Orthopedics — Spine Evaluation Template

Patient Information

Date: [Date]
Visit type: New / Follow-up / Post-operative
Region: Cervical / Thoracic / Lumbar / Multiple

Chief Complaint

[Primary spine symptom]
Duration: [Onset, timeline]
Current status: Improving / Stable / Worsening

Red Flag Screening

[ ] Bowel/bladder dysfunction (new incontinence, retention)
[ ] Saddle anesthesia
[ ] Progressive motor weakness
[ ] Fever/chills/unexplained weight loss
[ ] History of cancer
[ ] Night pain unrelieved by rest
[ ] IV drug use
[ ] Recent trauma
[ ] Age >50 with new symptoms
[ ] Immunocompromised state
Red flags present: Yes / No — If yes: [Urgent workup indicated]

History of Present Illness

Mechanism of onset: Traumatic / Gradual / Insidious / Acute on chronic

• Inciting event: [If applicable]
• Date of onset: [Date]

Pain Characteristics

Location: [Specific spinal levels, unilateral vs bilateral]
Axial pain: Yes / No — Severity: [X]/10
Radiating pain: Yes / No

• Pattern: [Dermatomal distribution]
• Right: [Arm/leg, specific distribution]
• Left: [Arm/leg, specific distribution]

Character: Aching / Sharp / Burning / Electric / Dull
Severity: [X]/10 worst, [X]/10 average, [X]/10 current
Timing: Constant / Intermittent
Aggravating: [Sitting, standing, walking, bending, extension, flexion]
Relieving: [Position, medication, rest]
Night pain: Yes / No — Sleep disruption: Yes / No

Neurological Symptoms

Numbness/tingling: Yes / No — Distribution: [X]
Weakness: Yes / No — [Specific muscle groups]
Gait disturbance: Yes / No — [Description]
Hand clumsiness: Yes / No (cervical myelopathy)
Balance problems: Yes / No
Bowel/bladder: Normal / [Changes]

Functional Status

Walking tolerance: Unlimited / [Distance before symptoms]
Standing tolerance: Unlimited / [Duration]
Sitting tolerance: Unlimited / [Duration]
Neurogenic claudication: Yes / No — [Shopping cart sign]
Vascular claudication ruled out: Yes / No
Work status: Full duty / Modified / Disabled
ADL impact: [Specific limitations]

Prior Treatment

Conservative:

• Physical therapy: Yes / No — [Duration, response]
• Medications: [NSAIDs, muscle relaxants, gabapentinoids, opioids]
• Chiropractic: Yes / No — [Response]
• Acupuncture: Yes / No

Injections:

• Epidural: Yes / No — [Type: interlaminar, transforaminal], Level, Date, Response
• Facet: Yes / No — Level, Date, Response
• SI joint: Yes / No — Date, Response
• Trigger point: Yes / No

Prior spine surgery: None / [Procedure, level, date, surgeon, outcome]

Past Medical History

Osteoporosis: Yes / No — T-score: [X], On treatment: [X]
Diabetes: Yes / No — Neuropathy: Yes / No
Rheumatologic conditions: Yes / No — [Specifics]
Peripheral vascular disease: Yes / No
Cancer history: Yes / No — [Type, treatment]
Depression/anxiety: Yes / No
Fibromyalgia: Yes / No

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Occupation: [Type, physical demands]
Workers' compensation: Yes / No
Litigation: Yes / No
Exercise: [Current activity level]

Physical Examination

General

Gait: Normal / Antalgic / Wide-based / Shuffling / [Other]
Stance: Erect / Forward flexed / Listing [direction]
Assistive device: None / Cane / Walker

Inspection

Alignment: Normal / Kyphosis / Lordosis / Scoliosis
Muscle bulk: Symmetric / Atrophy [location]
Scars: [Prior surgical scars]
Skin: Intact / [Abnormality]

Palpation

Midline tenderness: [Levels]
Paraspinal tenderness: [Levels, side]
SI joint tenderness: Yes / No — Side: [R/L/Bilateral]
Sciatic notch: Yes / No
Step-off: Yes / No — Level: [X]
Muscle spasm: Yes / No — Location: [X]

Range of Motion (Lumbar/Cervical)

Flexion: [X]° / Full / Limited [X]%
Extension: [X]° / Full / Limited [X]%
Lateral bending R: [X]° / L: [X]°
Rotation R: [X]° / L: [X]°
Limited by: Pain / Stiffness / [Other]

Neurological Examination

#### Motor (0-5 scale)

Cervical (if applicable):

Level	Muscle	Right	Left
C5	Deltoid	/5	/5
C5	Biceps	/5	/5
C6	Wrist extension	/5	/5
C7	Triceps	/5	/5
C7	Wrist flexion	/5	/5
C8	Finger flexion	/5	/5
T1	Interossei	/5	/5

Lumbar:

Level	Muscle	Right	Left
L2	Hip flexion	/5	/5
L3	Knee extension	/5	/5
L4	Ankle dorsiflexion	/5	/5
L5	Great toe extension	/5	/5
S1	Ankle plantarflexion	/5	/5
S1	Knee flexion	/5	/5

#### Sensory

Cervical dermatomes: Intact / Diminished [specific] Lumbar dermatomes: Intact / Diminished [specific]

• L4 (medial leg): Intact / Diminished [R/L]
• L5 (dorsum foot): Intact / Diminished [R/L]
• S1 (lateral foot): Intact / Diminished [R/L]

Perianal sensation: Intact / Diminished
#### Reflexes (0-4+)

Reflex	Right	Left
Biceps (C5-6)
Brachioradialis (C6)
Triceps (C7)
Patellar (L4)
Achilles (S1)

Babinski: Down / Up / Equivocal [R/L]
Clonus: Absent / Present [Beats]
Hoffmann's sign: Negative / Positive [R/L]
#### Special Tests

Tension Signs:

Straight leg raise: Negative / Positive [Degrees] — R / L
Contralateral SLR: Negative / Positive
Femoral stretch test: Negative / Positive — R / L
Slump test: Negative / Positive

Myelopathy Signs (Cervical):

Tandem gait: Normal / Abnormal
Romberg: Negative / Positive
Rapid hand movements: Normal / Slow/Clumsy
Lhermitte's sign: Negative / Positive

Other:

FABER test (SI joint): Negative / Positive — R / L
Gaenslen's test: Negative / Positive
Waddell signs: [Number present] /5

Vascular

Pedal pulses: 2+ bilaterally / [Abnormality]
Capillary refill: <2 sec / Delayed

Imaging Review

X-rays: [Date]

• Alignment: [Lordosis/kyphosis, scoliosis, listhesis]
• Disc height: [Normal, decreased at levels]
• Osteophytes: [Levels]
• Facet arthropathy: [Levels]
• Instability (flexion/extension): [If obtained]

MRI: [Date]

• Disc levels:
• [Level]: [Bulge, protrusion, extrusion, sequestration], [Central, paracentral, foraminal], [Severity]
• Canal stenosis: None / Mild / Moderate / Severe — Levels: [X]
• Foraminal stenosis: None / Mild / Moderate / Severe — Levels: [X]
• Ligamentum flavum: Normal / Hypertrophied
• Facet arthropathy: [Levels, severity]
• Cord signal: Normal / [Myelomalacia]
• Vertebral bodies: Normal / [Compression fracture, Modic changes]

CT/CT myelogram: [If obtained]
EMG/NCS: [If obtained, findings]

Assessment

1) [Primary diagnosis] — [Level(s)]
[Radiculopathy vs claudication vs mechanical]
2) [Secondary diagnoses]

Plan

Conservative Management

1) Medications:

• NSAIDs: [Specific recommendation]
• Muscle relaxant: [If indicated]
• Neuropathic: Gabapentin / Pregabalin / [Other]
• Analgesics: [As appropriate]

2) Physical therapy:

• Focus: [Core strengthening, McKenzie, flexion-based, modalities]
• Frequency: [X] times/week for [X] weeks

3) Activity modification:

• [Specific lifting restrictions, positional advice]

4) Injections (if indicated):

• Type: [ESI, facet, SI joint]
• Level: [X]
• Timing: [Schedule]

Surgical Management (if indicated)

Indication: [Failed conservative, progressive neuro, myelopathy, cauda equina]
Procedure: [Specific procedure]

• Decompression: [Laminectomy, laminotomy, discectomy, foraminotomy]
• Fusion: [ALIF, PLIF, TLIF, ACDF, posterior fusion]
• Artificial disc: [If candidate]
• Minimally invasive options: [If applicable]

Timing: [Urgent vs elective]
Pre-operative: [Optimization - smoking cessation, diabetes control, etc.]

Follow-up

Return: [Timeframe]
Urgent return: Progressive weakness, bowel/bladder changes, worsening numbness

Patient Education

Diagnosis explanation, natural history, activity modifications, posture and body mechanics, home exercise program, weight management, smoking cessation if applicable, warning signs requiring urgent evaluation.