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Clinical Evaluation-History

The sports physician may be required to assess for a spinal problem in situations varying from an unconscious athlete in a difficult environmental presentation, such as on a steep ski slope or in a crumpled racecar, to a preparticipation examination in a sports medicine clinic.

The history may be the most important aspect of a clinical evaluation; however, the details of the incident may have to come from on-field officials or other participants if the athlete has a diminished level of consciousness. Occasionally, the true story is not known until videotapes of the incident reveal the directions and magnitude of the force vectors to which the athlete’s spinal column was exposed.

Finding or excluding the presence of a spinal injury is much simpler in an alert, awake patient with no other distracting injuries. If the patient has any disorientation or a depressed level of consciousness, the spine should remain protected with a cervical collar and with log-roll precautions for the lumbar spine.

Even when the athlete regains consciousness, he or she may have retrograde amnesia of the accident. The firm spine board used for immobilization during patient transport should be removed as soon as possible to prevent serious decubitus ulcers.

The most common symptom following injuries to the thoracolumbar spine is pain, and the details regarding the time of onset, quality, location, alleviating and aggravating factors must be obtained. Associated symptoms, such as weakness and numbness, are important in localizing the area of injury.

Constitutional symptoms, such as fever, fatigue, unexplained weight loss, or night pain, may raise flags to investigate for other diseases, such as infections or neoplasms, that may lead to a pathologic fracture of the spine during a session of athletic activity.

The location of the predominant pain will be important in determining the neurological status of the condition. The sharp, electrical pain shooting down a single dermatome to the toes is a classical sign of nerve root irritation and is known as radicular pain. When this occurs with nerve roots that form the sciatic nerve (L4, L5, and S1), the term sciatica is used.

The term femoratica describes the radicular pain in the dermal distribution of the nerve roots forming the femoral nerve (L2, L3, and L4). If low back pain is predominant with a diffuse, dull aching in the buttocks or upper thighs, this is likely to be referred mechanical back pain. This type of referred pain is best explained to the patient using the classical left arm pain of coronary angina as an example.

The converse also is possible, in that conditions in the hips, pelvis, and abdomen may refer pain to the thoracolumbar spine area. Renal calculi, which may be more common in athletes who experience frequent dehydration, may first present with episodes of severe lumbar pain.

The classical neurogenic claudication symptoms of leg pain and weakness brought on by activities with the spine extended and relieved with flexion of the lumbar spine are suggestive of spinal stenosis. Although this usually is seen in elderly patients, the problem also can occur in younger adults who have the underlying condition of shorter pedicles (commonly reported by radiologists as having congenital spinal stenosis).

Typically, these athletes may have difficulty walking more than 100 meters yet will be able to bike more than 10 kilometers. The diagnosis can be confirmed with further spinal imaging.

The patient’s past medical, surgical, family, and social history may be very helpful. This can be especially true in cases of nontypical mechanical or radicular back pain.

Myelopathy resulting from spinal cord compression or vascular insufficiency may involve little or no back pain. Neurological deficits, such as loss of balance, weakness, and numbness, may be the first symptoms. Painless myelopathy needs further investigation to check for neuropathies, such as multiple sclerosis, amyotrophic lateral sclerosis (Lou Gerhig’s disease), or transverse myelitis.

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