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and non -existent in adults.
DIAGNOSIS
Obtaining the history and examining the patient is the most reliable way to determine the site of the pathology. Pain that is associated with changes in sensation or weakness should be addressed more aggressively, not necessarily with surgery. It is the amount of these signs and symptoms that determine ultra- early surgery. Even bowel and bladder changes are not the sin queue non of surgery but they should not be taken lightly. Bladder changes can be affected by pain; bowel changes can be caused by pain medication. It is important to ask when the symptoms started and under what circumstances. Pain that is improving and less than 3 months or greater than 6 months and stable does not respond best to surgery. Back or radicular pain related to a workman's compensation injury responds 90% of the time to any therapy. If patients are out work for 6 months only 50% ever return. After 1 year of missing work only 25% return and if the individual is out for 2 years or more, it is unlikely that they will return to work. If pain is exacerbated with Valsalva maneuver it may be a herniated disc. If pain is increased with walking it usually is stenosis leading to claudication. If pain is increased with extension or palpation then it may be the facets, especially if there is marked reduction in interspinous movement. If there is tenderness to percussion over the midline, infection can not be ruled out, even if there has not been an antecedent event or cancer. Pain upon awakening can be facet disease or a mass. Pain at the end of the day is usually from the muscles, tendons and ligaments. This is from poor posture, overuse, or stretching poorly conditioned structures. The physical exam usually demonstrates pain, paresthesia and paresis confined to a specific myotome and dermatome for a herniated disk with radiculopathy.
The physical can be normal from central stenosis with claudication since this is an intermittent ischemia, as well as from facet disease, discogenic disease and cancer. If the muscles, tendons or ligaments are involved solely or partially then there can be any amount or distribution of pain, paresthesia or give way weakness. Only the reflexes don't lie. Changes in reflexes usually signify that a nerve is being compressed. Given that the vast majority of people have problems unrelated to a disc and if the physical findings are vague or follow multiple dermatomes, then other types of diagnostic tests must be entertained.
DIAGNOSTIC TESTS
If pain is not in a radicular pattern (extremity), or if it is axial in nature (back) then an x-ray may be appropriate. An x-ray can tell if a fracture or spondylolisthesis (slippage) is present. Sometimes ligamentous laxity, as a cause of back pain can be documented with flexion and extension x-rays. Furthermore, x-rays can give the ominous sign of pedicle invasion or replacement. A bone scan may then demonstrate metastasis. Other times a bone scan may be positive, such as in infection, fractures or degenerative arthritis. A CT-scan is an excellent test to demonstrate bone anatomy such as stenosis in the lateral recess, in the foramen or centrally. A high definition CT scan after a myelogram is still considered by some as the gold standard for all types of pathology. This is an invasive test requiring a short outpatient stay. MRI has rapidly become the test of choice for diagnosis of spinal disease. Not only does it show disc pathology, it can demonstrate bone changes of swelling, infection, stenosis and joint changes. MRI allows the rapid distinction between different soft tissues, for example (Continued on page 16)
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