Spine Basics: History and Examination
The cause (or diagnosis) of a medical complaint can be made in the majority of cases by taking a good medical history. A clinical examination will supplement the history.
Symptoms of spinal problems include:
- Neck and back pain
- Arm and leg pain
- Numbness, weakness, heaviness and tingling in the arms and / or legs
- Unsteadiness and loss of coordination and balance
- Bladder and bowel dysfunction such as incontinence and loss of sensation
- Development of a spinal deformity
A series of questions about your current complaint and also your general health and well being will be asked. These should include:
- Past medical history such as previous illness and operations
- Current medications
- Smoking and alcohol history
- Home environment and support
These questions are aimed at tailoring treatment to the patient’s individual needs.
Clinical examination of the spine not only includes an assessment of the spine itself but also the nerves and joints in the limbs. I perform a clinical examination of the spine in four stages. Firstly I examine the patient walking and assess their gait. Secondly, I inspect the spine by looking at it. Next I observe the spine moving. Finally, I ask the patient to sit on the examination couch and I examine the nerves in their arms, legs or both and also the joints.
Only a thorough history and examination can help the doctor determine whether the problems are coming from the limbs or the spine, as there can be a large overlap.
I tend to use a standardised spinal assessment form for all of my patients, which you can view by clicking the link. Also available are full versions of:
- The American Spinal Injuries Association (ASIA) Assessment Chart
- ASIA Motor Examination Guide
- ASIA Sensory Examination chart
- ASIA Autonomic Standards Assessment Form
All of my patients will be asked to complete a standard questionnaire. They help me to assess your problems and also monitor the impact of any interventions. More information on patient reported outcome measures (PROMs) and why doctors are using them can be found on the NHS and the NHS Information Centre websites.