SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.
"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."
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Listening to patients describe their back pain history can be one of the simplest ways to isolate the problem.
The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?
"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."
In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.
"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."
Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."
Dr. Robert K. Eastlack
Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."
Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.
Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."
CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."
Dr. Eastlack said that he had no relevant financial disclosures.