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History (spine)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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When taking a history from a patient with spinal problems, the following areas should be broached:

  • pain:
    • onset, site, radiation
    • does the pain radiate to the leg as in sciatica
    • aggravating and relieving factors e.g. posture, or if neurogenic claudication appears to be the problem, is cycling easier?
    • persistent pain which occurs throughout the night should alert one to the possibility of a tumour

  • stiffness:
    • sudden and complete in disc prolapse, or continuous and worse in the morning with arthritis or ankylosing spondylitis

  • deformity:
    • onset, changes, general history, neurological features, pain

  • neurological symptoms:
    • numbness, paraesthesia; onset, progress, degree
    • spinal claudication ?

It is also important to ask specifically about weight loss, bowel, pulmonary and bladder dysfunction.

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