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History & Physical Condition
History & Physical Examination
The diagnostic approach to spinal disorders is carried out through the recording of medical history and physical examination.
When a patient visits the clinic, the doctor gathers valuable information regarding their health. This includes recording possible injuries, diseases, and obtaining a full description of symptoms.
The doctor then proceeds with a clinical examination, which, combined with the medical history, allows for the identification of the problem.
Medical history and physical examination are two essential steps for the accurate diagnosis of spinal conditions. The doctor will use the collected information to determine if further diagnostic tests are needed.
Diagnosis – Recording Medical History
During the initial visit, the doctor records the patient’s medical history by asking a series of questions about symptoms, medical history, and other relevant details.
Some of these questions include:
Symptoms
- What is the primary symptom that led you to visit the clinic?
- When did the symptoms start?
- Have you undergone any previous treatment, and how did you respond to it?
- Are the symptoms related to an injury or accident?
- Where does the pain originate? Do you experience any radiating pain?
- How often does the pain occur, and when (e.g., at night, when standing)?
- What is the intensity of the pain (on a scale from 0 to 10)?
Medication & Allergies
- Have you taken any medication for pain relief? Was it effective?
- What medications are you currently taking, and in what dosages?
- Do you have any medication allergies?
- Do you have any allergies to substances (non-medication), such as iodine, dye, or shellfish?
Previous Medical History
- Are there any past medical conditions for which you have received treatment?
- Have you undergone any previous surgeries? What was the outcome? Were there any complications?
- Is there a family history of spinal disorders?
Additional questions may relate to the patient’s profession, daily activities, alcohol consumption, and smoking habits. Although these questions are personal, they are crucial for the diagnostic process.
Diagnosis – Physical Examination
During the initial visit, the spine surgeon conducts a thorough physical examination. By observing how the patient stands or sits, the doctor can gather significant information about spinal health. The examination also evaluates the patient’s overall health.
A standard physical examination may include some or all of the following:
- Evaluation of height, weight, and vital signs (e.g., temperature, heart rate, blood pressure).
- Examination of the skin.
- Gait analysis, where the patient is asked to walk on their toes or heels (for women).
- Assessment of spinal curvature while the patient stands, with the doctor examining the spine from the back and the side.
- Range of motion testing, where the patient is asked to bend forward, backward, and sideways, as well as rotate their neck in different directions.
- Palpation of the spine by applying light pressure to identify areas of pain or muscle spasms. The doctor also checks for masses or swelling.
- Nerve tension testing by raising the legs while the patient is sitting or lying down to assess nerve root tension.
A neurological evaluation is always part of the physical examination and includes reflexes, sensation, and limb strength assessment.
Diagnosis – Imaging Tests
After reviewing the patient’s history and conducting a physical examination, the doctor may refer them for imaging tests, which may include:
- X-rays
- MRI (Magnetic Resonance Imaging)
- CT Scan
- Myelogram or bone scan
In some cases and under specific conditions, diagnostic injections may also be necessary.
Χειρουργός Σπονδυλικής Στήλης
- Ο Χειρουργός Σπονδυλικής Στήλης/ Σκολίωσης Δρ. Ηλίας Χαρ. Παπαδόπουλος γεννήθηκε και μεγάλωσε στην Αθήνα. Αποφοίτησε με Άριστα από την Ιατρική Σχολή Αθηνών το 1994 και στη συνέχεια ειδικεύτηκε στην ορθοπαιδική, στην Α’ Ορθοπαιδική Κλινική του Πανεπιστημίου Αθηνών.
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