
bone and solid tissue than the NMR imaging method which is
superior for soft tissue. In comparison to NMR imaging, CAT is
less expensive but does require the patient to receive a small
amount of X ray irradiation.
A bone scan is another diagnostic test which may be considered
for some patients. During this test a small amount of slightly
radioactive dye is injected into the blood stream. Several hours
after the injection, the patient is placed on a table or bed
above which a radioactivity detector or sensor is slowly moved
to detect accumulations of the radioactive material. Normal bone
cells pick up or collect measurable amounts of this special
radioactive material. Bone cells which are abnormal or dead may
pick up little of the material. Finally, bone cells which are
diseased, healing from fracture or hyperactive from tumor growth
pick up extra amounts of the radioactive material. This "map" of
concentrations of the radioactive material can thus reveal
unusual bone cell activity or lack of it and thus assist in
diagnosis. Arthritis of the spine, tumors and old fractures can
thus be revealed by this diagnostic method.
A myelogram is another test which may be suggested for some back
pain patients. An injection of X ray dye is made into the spinal
canal. This is normally done in the hospital on an X ray table
or bed. After the dye has entered the spinal canal, X rays are
taken. In most cases the patient will be tilted or rotated to
allow the dye to flow upwards or downwards in the spinal canal.
Additional X rays are taken after movement of the dye to a new
area within the spinal canal. It should be noted that NMR or MRI
imaging produce nearly the same or better detail than this
method and for that reason the myelogram is gradually becoming
less popular than the non-invasive NMR imaging exam. However in
difficult diagnosis, the myelogram still has unique diagnostic
value.
A variation of the myelogram takes advantage of the fact that
since the dye is designed for X ray detection, some physicians
order a CAT scan following the myelogram to enhance the CAT
image. The myelogram dye in the spinal canal is eventually
absorbed by the body and excreted in the urine within a few
days. Excellent images of the spinal canal are obtained by this
method and are quite useful to a physician in diagnosing some
types of back pain.
A diskogram is an imaging method which examines a specific
intervertebral disc. An X ray dye is inserted by needle directly
into a disc which is suspected as damaged or ruptured. If a
rupture has taken place, the X ray image of the dye will tend to
flow out of the central core of the disc towards the area of
disc rupture and thus reveal the presence or absence of disc
injury. The test is obviously done under the control of a
radiologist and placement of the needle is precisely located
within a single disc.
The EMG test does not involve X rays or imaging methods but is
instead a test of nerve condition. Electrically conductive wires
are inserted directly into a specific muscle and measurements
are made of electrical activity. Damaged, spastic or injured
muscles provide unique "signatures" of activity which are shown
as tracings on graph paper. Thus the health of a specific muscle
can be examined reliably.
A nerve conduction test also uses electrical sensors to measure
muscle activity, but in this case attempts to determine the
speed at which a nerve impulse travels down a nerve path to or
through a muscle. The time is takes for the impulse to travel
can be graphed and nerve and muscle health or damage can be
deduced from this data.
This tutorial is merely a starting point! For further
information on back care and back pain, be sure to register this
software ($25.00) which brings by prompt postal delivery a
printed, illustrated guide to back pain written by a physician
plus two software disks. From the main menu select "Print
Registration Form." Or from the DOS prompt type the command
ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO
Box 1506, Mercer Island, WA 98040. If you cannot print the order
form, send $25.00 to the above address and a short letter
requesting these materials. End of chapter.