------------------------------------------------------------ BACK PAIN EXAMINATION AND DIAGNOSIS ------------------------------------------------------------ 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.