Diagnosis of Spinal cord injury

Diagnostic Tests for Spinal cord injury: Online Medical Books

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BACK PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the pain of acute onset or gradual onset? If it is acute onset, one must consider the possibility of epidural abscess, pyelonephritis, or other abdominal conditions as the cause of the back pain. If it is gradual onset, one should consider that it may be a tumor, particularly of the spinal cord or cauda equina, a pelvic tumor, or an aortic aneurysm that is compressing one of the nerve roots. In addition, chronic conditions such as lumbar spondylosis, rheumatoid spondylitis, and prostatitis must be considered.
2. Is there a history of trauma? If there is a history of trauma, one should consider a compression fracture of the spine, a sprain or herniated disk, as well as spondylolisthesis. Without a history of trauma, one should consider a tumor, herpes zoster, or dissecting aneurysm. Lumbar spondylosis might be silent for a while only to cause pain after a significant traumatic event.
3. Is there radiation of the pain around the trunk or into the extremities? Radiation of the pain would certainly be more likely to signify a space-occupying lesion of the spinal column such as a tumor, an epidural abscess, or a herniated disk. If there is no radiation, one would consider osteoarthritis or lumbar spondylosis and rheumatoid spondylitis.
4. Finally, are there bladder symptoms associated with the pain? If there are, then one must consider the possibility of a spinal cord tumor, cauda equina tumor, or kidney disease.

DIAGNOSTIC WORKUP

All patients with back pain need to have a CBC, urinalysis, and probably a urine culture, as well as a chemistry panel. A sedimentation rate should be done if rheumatoid arthritis is suspected. All patients should also have plain x-rays of the thoracic and/or lumbar spine. It is very important to get anterior posterior views, as well as oblique and lateral views. At this point it is wise to observe the results of conservative therapy before ordering expensive diagnostic tests. If there is doubt about the diagnosis at this point, a neurologic or orthopedic specialist may be consulted. If there is radiation of the pain into the extremities or around the trunk and definite neurologic findings, one should proceed to a CT scan or MRI immediately. The CT scan costs about half as much as the MRI and usually will show any significant herniated disks, primary or metastatic tumor. Even without radiation of pain into the extremities or definite neurologic findings, a patient with persistent back pain should have a CT scan or MRI. EMG will be useful in identifying radiculopathy.

When all these studies are negative, it might be wise to get a bone scan because this will show the increased uptake of the sacroiliac joints in rheumatoid spondylitis. Also, one should test for the HLA B27 antigen. In the event that all of the above studies are negative, the possibility of a non-neurologic condition or nonorthopedic condition causing the back pain should be considered. Perhaps abdominal ultrasound should be done to rule out an aortic aneurysm. Perhaps a pelvic tumor or prostatic tumor should be reconsidered. Perhaps there is a pancreatic tumor that is causing the back pain. Occasionally, combined myelography and CT scan is the only way to identify a lesion. Exploratory surgery is rarely necessary. Older patients should have a serum protein electrophoresis (for multiple myeloma) and acid phosphatase or PSA to rule out prostatic carcinoma.

 

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Low Back Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Lumbosacral muscle strain
  –Most common etiology of low back pain
  –Most common cause of disability in adults <45 years old
  –Aggravated by movement, better with rest
• Lumbar disc herniation
  –Especially of L4-L5 and L5-S1
  –Usually with unilateral radiation down the leg in a dermatomal pattern
  –Increased pain with sitting
  • Spinal stenosis
    –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
    –Increased pain with standing
  • Sacral-iliac joint dysfunction
    –Especially in young, thin women or in pregnancy
    –Unilateral upper buttock pain, relieved with movement
  • Vertebral fracture
    –Often associated with trauma or osteoporosis
  • Spondylolisthesis
    –Especially in young athletes
  • Secondary gain (e.g., drug seeking, disability or liability issue)
  • Extraspinal causes (e.g., radiation from kidney stones)
  • Systemic causes (<1%)
    –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
    –Infection: Osteomyelitis, abscess
    –Abdominal aortic aneurysm
    –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
    –Cauda equina syndrome
    –Paget's disease

  Workup and Diagnosis

  • History and physical are the most important diagnostic tools
    –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
  • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
  • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
    –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
    –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
    –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
  • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study
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Back Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Muscular strain, disk herniation
  –Most common in adolescents who are involved in competitive or contact sports; may be occupational
• Spondyloarthropathy
  –Ankylosing spondylitis is found primarily in boys, characterized by sacroiliitis, LE oligoarthritis, and may be associated with IBD
  • Malalignment
    –Scoliosis: Idiopathic form is most common in girls, may be familial, may be secondary to neurologic disorder
    –Hyperlordosis
  • Infectious
    –Diskitis: Characterized by spine stiffness and muscular spasm, Staphylococcus aureus is the usual pathogen, blood culture may be positive
    –Vertebral osteomyelitis: Exquisite point tenderness, pathogen may be S. aureus, Streptococcus pneumoniae, or others such as tuberculosis or brucellosis
    –Acute transverse myelopathy: Generally follows an upper respiratory tract infection; characterized by back pain, distal weakness and paresthesias at the midthoracic level
  • Urinary tract
    –Urinary tract infection: Most common in postpubertal girls, occurrence in boys or prepubertal girls may require evaluation for urinary tract anomalies, especially if recurrent
    –Urolithiasis: Associated with hypercalcuria, cystinuria, Lesch-Nyhan; characterized by intense flank pain and hematuria
  • Malignancy
    –Primary spinal cord or column tumors (osteogenic sarcoma, neuroblastoma)
    –Metastatic tumors (neuroblastoma)
    –Bone marrow infiltration (leukemia, lymphoma)
  • Gynecologic
    –Menstrual cramps
    –PID
    –Endometriosis

  Workup and Diagnosis

  • History
    –Onset, duration, location of symptoms
    –History of trauma, heavy lifting, overuse, athletics
    –Systemic symptoms such as fever, irritability
    –Menstrual and sexual history
    –Past medical history of similar complaints, orthopedic conditions, general medical conditions
    –Family history of scoliosis, rheumatic disease
  • Physical exam
    –General appearance, fever, irritability
    –Spinal contour, symmetry
    –Gait, posture
    –Range of motion limitations
    –Point tenderness, SI tenderness
    –Associated neurologic findings (sensation, strength, DTRs)
  • Labs
    –If rheumatologic condition is suspected, consider CBC, ESR, ANA, RF, HLA typing
    –If infectious process is suspected, obtain CBC, ESR
    –Urine microscopy and culture
  • Studies
    –Plain films can reveal fractures such as spinal compression fractures, disk space abnormalities, and sacroiliac abnormalities associated with spondyloarthrosis
    –MRI may be required to discover disk herniation, disk space infection, tumors

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Analgesia: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

After you’re satisfied that the patient’s spine and respiratory status are stabilized — or if the analgesia isn’t severe and isn’t accompanied by signs of spinal cord injury — perform a physical examination and baseline neurologic evaluation. First, take the patient’s vital signs and assess his level of consciousness. Then test pupillary, corneal, cough, and gag reflexes to rule out brain stem and cranial nerve involvement. If the patient is conscious, evaluate his speech, gag reflex, and ability to swallow.

If possible, observe the patient’s gait and posture and assess his balance and coordination. Evaluate muscle tone and strength in all extremities. Test for other sensory deficits over all dermatomes (individual skin segments innervated by a specific spinal nerve) by applying light tactile stimulation with a tongue depressor or cotton swab. Perform a more thorough check of pain sensitivity, if necessary, using a pin. (See Testing for analgesia, pages 38 and 39.) Also, test temperature sensation over all dermatomes, using two test tubes — one filled with hot water, the other with cold water. In each arm and leg, test vibration sense (using a tuning fork), proprioception, and superficial and deep tendon reflexes. Check for increased muscle tone by extending and flexing the patient’s elbows and knees as he tries to relax.

Focus your history taking on the onset of analgesia (sudden or gradual) and on any recent trauma — a fall, sports injury, or automobile accident. Obtain a complete medical history, noting especially any incidence of cancer in the patient or his family.

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Back pain: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜" (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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Spinal injuries: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

The diagnosis is typically based on the patient’s history, physical examination, X-rays, computed tomography (CT) scan, and magnetic resonance imaging (MRI).

The patient history may reveal a traumatic injury, a metastatic lesion, an infection that could produce a spinal abscess, or an endocrine disorder. The physical examination (including a neurologic evaluation) locates the level of injury and detects cord damage.

Spinal X-rays, the most important diagnostic measure, locate the fracture. In spinal compression, a lumbar puncture may show increased cerebrospinal fluid pressure from a lesion or trauma; a CT scan or MRI can locate a spinal mass.

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Analgesia: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Once you’re satisfied that the patient’s spine and respiratory status are stabilized—or if the analgesia isn’t severe and isn’t accompanied by signs of spinal cord injury—perform a physical examination and baseline neurologic evaluation. First, take the patient’s vital signs and assess his level of consciousness. Then test pupillary, corneal, cough, and gag reflexes to rule out brain stem and cranial nerve involvement. If the patient is conscious, evaluate his speech and ability to swallow.

If possible, observe the patient’s gait and posture and assess his balance and coordination. Evaluate muscle tone and strength in all extremities. Test for other sensory deficits over all dermatomes (individual skin segments innervated by a specific spinal nerve) by applying light tactile stimulation with a tongue depressor or cotton swab. Perform a more thorough check of pain sensitivity, if necessary, using a pin. (See Testing for analgesia, pages 48 and 49.) Also, test temperature sensation over all dermatomes, using two test tubes—one filled with hot water, the other with cold water. In each arm and leg, test vibration sense (using a tuning fork), proprioception, and superficial and deep tendon reflexes (DTRs). Check for increased muscle tone by extending and flexing the patient’s elbows and knees as he tries to relax.

Focus your history taking on the onset of analgesia (sudden or gradual) and on any recent trauma, such as a fall, a sports injury, or an automobile accident. Obtain a complete medical history, noting especially any incidence of cancer in the patient or his family.

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Back pain: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient’s expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescription and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient’s posture if pain doesn’t prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜” (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, place the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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Low Back Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 The history should include evaluation for “red flag” conditions.

A. Pain characteristics. Assess the nature of the pain, along with the onset and duration of the symptom. Is there any radiating pain, leg weakness, or paresthesia? Pseudoclaudication is suggestive of spinal stenosis. Pain radiating below the knee is more likely to be a true radiculopathy (1). Nerve root compression is highly unlikely without sciatic pain (1). Was the onset after a traumatic event? A seemingly insignificant episode (e.g., a minor fall) may be a “red flag” for fracture in an elderly patient. Are there alleviating or exacerbating factors? Does the pain limit the patient physically or socially? Is there a history of previous back problems or back surgery?

B. Review of systems. Look for associated symptoms that can indicate a “red flag” condition or an underlying medical cause. Gastrointestinal and genitourinary symptoms are particularly important, especially incontinence (Chapter 10.10).

 C. Psychosocial information. Has the patient initiated any new activities? If work-related, assess typical job tasks. Investigate whether the back pain could have any relationship, sexual, or mood implications. Sexual activity can be severely affected simply because of pain, but sexual dysfunction can also result from neurologic abnormalities associated with the cause of the back pain. Back pain is associated with depression and poor sleep patterns. Drug-seeking behavior may be exhibited along with a complaint of back pain. Addiction may have resulted from former or on-going treatment of the pain. Legal issues can complicate the diagnosis and treatment of back pain. Ask the patient whether litigation involving the back pain is under consideration.

Physical examination

Evaluation should be both general and specific. It is prudent to leave the potentially most painful parts of the examination to the end.

 A. General. Examination includes auscultation of the heart and assessment of peripheral pulses and blood pressure. Abdominal examination should focus on possible causes of back pain (Table 12.5). Assess gait.

 B. Neurologic. The lower extremity examination includes motor strength, deep tendon reflexes, sensation, proprioception, and certain functional maneuvers (Table 12.6). Romberg and Babinski reflexes should also be assessed. Rectal examination should assess sphincter tone, which can be compromised in sacral root dysfunction. In the primary care setting, most clinically significant disc herniations will be detected by the following limited examination: dorsiflexion of the great toe and ankle, Achilles reflex, light touch sensation of the medial (L ₄), dorsal (L₅), and lateral (S₁) aspect of the foot, and the straight leg raise (SLR) test (1).

 C. Musculoskeletal. Assess range of motion of the spine and lower extremities. Perform the SLR test passively with the patient supine. Note the angle of leg elevation precipitating pain. A positive test for sciatica is buttock pain radiating to the posterior thigh, and perhaps to the lower leg and foot. Sciatica, with pain and resistance on internal rotation of the hip, can indicate piriformis muscle spasm or strain. The SLR test is usually negative in spinal stenosis (2). Percussion of the spine and upper pelvis helps to identify areas of localized tenderness, as in fracture, metastatic disease, and some rheumatologic conditions. Palpate standard trigger points looking for fibromyalgia. Check for paraspinal muscle spasm. Measure thigh and calf circumferences to look for muscular atrophy.

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Low Back Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Musculoligamentous strain

❑ Lumbar disc herniation

❑ Osteoarthritis

❑ Compression fracture

❑ Pyelonephritis

❑ Secondary gain

❑ Scoliosis

❑ Spondylolisthesis

❑ Metastatic cancer

❑ Spinal stenosis

❑ Transverse process fracture

❑ Pancreatic cancer

❑ Ankylosing spondylitis

❑ Sacroiliitis

❑ Aortic dissection

❑ Cauda equina syndrome

❑ Vertebral osteomyelitis

❑ Epidural abscess

Diagnostic Approach

Radicular pain has such a high sensitivity for nerve root compression that its absence makes important disc herniation unlikely. Not all radicular pain is due to a herniated disc however. Other causes include spinal stenosis, ligamentous hypertrophy, deep lumbar muscle spasm, and deep trochanteric bursitis.

Back pain at rest or unassociated with posture/movement should increase the suspicion of tumor, fracture, infection, or referred visceral pain. Spinal tenderness is a sensitive but not specific indicator. Clues to metastatic cancer include a history of cancer, unexplained weight loss, and signs of cord compression, such as motor weakness of the legs, urinary or fecal incontinence, and absent anal reflex. Recent bacterial infection, injection drug use, or immune suppression (from steroids, chemotherapy, or HIV) should raise suspicion for infection. Fever occurs in osteomyelitis (50%), epidural abscess (83%), and tuberculosis (27%).

A red flag for fracture in a young adult is major trauma, such as a fall from a height or a motor vehicle accident. In older adults, minor trauma or strenuous lifting can cause a compression fracture.

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Spinal cord defects: Diagnosis
(Handbook of Diseases)

The diagnosis varies with the type of defect.

Spina bifida occulta

Although often overlooked, spina bifida occulta is occasionally palpable, and a spinal X-ray can show the bone defect. Myelography can differentiate it from other spinal abnormalities, especially spinal cord tumors.

Meningocele and myelomeningocele

Meningocele and myelomeningocele are obvious on examination; transillumination of the protruding sac can sometimes distinguish between them. (In meningocele, it typically transilluminates; in myelomeningocele, it doesn’t.)

In myelomeningocele, a pinprick examination of the legs and trunk shows the level of sensory and motor involvement; skull X-rays, cephalic measurements, and a computed tomography scan demonstrate associated hydrocephalus.

Other appropriate laboratory tests in patients with myelomeningocele include urinalysis, urine cultures, and tests for renal function starting in the neonatal period and continuing at regular intervals.

Although amniocentesis can detect only open defects, such as myelomeningocele and meningocele, this procedure is recommended for all pregnant women who have previously had children with spinal cord defects; these women are at an increased risk for having children with similar defects. If these defects are present, amniocentesis shows increased alpha-fetoprotein levels by 14 weeks’gestation.

Ultrasonography can also detect or confirm the presence and extent of neural tube defects.

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Spinal injuries: Diagnosis
(Handbook of Diseases)

Typically, a diagnosis is based on the patient history, the physical examination, X-rays and, possibly, lumbar puncture, computed tomography (CT) scan, and magnetic resonance imaging (MRI).

❑ Patient history may reveal trauma, a metastatic lesion, an infection that could produce a spinal abscess, or an endocrine disorder.

❑ Physical examination (including a neurologic evaluation) locates the level of injury and detects cord damage.

❑ Spinal X-rays, the most important diagnostic measure, locate the fracture.

❑ Lumbar puncture may show increased cerebrospinal fluid pressure from a lesion or trauma in spinal compression.

❑ CT scan or MRI can locate the spinal mass.

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Analgesia: Assessment
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

History

After assuring spinal cord stabilization, proceed with assessing the patient. Establish the onset of analgesia (sudden or gradual). Did the patient suffer recent trauma, such as a fall, sports injury, or automobile accident?  Obtain a complete medical history, noting incidence of cancer in the patient or his family.

Physical examination

Assess the patient’s vital signs, including the pattern of respirations. Determine his level of consciousness. Assist to test pupillary, corneal, cough, and gag reflexes to rule out brain stem and cranial nerve involvement. If the patient is conscious, evaluate his ability to swallow.

Assist to perform a full neurologic assessment, including orientation to person, place, and time. Assess the patient’s ability to speak clearly, pupil size and reaction to light, ability to follow commands, ability to wiggle extremities, and awareness of touch. Test for other sensory deficits over all dermatomes (individual skin segments innervated by a specific spinal nerve) by applying light tactile stimulation with a tongue depressor or cotton swab. Perform a more thorough assessment of pain sensitivity, if necessary, using a pin. (See Testing for analgesia, pages 18 and 19.) Assess the patient’s temperature sensation over all dermatomes, using two test tubes — one filled with warm water, the other with cold water. In each arm and leg, test vibration sense (using a tuning fork), proprioception, and superficial and deep tendon reflexes (DTRs). Check for increased muscle tone by extending and flexing the patient’s elbows and knees as he tries to relax.

After a spinal cord injury is ruled out, observe the patient’s gait and posture and assess his balance and coordination. Evaluate muscle tone and strength in all extremities.

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Back pain: Assessment
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

History

Ask the patient where the pain is located; back pain in some areas can signal the presence of a life-threatening condition.

Act Now: If the patient reports acute, severe back pain, quickly obtain his vital signs and perform a rapid evaluation to rule out life-threatening causes. If he describes deep lumbar pain unaffected by activity, observe for a pulsating epigastric mass. Presence of this sign may indicate a dissecting abdominal aortic aneurysm. Withhold food and fluids because the patient may require emergency surgery. Prepare for I.V. fluid replacement and oxygen administration.

If he reports severe epigastric pain that radiates through the abdomen to the back, assess for absent bowel sounds and abdominal rigidity and tenderness. These symptoms may indicate a perforated ulcer or acute pancreatitis. Start an I.V. line for fluids and medications, administer oxygen, insert a nasogastric tube, and withhold food.

If the patient complains of scapular area back pain, especially if accompanied by shortness of breath or diaphoresis, give oxygen via a nasal cannula or mask and obtain a 12-lead electrocardiogram to rule out myocardial infarction.

After you have ruled out potential life-threatening causes of back pain, continue to obtain the patient’s history. Observe him for expressions of pain while gathering information. Ask about previous injuries and illnesses, dietary habits, alcohol intake, and cigarette smoking. Inquire about medications, including past and present prescriptions, use of over-the-counter drugs, and disease processes or pain control regimens.

Ask the patient about the onset of his back pain. Were there precipitating factors? Ask the patient to rate the pain on a standardized pain scale. Ask him for details about the pain — is it burning, stabbing, throbbing, or aching? Constant or intermittent? If it’s intermittent, does it occur at a specific time of day? Does the pain radiate? Is there associated weakness? Does he experience repetitive pain or different types of pain? What, if anything, lessens the pain? What aggravates it? The patient’s answers will help identify the cause of his back pain. For example, visceral referred back pain is indicated if the patient states that the pain isn’t affected by activity and rest. In contrast, spondylogenic-referred back pain is likely if the pain increases with activity and decreases with rest. Pain of neoplastic origin is indicated if the patient reports that he can obtain relief by walking and that the pain increases at night.

Physical examination

Perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask the patient about unusual sensations in the legs, such as numbness and tingling. If pain doesn’t prevent standing, observe the patient’s posture — does he stand erect or lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes (stand close by during these tests so that you can assist the patient if he falls). Weakness may reflect a muscular disorder or spinal nerve root irritation.

Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. (See How to elicit Babinski’s reflex.) Evaluate the strength of the extensor hallucis longus by asking the patient to keep his great toe firmly in place against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜"(1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, assist the patient into a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica.

Note the range of motion of the hip and knee. Palpate the flanks and percuss with your fingertips or fist to reveal the presence of costovertebral angle (CVA) tenderness.

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Back pain: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If life-threatening causes of back pain are ruled out, continue with a complete history. Be aware of the patient’s expressions of pain as you do so.

CULTURAL CUE:A patient’s cultural background may impact his response to pain. For example, a patient of Irish descent may have a stoic response. A Jewish patient or one of Italian descent may be more vocal. The Navajo patient may view pain as a way of life. A patient of Filipino descent may regard pain as a chance to atone for past transgressions.

Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs as well as herbal remedies.

Physical assessment

Perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient’s posture if pain doesn’t prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜" (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, position the patient in a supine position on the examination table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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Back Pain: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Congenital

Congenitalspine anomalies, including absence of lumbar pedicle, spinal fusion,or spinal stenosis, are unusual causes of back pain.

Plain radiographs are useful for diagnosis.In some cases, MRI is necessary for diagnosis.

Developmental

Scoliosis

Idiopathic scoliosis may be associated withmild back pain, particularly after long activity. When scoliosisis associated with more severe back pain, other underlying disordersshould be considered (e.g., infection, herniated disc, spondylolysis,spondylolisthesis, and tumor).

Scheuermann Disease

Disorderof unknown cause that usually occurs in older children and adolescentsinvolved in athletics.

Most common site is thoracolumbar area,although thoracic or lumbar spine may be affected alone. Pain isusually worse with forward flexion and relieved by rest.

Spine radiographs show increased kyphosiswith anterior wedging of ≥1 vertebrae, irregular vertebral endplates, and disc herniation upward or downward into adjacent vertebra(Schmorl node).

Trauma

Musculoskeletal

Muscle strainis common cause of back pain and is usually result of improper conditioning,heavy lifting, overuse in sport-related activity, or contusion.

History of trauma followed by spasmof paraspinous muscles and limited range of motion of spine suggestdiagnosis. Tenderness over vertebrae may indicate fracture.

Although spine radiographs are usuallydiagnostic, some fractures may not be visible, and technetium bonescan can be useful in localization of occult fracture.

Herniated Disc

Most commonin individuals who participate in vigorous athletic activities.

Trauma is often predisposing factor.

Most commonly involved discs are thosebetween L4 and L5 and L5 and S1.

Intermittent or constant lower backor buttock pain with radiation down the leg is most common presentation.Limp and disturbed gait are frequent findings.

Sneezing, coughing, or laughing mayaggravate pain.

There is limitation of movement oflumbosacral spine and often spasm of paraspinous muscles.

Straight leg raising test is usuallyabnormal.

Decreased sensation in L4–S1dermatome and motor weakness are variable findings.

MRI confirms diagnosis.

Spondylolysis

Definedas fracture of pars interarticularis of vertebral arch, which occursprimarily in older children and adolescents, especially in thoseparticipating in gymnastics, dance, or weight lifting.

Usual location is lumbar spine, andless commonly thoracic spine.

Pain is especially aggravated by extensionmovements of leg. There is localized tenderness and limited rangeof motion of spine.

Plain radiographs usually demonstratedefect.

Spondylolisthesis

Involvessame defect as spondylolysis, but there is also forward slippageof 1 vertebra on the other, usually L5 on S1.

Plain radiographs are usually diagnostic.

Slipped Vertebral Epiphysis

Posteriorrim of inferior epiphysis, usually L4, and adjacent disc are displacedinto spinal canal.

Pain usually occurs after heavy lifting.

Diagnosis may be confirmed by plainradiographs or CT.

Spinal Epidural Hematoma

May occurafter a fall, another injury, or spontaneously in children withbleeding disorders.

Pain is usually followed by signs ofspinal cord compression.

CT or MRI is diagnostic.

Infection/Inflammation

Discitis

Thoughtto result from bacterial or low-grade viral infection and usuallyoccurs in preschool or school-age children.

Most common sites of infection aredisc spaces in lumbar region.

Affected children may have low back,hip, or lower abdominal pain; limp or reluctance to walk; and sometimesfever. Localized tenderness over involved disc space, spasm of adjacentmuscles, and pain with straight leg raising are usually found.

Early in course of illness, plain radiographsare normal; later, they show narrowing of disc space with irregularerosions and sclerosis of vertebral end plates. Nuclear scintigraphyshows increased uptake in vertebral bodies on each side of involveddisc space. CT or MRI may be useful in atypical or questionablecases by confirming presence of disc space narrowing and vertebralend-plate destruction.

Although controversy exists about whetherdisc space aspirate should be performed, in some cases S. aureuscan be cultured from disc space aspirate or blood.

Disc Space Calcification

Rare lesionin pediatric population. Although pathogenesis is uncertain, itmay follow nonspecific inflammatory reaction of disc space. Mostcommonly involved area is cervical spine.

There is cervical or thoracic pain,localized tenderness over disc space, muscle spasm, and occasionalfever.

Plain radiographs show calcification.

Osteomyelitis

Most commonpathogen causing osteomyelitis of spine is S. aureus. Other pathogens includeS. pneumoniae, group A Streptococcus, E. coli, P. aeruginosa, andSalmonella species.

Localized back pain, tenderness overinvolved vertebrae, restriction of spine motion, and fever are commonfindings. There is usually leukocytosis and increased sedimentationrate.

Plain radiographs may be normal earlyin course of illness, but after about 10 days, radiologic findingsinclude disc space narrowing, decreased height of vertebra, andsclerotic/lytic lesions of vertebral body, pedicles, orneural arches. Extension into soft tissues can produce paravertebralmass. Nuclear scintigraphy usually shows increased uptake earlyin illness.

Bone aspirate or biopsy may revealpathogen, and blood cultures also may be positive.

Tuberculosis of Spine

Much lesscommon than pyogenic infection.

Thoracic spine is most common siteof involvement, with pain radiating to intercostal areas. Involvementof cervical spine may produce neck pain and torticollis, whereaslumbar spine involvement may produce lower back pain and limp. Feveralso may occur.

Plain radiographs show destructionand collapse of vertebrae with narrowing of disc spaces.

Involvement of spinal cord at any levelmay produce extremity weakness.

Diagnosis should be considered in childrenwho have history of exposure or who live in endemic area and whohave persistent back or neck pain.

CBC, sedimentation rate, chest radiograph,Mantoux test, early morning gastric aspirates, and bone biopsy foracid-fast bacilli and culture should be performed.

Iliac Osteomyelitis

Uncommoninfection.

Clinical manifestations include lowback pain, fever, and tenderness over ilium.

Nuclear scintigraphy shows increaseduptake. Bone aspirate or biopsy is diagnostic.

Sacroiliac Joint Infection

Most commonpathogen is S. aureus. Prior pelvic fracture is risk factor.

Usually presents with pain in lowerback, hip, or buttock; limp; and fever. Flexion, abduction, andexternal rotation of leg cause sacroiliac pain if joint is involved.

Plain radiographs may be normal earlyin illness, but within 10 days, lytic and sclerotic changes of bonemargins and widening of joint space are usually seen. Nuclear scintigraphyshows increased uptake in affected bone.

Aspiration or open biopsy is usuallyrequired to establish specific diagnosis. Blood culture also mayreveal pathogen.

Juvenile Rheumatoid Arthritis

Can affectthe spine at any level and cause persistent back pain and decreasedrange of motion. Most commonly involved area is cervical spine.

Plain radiographs of cervical spinemay show atlantoaxial displacement, ankylosis of apophyseal joints,and narrowing of disc spaces.

See Chap.37, Limp

Ankylosing Spondylitis

Disorderof unknown cause that primarily affects boys >8 yrs.

Most common feature is arthritis oflower extremity joints, which may include hips, knees, ankles, andfeet. Back pain and limitation of motion of lumbosacral spine orsacroiliac joints also can occur.

Diagnostic clue is presence of enthesitis,especially involving heel.

Plain radiographs of lumbosacral spineand sacroiliac joints may show changes consistent with sacroiliitis.

Slit-lamp exam should be performedbecause uveitis can occur.

HLA-B27 antigen is positive in about90% of cases. Antinuclear antibody and rheumatoid factorare usually negative.

Spinal Epidural Abscess

Rare infectionin childhood that can be acute or chronic.

Most common pathogen is S. aureus.Predisposing factors include local wound infection, decubitus ulcer,or spine surgery.

Back pain, localized spine tenderness,tender spinal mass, and fever are common findings. Lumbosacral involvementmay produce buttock and leg pain with leg weakness, impaired sensation,decreased deep tendon reflexes, and impaired bowel and bladder function.

Radiographs of spine are usually normalbut sometimes show evidence of osteomyelitis. CT or MRI may be diagnostic.

Diagnosis is confirmed at surgery.

Sickle Cell Disease

Back painmay occur in sickle cell vasoocclusive episode and is usually musculoskeletalin origin. Infarction of posterior ribs or vertebrae may cause backpain and bone tenderness.

Can usually be demonstrated by bonescintigraphy.

Neoplasm

Tumors ofthe spine or spinal cord are uncommon in pediatric population.

Clinical features include persistentpain sometimes waking child during night, sciatic pain, painfulscoliosis, localized tenderness, palpable mass, lower extremityweakness, sensory changes, and bowel or bladder disturbances.

Histologic diagnosis is necessary exceptfor perhaps osteoid osteoma.

Vertebral Tumors

Most commonbenign tumor of spine is osteoid osteoma.

Pain often awakens child from sleep.

Localized tenderness and scoliosisalso may occur.

Spine radiograph shows small radiolucentarea surrounded by sclerosis.

Osteoblastoma has same histology asosteoid osteoma but is larger.

Aneurysmal bone cyst may affect posteriorelements of spine, vertebral bodies, or ribs, causing pain and sometimespalpable mass.

Commonlyoccurs in adolescence.

Spine radiograph shows cyst with finetrabeculae and thin cortex.

MRI shows extent of tumor and any neuralcompression.

Eosinophilic granuloma commonly presentswith persistent thoracic back pain in adolescence. Radiographs showcircumscribed area of osteolysis and any vertebral collapse.

Most common primary malignant bonetumors affecting spine are osteogenic sarcoma and Ewing sarcoma.Common metastatic lesions include neuroblastoma, Wilms tumor, leukemia,and lymphoma. Usual findings are persistent pain, bone tenderness,fever, and weight loss. Spine radiographs, nuclear scintigraphy,CT, and MRI are useful in locating and defining the extent of thetumor.

Intraspinal Tumors

May arisewithin spinal cord (astrocytoma, ependymoma), within dura but outside spinalcord (neurofibroma, lipoma, dermoid), and outside dura (commonly,extension of paravertebral neuroblastoma).

May present with spinal pain with radiationto specific dermatome, leg or arm weakness, limp or difficulty walking,and bowel or bladder disturbance. Clinical findings include weaknessor spasticity of extremities, decreased sensation, pathologic reflexes,relaxation of anal sphincter, and scoliosis.

Spine radiographs are useful, but CTand MRI help locate and define extent of lesion.

Referred Pain

Infection/inflammationor mass in abdominal, thoracic, retroperitoneal, or pelvic regionscan cause referred back pain. Examples are pneumonia, pyelonephritis,pancreatitis, appendicitis, cholecystitis, and hydronephrosis.

History and physical exam suggest thesediagnoses, which are discussed in other chapters.

Psychogenic

Back paincan be due to anxiety, depression, hypochondriasis, or conversionreaction.

Pain is nonspecific and nonlocalizing.

Physical and neurologic exams, CBC,sedimentation rate, and spine radiographs are normal.

Psychosocial history provides cluesto diagnosis.

Diagnostic Approach

History,physical exam, and spine radiographs are usually diagnostic of congenital spineanomalies, fractures, Scheuermann disease, spondylolysis, and spondylolisthesis.

MRI is procedure of choice to confirmdiagnosis of herniated disc.

Fever usually occurs with inflammatorydisorder or infection affecting spine. When fever accompanies backpain, CBC and erythrocyte sedimentation rate should be performed.

Nuclear scintigraphy is useful, especiallywith suspected osteomyelitis, discitis, or sacroiliac joint infection.

Aspirate or biopsy of lesion shouldbe strongly considered with suspected osteomyelitis. Blood culturemay reveal organism, but yield is often low.

Spine radiographs are useful in diagnosisof vertebral spine and intraspinal masses.

CT and MRI are valuable in diagnosingtumors as well as spinal epidural abscess.

For all tumors except possibly osteoidosteoma, histologic exam is necessary for diagnosis.

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Analgesia: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

After you're satisfied that the patient's spine and respiratory status are stabilized—or if the analgesia isn't severe and isn't accompanied by signs of spinal cord injury—perform a physical examination and baseline neurologic evaluation. First, take the patient's vital signs and assess his level of consciousness. Then test pupillary, corneal, cough, and gag reflexes to rule out brain stem and cranial nerve involvement. If the patient is conscious, evaluate his speech, gag reflex, and ability to swallow.

If possible, observe the patient's gait and posture and assess his balance and coordination. Evaluate muscle tone and strength in all extremities. Test for other sensory deficits over all dermatomes (individual skin segments innervated by a specific spinal nerve) by applying light tactile stimulation with a tongue depressor or cotton swab. Perform a more thorough check of pain sensitivity, if necessary, using a pin. (See Testing for analgesia, pages 32 and 33.)

Test temperature sensation over all dermatomes, using two test tubes—one filled with hot water, the other with cold water. In each arm and leg, test vibration sense (using a tuning fork), proprioception, and superficial and deep tendon reflexes. Check for increased muscle tone by extending and flexing the patient's elbows and knees as he tries to relax. Focus your history taking on the onset of analgesia (sudden or gradual) and on any recent trauma—a fall, sports injury, or automobile accident. Obtain a complete medical history, noting especially any incidence of cancer in the patient or his family. Obtain a complete drug history.

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Back pain: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries, surgeries, and illnesses, and a family history. Ask about diet and alcohol intake. Take a drug history, including past and present prescriptions, over-the-counter drugs, and herbal medicines. Ask the patient to rate the pain according to a pain scale and describe the type and location of his pain.

Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than 3⁄89 (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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