History and Exam for Spine-Related Pain

A proper history helps to determine the differential diagnosis. Key potential pain generators include the discal fibrous ring and the spinal nerve roots. When the fibrous ring is stretched, there is axial pain. When the anulus breaks and the nucleus pulposus extrudes (chemically or physically affecting the nerve roots), a radicular pain can ensue. Notably, pain radiating below the knee is more likely to represent a true radiculopathy than pain radiating to the posterior thigh.

Red flags on history suggestive of an underlying systemic disease responsible for the spinal pain include advanced age, history of cancer, history of IV drug use, fever, unexplained weight loss, and failure of bed rest to relieve the pain.

Differential diagnosis of acute spinal pain

Fracture –	Spinous process Pars interarticularis (spondylolysis) Vertebral body (osteoporotic, neoplastic [primary: multiple myeloma, osteosarcoma; metastatic: lung, breast, prostate, kidney, thyroid], traumatic [typically thoracolumbar])
Infection –	Osteomyelitis (tuberculosis/Pott’s disease) Discitis Epidural abscess (staphylococcus, streptococcus, pseudomonas) Herpes zoster (shingles)
Soft tissue –	Muscle strain Neural elements (radiculitis, spinal cord, arachnoiditis, meningeal irritation) Disc herniation, sequestration Ligamentous disruption/injury
Other/medical –	Genitourinary (kidney stone, pyelonephritis) Gastrointestinal (gallstone, pancreatitis) Vascular (abdominal aortic aneurysm, aortic dissection) Retroperitoneal process/bleed Bone infarct (sickle cell disease)

Differential diagnosis of subacute/chronic spinal pain

Somatic nociceptive – Degenerative disc disease

Ligamentous (anterior longitudinal ligament, posterior longitudinal ligament, interspinous ligament)

Facet arthropathy

Spondylolisthesis (L4-5 common in degenerative, L5-S1 most common in young acquired/congenital)

Rheumatological disorder (Ankylosing spondylitis, rheumatoid arthritis)

Sacroiliac joint dysfunction

Piriformis syndrome

Myofascial pain

Post-surgical changes (failed back surgery, scar tissue)

Visceral referred pain – Gastrointestinal (bowel distention, chronic pancreatitis)

Genitourinary

Cardiovascular

Neuropathic – Radiculopathy, spinal stenosis, arachnoiditis, neoplasm

Psychogenic – Somatization, depression, anxiety, malingering

Physical exam

Observation of gait and posture – A forward stooped gait may suggest hip flexion contractures or compensatory positioning to alleviate symptoms of lumbar spinal stenosis.

Inspection – The normal spine has four postural curves: cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis. Reduced curvature may be secondary to cervical or lumbar paraspinal muscle spasm. A loss of lumbar lordosis may be indicative of disc or vertebral body collapse. Thoracic kyphosis or “dowager’s hump” can be due to thoracic compression fractures. Increased lumbar lordosis may be seen with high grade spondylolisthesis or in the very obese.

Additionally, scoliosis should be noted because chronic rotation and lateral curves may lead to spinal stenosis and narrowing of lateral recesses as well as intervertebral foraminal stenosis leading to radiculopathy. If Adam’s forward bending test (a screening test used in grade schools) reveals asymmetrical rise of the thorax upon forward flexion, scoliosis should be suspected.

Palpation – Spinous processes, paraspinal muscles, iliolumbar and sacroiliac ligaments, iliac crests, posterior superior iliac spine, greater trochanters, and piriformis muscles should be palpated. Midline tenderness could reflect a disc problem, bone neoplasm, or bone fracture. Pain on percussion can be a sign of a potentially serious problem such as a metastasis or infection. Tenderness over the sacroiliac joint is the leading presenting symptom for sacroiliac joint dysfunction. Trigger points can be identified within muscles by exquisite tenderness, palpable taut band, twitch sign, and referred pain in a predictable pattern reproducible by deep palpation.

Range of motion testing – Reduced soft tissue flexibility and positions that provoke or alleviate symptoms should be noted in ROM testing. Test for the presence of asymmetrical limitations, e.g., at the hip vs. spine, should also be performed. Tight hamstrings or paraspinal muscles limit flexion, whereas tight hip flexors or facet arthropathy limits extension.

Provocative tests:

Cervical radiculopathy/myelopathy pathology: A literature review by Rubinstein (2006) concluded that, when compatible with the history and other physical findings, a positive Spurling’s test, traction/neck distraction, and Valsalva maneuver can be suggestive of cervical radiculopathy (high specificity), while a negative upper limb tension test can help rule it out (high sensitivity). No single test, however, had both high sensitivity and specificity. Methodological problems with the primary studies precluded strong recommendations about the validity and utility of the tests. No studies on the axial compression test met the review’s minimal criteria for inclusion.

In a 2003 review, Malanga, et al., found high specificity, low sensitivity, and fair to good interrater reliability for the shoulder abduction, Spurling’s, and neck distraction tests. Conclusions about the sensitivity, specificity, or interrater reliability of L’hermitte’s sign could not be drawn from the existing literature.

In the axial compression test, the examiner places a caudally directed force on top of the patient’s head. Local neck pain suggests cervical spinal degenerative disease, while radiating pain suggests cervical nerve root impingement. Test sensitivity, however, is low (Viikari-Juntura, 1989).

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