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Spine Diagnosis Elements

What are the pieces of information Spine Specialists use to make a Diagnosis?

Here are some of the pieces of information spine specialists use to make a diagnosis:

  1. Medical Records

Medical records of your prior spine care are essential for the spine specialist. If you have been given a diagnosis of a spine problem, the spine specialists will take that into consideration and focus the exam on whether he/she agrees with that diagnosis.

Even medical records from primary care physicians who have given you conservative spine care are important. They may have taken tests or prescribed medications which help the spine specialist make a diagnosis.

Patients with prior spine surgery are often the most difficult to diagnose. For that reason, having as much detail of the prior surgery and what lead to it is critical. Ideally, as many records as possible, including the Operative Report (surgeon’s report of the surgery) should be brought in.

The spine specialist may not be able to make a diagnosis without ordering further imaging studies or other tests.

     2.  Medical History

Even though you are seeing a spine specialist, your general medical history is still important. There are spine conditions which may be the result of a general health problem. For instance, patients who have Rheumatoid Arthritis and complain of neck pain, may have instability at the two highest vertebrae in the neck. This is a common problem in patients with this chronic disease.

Another example are patients with poorly controlled diabetes who present with severe back pain. In this situation, the spine doctor would be concerned about a disc infection (discitis).

It is very important to be very complete about your general medical history even when you see specialist such as a spine specialist.

3. Spine History

The information the patient fills out at the time of the first office visit (consultation) is very important in helping with a diagnosis. Often spine specialists will review that information before they enter the exam room to get some idea of what they are dealing with. The other pieces of the history are the answers you give to specific questions the doctor will ask. They are often based on the written history you provided. So, filling out the spine history as completely as you can on the intake forms (initial forms you fill our before the visit) is very important.

4. Spine Examination

The examination the spine specialist performs on you is another important piece of the puzzle. Often the doctor will key in on specific exams which are meant to either confirm what they think the diagnosis is based on your history, or to exclude other possibilities. The neurological part of the examination is very important to assess if the patient has a nerve or spinal cord problem which could point to a more serious condition.

5. Spine Tests

Spine images are often one of the most important Spine Tests and the key to understanding your condition.

Often plain X-Rays are taken first, followed by more in depth studies such as MRIs, CT-Scans, bone scans, etc. By itself, a spine image can make the diagnosis but spine specialists often want to make sure that the information on the images matches up to your symptoms. For instance, a patient may have a disc herniation on an MRI, but the symptoms point to a facet joint problem. So, the history and the physical exam still bear significant weight on making a final diagnosis.

Other spine tests such as Nerve Studies and Laboratory Tests can help with the diagnosis.


Altogether, spine specialists use the information from the Medical Records, the Medical History, the Spine History, the Spine Examination and Spine Tests to make the Spine Diagnosis. Once the Spine Diagnosis is established, the correct Spine Treatments can be chosen.