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THE FIRST MONTH          
I. INITIAL EVALUATION – seeking "Red Flags?", Radiculopathy? or Neurologically negative Back Pain? 
Goal of Evaluation: Good News - Nothing Serious!  Stay as active as possible. 
 
Care is helping the patient cope with symptoms, fears and potential confusion. Caring for patients with back problems usually hinges upon a safe, efficient search for serious conditions.  After ruling out serious conditions proven effective comfort means helps avoid the inactivity that can delay recovery and threaten a patient’s livelihood. The initial diagnostic approach hinges upon time honored history and physical examination combined with "Red Flags". to detect serious issues requiring urgent or specific attention. Absent Red Flags we gain baseline information for evaluating any change in symptoms and a window to expected recovery. “Red Flags” specifically seek hints of serious back pain impersonators (infection, aneurysm, etc.,) that require special diagnostic attention and if confirmed a different treatment paradigm.  From the beginning patients need to understand that all of our diagnostic strategies are to seek serious problems though a specific treatment based diagnosis is only obvious in about 12% of patients.  
Table 1: 12% Specific Diagnosis 
 
 
In the absence of "Red Flags" the patient’s age, prior activity level, general health and the presence of radiculopathy best set the expected recovery timeline. While 25-40% of back patients have some symptoms below the gluteal fold that does not change expectations significantly, but in the approximately 5% with some neurologic findings recovery can be slower.  A true radiculopathy (Neurologically Positive) may delay the expected rapid recovery and requires a different approach to slow recovery.  
 
The initial evaluation provides the clinician with the ability to:  
1. Assure the patient by sharing our relief that nothing serious seems to be causing symptoms. Recall that we are pretty good at finding serious problems, but no Nobel Prize has been won for finding a specific treatable cause of back symptoms in about 88% of our patients."  
2.  Classify symptoms as back only (Negative Neuro.) or radiculopathy (Positive Neuro.).  
3.  Confidently encourage patients to stay active, expect a rapid recovery that avoids further diagnostic workups for the slowest 10% to recover, and discuss care for limiting symptoms in the interim and how to limit future problems.  
 
A.We first seek serious problems in the General History taking.  "RED FLAGs" (Table Red Flag) can be detected through questionnaires of Past Medical History, Review of Systems and Present Medications. The addition of a Pain Drawing with a Visual Analog Scale can save time and improve the quality of information you gather to determine if symptoms are due to something serious.  
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Table  Red flags: seeking potentially serious conditions  
 
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In the absence of serious problems, the H&P differentiates an activity problem from a pain problem. A basic pain paradigm is more appropriate for those either unlimited, those who refuse activity or the true invalids and should not be confused with those seeking care for reduced activity tolerance due to back or related leg symptoms.  
 
Patient's can respond to inquiries about "Red Flags" on questionnaire to set a specific history taking path. Either hints of something serious conditions are further explored or the back problem can be further categorized in the activity problem as neurologic, (Neuro-Positive) or non-neurologic (Neuro-Negative).  The neurologically positive or negative distinction is prognostic for expected recovery recommendations and to determine the most appropriate work-up for the unfortunate few who are slowest to recover (limited >4 weeks).   If neurologically positive the workup tends to be neurologically oriented at 4 -8 weeks depends upon urgency driven by level of symptoms, disability and fears. If not the workup then becomes more general health oriented. 
B. Specific History: A poignant History of Present Illness (HPI) illuminates symptom Quality, and Severity according to Limitations, Prior back health and activity issues and the patient's Goals.  These cornerstones guide any detours in the physical examination and provide a baseline for detecting any change in symptoms.  
 
1) Quality of Symptoms 
 
Guided by a pain drawing, ask the patient to prioritize from worst to least the areas involving Pain, Weakness, Numbness, Stiffness. (You want to know if radicular symptoms are intermittent since electro-diagnostic studies (EMG) rarely detect surgically significant findings unless symptoms have been constant for 3-4 weeks.) 
 
2) Severity according to Limitations provide insight into the subjective Severity of the symptoms described.      
 
    Which activities does your back not let you do? ___________ 
 
    Date Limitation began?      Incident? ____________________________ 
 
    Specific Limitations now: 
 
"Without fearing that you are doing structural damage - How many:      
 
   a. minutes can you can SIT, without fearing damage? _________________ 
 
   b. minutes can you  STAND, without fearing damage? ________________ 
 
   c. minutes or distance you can WALK*, without fearing damage? _______ 
        
   d. pounds can you  LIFT,  without fearing  damage? _________________         
 
Responses of less than 20 lbs or 20 minutes are extreme (which is less than an invalid) and deserve further probing. The potential for damage with reasonable use of the symptomatic back in much higher ranges is unfounded.  
 
*If walking is limited to less than 20 minutes or 300 yards in the elderly, then ask, "After you have walked as far as possible, can you just stand there to rest to relieve the pain?" (If yes, consider vascular claudication).  True neuroclaudication requires the individual to sit, bend over or squat a few minutes before continuing (see spinal stenosis). 
 
Fear of activity predicts a patient's response to subsequent activity recommendations. The most important issue is the perceived activity level at which the patient fears structural damage.  If limited not by fear of structural damage, ask the patient to determine if the limit is based upon either worsening or bringing on symptoms.  These responses become a foundation for negotiating future suggested activity.  [The importance of gaining such information early in the history is only born out by experience of much lower levels shared later if work activities are an issue.] 
 
Should a patient later decline recommended normal activity after assurance and recommendations, these early question responses about sitting, standing, walking and lifting, provide the clinician with a strong reference point for negotiating limited daily activity (See  extremely conservative basis for work recommendations).  Early face-to-face Limitation inquiry tends to provide more reasonable responses than a later inquiry as early in the history, patients try harder to put the best foot forward.   
 
Knowing when and how limitations began helps you determine when the patient becomes one of the slowest 10% to recover (limited by symptoms longer than 4 weeks).  Considerations at 4 weeks of further diagnostic studies depends upon the individuals fears, life situation and of course type of symptoms.   
 
 
3) Prior Spine History, musculoskeletal or other reasons that may have resulted in a debilitating period of limited activity and was surgery required?   
 
When and what were the latest related spine tests performed.  
 
What prior treatment or activity gave lasting comfort? ______________ 
 
What do you usually do to stay in shape? ______________ Now? ______________ 
 
If not working, ask what is required at work that "you feel you cannot do?" 
 
Inquire about specifically work requirements.  "How long or much sitting, standing, walking or lifting is required."  
 
Cause of present problem?  If patient has an opinion, give the patient's description of what body part(s) was exposure and how, a timeline of symptoms since the exposure and an exposure description -  load or distance, frequency, repetition and recovery time allowed if a repeated exposure. 
 
4) The Patient's Goal is attained by asking, "What brings you here and specifically what do you want me to do for you today?"  Answers offer important clues as to whether the patient is seeking facts, assurance, a specific remedy or just came because someone demanded he or she come. This can be a time saver. 
 
C. Physical Examination  
       The physical examination confirms the problem as neurologically positive or neurologically negative, or detects potentially serious problems.  Both can impact both expected recovery rate and the type of work-up if the patient is one of the slowest 10% to recover reasonable a activity tolerance.  Subjective findings, such as sensation and range of motion, depend upon the patient's interpretation or volition. The only objective back examination techniques, whether positive or negative, are circumferential measurements for atrophy and absent or incongruent reflexes.  Some subjective findings can be further qualified by simple augmentation maneuvers. 
 
The sensory examination is subjective but can be augmented by having the patient look away while traveling with a tapping motion or touch from areas of normal sensation to where sensation seem altered.  By traveling from normal sensation over the same border from multiple directions and at different rates of speed can determine the border variation. The border should be quite close in the fingers and face and less in the back and legs.  
Figure Sensation testing. The border should NOT wander more than 2 centimeters anywhere
 
 
 
Straight leg raising for sciatic tension is not objective - relying upon the patients response. Yet sciatic tension signs are the most reproducible finding of the physical examination maneuvers(See Guide Table 1 Estimated Accuracy).  We are aided by qualifying techniques to evaluate sciatic tension.  We expect increased pain with ankle dorsi-flexion and limb internal rotation of the already raised leg (but no increase in symptoms with ankle plantar-flexion or external rotation as they actually reduce the tethering of the nerve roots) as in  Fig. Most Sensitive & Fig. Augmentation and Fig. Most Specific).  Thus, at the point of pain on straight leg raise, flex the ankle up and down and rotation of the limb in both direction to better determine if symptoms are due to tension on the sciatic nerve rootlets or not. Another augmentation technique for seeking nerve root irritation is knee straightening in the sitting position, to further help differentiate neurological from non-neurological issues (See below figure Sitting Knee Extension).  
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Figure Sitting knee extension during the knee or foot examination helps qualify the nerve root tension (Waddell Embellishment 3 -distraction).  If a SLR is positive in the supine position, sitting leg straightening should elicits somewhat similar findings. Back extension, falling back or complaints of discomfort into the limb with knee extension should be found in the sitting position.  This should be considered in reference to sciatic tension signs noted in Fig. Most Sensitive & Fig. Augmentation and Fig. Most Specific.  The patient should not be able to sit comfortably upright while you distract the patient from the knee extension by examining the knee or stroking the bottom of the foot (Babinski), then later be unable to tolerate well less than 50 degrees of straight leg raising from the supine position.  Since it commonly is not expected it may be most specific for ruling out true sciatic tension while equally as reliable as supine Straight Leg Raising. 
 
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The following examination should take no longer than 4-5 minutes, most easily performed with the patient wearing shorts or a gown. 
 
Standing Exam
1. Walking normally, walking on heels (L4-5) and walking on the toes (S1-2) followed by a squat and rise (L2-S1) assesses the individual's general strength (For safety have patient hold onto a table or counter before attempting to squat). 
 
From behind patient: 
2.  Back Motion observation as the patient performs requested extension, side bending, rotation and flexion allows an estimate of range relative to that expected for age.  
 
There is no need to pull or push to see if the spinal range of motion is full beyond the patient's volition.  Seek hints of uncoordinated muscular activity or guarding (commonly termed dysmetria, spasm, etc,) rather than measurements as the range can vary widely among individuals.  Uncoordinated muscle guarding is but a mild non-specific finding that may indicate something is amiss but is not specific when the motion is asymmetric.   
 
3. Waddell Embellishment – First of 5 criteria is Subcutaneous Tenderness.  Run your hand lightly over back seeking discomfort. The second is Simulations - axial loading and twisting the trunk in unison while the patient is standing (see non-physical interference). 
 
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Figure Common expressions of nerve root compromise 
 
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Sitting Exam: 
4. Ankle and knee reflexes (provide objective data whether positive or negative)  
 
5. Circumferential measurements more than 1-2 cm at an equal distance above and below the knee signify possible atrophy. (Considered Objective if greater than 2 centimeters difference [Is it due to swelling or atrophy?]. 
 
6. Lower extremity joints: sitting hip rotation asymmetry (internal rotation loss may signify hip DJD), knee stability (flexed/extended), foot & ankle motion. 
 
7. Extending the knee in the sitting position during the knee or foot examination can help qualify nerve root tension signs of Straight leg raising as noted in fig. Sitting knee Extension. Waddell Embellishment 3 Distraction (see non-physical interference).         
 
8. Muscle strength (Note, a slight loss of strength is most easily detected in large muscles. Observe from strongest to weakest: hamstrings L5-S1, quadriceps (L2-4): great toe extensors (L5), toe flexors (S1-2), ankle dorsiflexors (L4-5), ankle evertors (L5-S1). 
 
9. Waddell Embellishment - 4. Giving away on muscle testing (see non-physical interference). 
 
Supine Exam: 
10) Abdomen & pulses:  Palpation of the abdomen is especially important for sero-negative spondylo-athropathies (Ankylosing Spondylitis, Reactive Spondylitis, etc.) along with pulses the elderly or in the presence of a positive "Red Flags" where aneurysm, peripheral vascular disease or other internal organ issues must be addressed.  
 
11) Straight-leg Raising (SLR) of nerve root irritation. Raise each lower limb while instructing the patient "I am going to raise your leg slowly. Please tell me to stop if this bothers you – say, "Stop!" Note the approximate angle and ask "Where is the pain?" back?  Same side or Opposite - hip? -thigh? -knee?  or below the knee?"  (See Fig.Most Sensitive & Fig. Augmentation, Fig. Most Specific
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Figure Most Sensitive: Ipsilateral Straight leg raising Testing for Sciatic Nerve Tension  (L4-S2). 
Radiating leg pain between 30-70 degrees when acute.  
 
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Between 30-70o you gain the greatest hint nerve root irritation when symptoms below the knee are elicited. As symptoms retreat, pain tends to be noticed less distally and numbness less proximally, allowing a greater leg raising angle.   
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Fig Augmentation.  While holding the limb at, or near, the painful angle, dorsi-flex then plantar-flex the ankle, externally and internally rotate the raised straight limb.   Note which maneuver increases or augment the pain that should radiate into the leg. 
Dorsi-flexion & Internal Rotation should increase symptoms. 
 
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Check for Augmentation of nerve root irritation with straight leg raising at the level where pain is realized.  
Ask the patient, "Does this make the pain - 
       -Worse? with Plantarflexion of the ankle - (shouldn't be) 
       -Worse? with Dorsi-flexion of the ankle - (should be) 
       -Worse? with External Rotation of the whole limb - (shouldn't be) 
       -Less? with Internal Rotation of the whole limb - (should not lessen the pain but make hot radiculopathy worse) 
Determine significant nerve root irritation by noting the response to Straight Leg Raising with the above maneuvers that both increase and decrease tension on the lumbar nerve roots relative to the response to a similar but less obvious stretch sitting knee extension (Fig. Sitting knee extension). 
 
Perform an Contralateral Straight (opposite or crossed) leg raise. A reproduction of symptoms in the symptomatic limb when raising the unaffected limb is the strongest predictor of potential anatomic lesion with imaging. The raised opposite leg is affected rarely by augmenting ankle motion or limb rotation. If negative Contralateral Straight Leg raise does not rule out sciatica. 
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Figure Most Specific: Contralateral Straight leg raise Testing for Sciatic Nerve Tension (L4-S2). 
 UNCOMMON Contralateral Augmentation of symptoms with dorsiflexion or internal rotation 
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Neck Problems? 
In the presence of neck symptoms evaluate neck motion for guarding, then upper extremities joints stability, muscle wasting (atrophy), and neurologic integrity as assessed in motor, sensory, and reflex examination (always to include seeking Babinski sign in response to eliciting Plantar reflex).  Anterior neck palpation, and at least partial cranial nerve and cerebellar testing (finger to nose coordination, Romberg) are also warranted.  Always let your history alert you to a possibility of lung cancer (Pancoast tumor), and CNS disease in the presence of neck and arm symptoms.  Shoulder problems are often difficult to differentiate from radicular neck symptoms. Without neck or shoulder complaints, it is reasonable to at least check the biceps, triceps and brachioradialis reflexes and gross grip and arm strength. (Neck Exam Information)  Remember, only strong concordant neurological and imaging findings predict reasonable results. See Neck Procedures
 
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