Physical Exam Key Points

1. Vital signs and general appearance. Evidence of systemic disorders is key: fever, weight loss, hypertension, adenopathy.

2. Spine. Check for congenital lesions, such as hair tufts. Observe flexion, extension, and lateral bending. Paraspinous muscle spasm is often seen with structural disorders. Does patient have scoliosis, either new onset or preexisting? Is there loss or accentuation of the lumbar curve? Search for a palpable ridge or "step," which may be seen with spondylolisthesis. Is there a localized tender area? Palpation and percussion of vertebrae is helpful.

3. Maneuvers a. Prone-supine to sitting-standing. Observe as patient changes position. Guarding of spine is present with serious disorders.

b. Gait and standing. Painful or weak?

c. Forward bending and then hyperextension of spine. Aids in a search for deformities and location of pain.

d. Straight leg raising. Patient lifts leg slowly with knee extended; pain at 30-60 degrees is positive.

e. FABERE. Mnemonic for Flexion (knee, with lateral malleolus on the opposite knee), ABduction, External Rotation, and Extension (hip). Downward pressure on the leg causes pain in patients with sacroiliac disease.

4. Neurologic exam. Critical in identifying conditions that require emergency treatment of potential spinal cord involvement. Evaluate tendon reflexes, strength, sensation, and bowel and bladder function.

B. Laboratory Data

1. CBC, differential, platelet count.

2. ESR, C-reactive protein. Inflammatory markers.

3. Cultures. Blood and, on occasion, direct bone aspirate may be indicated.

4. Other workup. HLA-B27, ANA, and other specialized testing may be required.

C. Radiographic and Other Studies

1. Plain x-rays. Initial spinal films may be helpful in patients with structural disorders (eg, spondylolisthesis).

2. Radionucleotide bone scan. Helpful in acute infectious processes (osteomyelitis, diskitis), but may also be useful in defining more chronic processes such as repetitive trauma. Single-photon emission computed tomography (SPECT) links CT with radioisotope scanning and may increase sensitivity, especially when looking for fractures of the lumbar spine.

3. cT scan. Useful in evaluating structural processes and can be used with myelography to define the spinal cord area.

4. MRI scan. Allows the most complete look at all structures, including nerve roots in inflammatory or demyelinating disorders. Very helpful in viewing extent of paraspinous processes, such as osteomyelitis.

V. Plan. Initial evaluation should center on establishing whether there is any evidence of spinal cord involvement. Follow with emergency radiographic and neurosurgical consultation. Next, decide whether a systemic disorder is present, and whether this primarily involves the spine or is referred pain. A detailed history will help in this situation. Search for any structural process involving the spine by examination and radiography.

A. Infection. In patients with osteomyelitis, diskitis, or paraspinous infection, obtain a culture of infected material, usually by CT-guided biopsy or aspiration. Then immobilize the spine and administer long-term antibiotic therapy. Orthopedic consultation is indicated.

B. Trauma. Often these patients are athletes with repetitive injury Once the diagnosis is suspected (eg, spondylolysis, spondylolisthesis), a comprehensive rehabilitation program is needed, supervised by a specialist in orthopaedic or sports medicine.

C. Mass Lesions or Neurologic Condition. A planned approach involving multiple disciplines is necessary. Maximum care must be taken to protect the spinal cord from any injury or progression of disease. Biopsy may be indicated after careful radiographic studies are completed.

VI. Problem Case Diagnosis. The 6-year-old girl had low back pain for several months that became acutely worse after she underwent chiropractic manipulation. Later that night, she refused to walk. Examination revealed markedly decreased deep tendon reflexes and sensation in the legs. Plain films were normal, but CT scan revealed a hemor-rhagic, cystic lesion in the upper lumbar spine that was later confirmed to be an aneurysmal bone cyst. Neurosurgical intervention led to slow but complete return of neurologic function.

VII. Teaching Pearl: Question. What is a typical history for a school-aged child with an osteoid osteoma of the lumbar spine?

VIII. Teaching Pearl: Answer. Osteoid osteoma often produces pain that is worse at night and awakens child from sleep. Pain, described as "boring," is dramatically relieved by aspirin or other NSAIDs. Plain films are often normal initially, but the lesion may be seen by other imaging modalities.

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