Patient Evaluation and Diagnosis
Core concepts
A defensible pain diagnosis rests on mechanism plus anatomy, not on imaging alone. Expect questions on the history elements that change management: onset and trajectory, nociceptive versus neuropathic descriptors, red flags (fever, unexplained weight loss, night pain, bowel/bladder change, progressive weakness, saddle anesthesia), and psychosocial screening (catastrophizing, depression, opioid risk tools).
Examination and testing
The neurologic exam is high-yield: dermatomal sensory mapping, myotomal strength testing, and reflexes localize lesions. Provocative maneuvers (straight-leg raise, Spurling, facet loading) are supportive, not diagnostic. Understand when electrodiagnostics help (confirming radiculopathy, distinguishing peripheral from central) and their limits (they do not measure pain and may be normal early).
Traps
- Treating an MRI finding as the diagnosis: disc bulges and facet arthropathy are common in asymptomatic adults.
- Missing a non-spinal cause (hip or shoulder pathology referring to the spine).
- Skipping red-flag screening before any injection.
- Confusing radicular pain (dermatomal, lancinating) with claudication (positional, bilateral).
Worked rule of thumb
Localize before you inject: if symptoms cross more than one dermatome or do not fit a root, question the diagnosis and consider plexus, peripheral nerve, or non-neurologic sources. A single-level, concordant exam with imaging that matches is the strongest indication for targeted intervention.
Documentation
Record mechanism, functional impact, prior treatments and response, and objective findings. A diagnosis that cannot be tied to exam and mechanism invites denial and is a common exam distractor.