Any patient experiencing back pain or stiffness in a joint or joints for more than two weeks should see his or her physician for an evaluation. The evaluation usually consists of a discussion of symptoms and a detailed medical history, a physical examination and—if osteoarthritis is suspected—a series of x rays. Other tests (blood tests, MRI or CT scans) may be performed to confirm the presence of spinal arthritis or to rule out other conditions that can cause similar symptoms, such as a tumor, infection, fracture, or other types of arthritis.
Medical history. The patient will be asked to describe his or her symptoms, such as a description of the pain, stiffness and joint function, when and how the symptoms started, and how the symptoms have changed over time. The patient should also discuss how the symptoms affect his or her everyday life and work activities. The doctor also needs to know about the patient’s other medical conditions, current medications, past experience with other treatments, family history, and general lifestyle habits (such as alcohol intake, smoking, etc.). When dealing with pain problems, the doctor is likely to ask key questions related to those things that reliably cause or aggravate the pain and those that reliably bring relief or prevent the pain. Other questions may relate to certain lifestyle topics, such as exercise, nutrition and activities for diversion, sports, etc.
Physical examination. The doctor will conduct a physical exam to assess the patient’s overall general health, musculoskeletal status, nerve function, reflexes and direct evaluation of the problematic joints in the back. The doctor will be looking at muscle strength, flexibility, and the patient’s ability to carry out daily living activities such as walking, bending, and reaching. The patient may also be asked to perform some exercises to test range of motion and determine whether pain worsens during any particular type of movement.
X-rays. The doctor will likely order an x-ray to see if there is joint damage and how much joint damage has occurred. The x-ray can show cartilage loss, bone damage, and the presence and location of bone spurs. X-rays are also useful in helping to exclude other causes of pain and to better inform possible considerations about surgery. However, it is important to keep in mind that what shows up in an x-ray may not correlate to the presence or absence of osteoarthritis and associated pain. For example, most people over age 60 have degenerative changes in their spine consistent with osteoarthritis, but for perhaps 85% of them there is no pain or stiffness. Conversely, an x-ray conducted during the early stages of osteoarthritis may not yet show any visible damage to the joints. For all these reasons, the clinical history and physical examination are essential to arriving at an accurate clinical diagnosis and plan of treatment.
Other tests may also be used to rule out conditions other than osteoarthritis that may be causing the patient’s symptoms. For example, blood tests are used to exclude diseases that can cause secondary osteoarthritis or other types of arthritis that simulate osteoarthritis. Joint aspiration, where fluid is drawn from the joints through a needle for examination, can help rule out conditions such as infections or gout.
Additional tests that may be needed to rule out other causes of pain or to identify the presence of arthritis with more sophistication than an x-ray can include:
A radioactive bone scan, used to rule out inflammation, a tumor, infection or a small fracture. With a bone scan, the radioactive ‘tracer’ material is injected intravenously and then is concentrated by the body where there is high metabolism or bone turnover. If something suspicious is found on the bone scan, it is usually followed by a CT or MRI scan to distinguish what the bone lesion might represent, since the bone scan alone cannot distinguish among tumors, infections or fractures.
A CT scan may be used to better show the adequacy of the spinal canal and surrounding structures. A CT scan may also include myelography, where an x-ray contrast dye is injected into the spinal column to show structures such as a bulging disc or bone spur possibly pressing on the spinal cord or nerves.
The MRI or magnetic resonance imaging scan, is a very sophisticated imaging method that can show great anatomic details of the spinal cord, nerve roots, discs, ligaments and surrounding tissues and spaces. Most MRI studies require the patient to lie flat in a tube for about 40 minutes, although open frame and even standing MRI scanners exist and seem particularly appropriate for patients having claustrophobia (fear of tight spaces). MRI scans can be adjusted to show different tissues including their water content, important in determining disc degeneration, infections or tumors. The goal of all diagnostic studies is to discover patterns or confirmations between the various tests that point to a clear diagnosis among various possible ones.
The key is to diagnose the condition causing the patient’s pain and disability and to guide appropriate treatment, including psychological, physical, medical and/or surgical. Diagnosis is a detective hunt for causes and effects with the goal of improved treatment.
By: Charles D. Ray, MD
June 7, 2005
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