Longitudinal Orientation



Longitudinal Orientation

Low Back Pain

Case 1:

A 35 year old male with long intermittent history of low back strains presents with new symptoms of pain radiating down the right leg, difficulty jogging because of lower leg weakness and tingling sensation on the outside of the right foot.

Pertinent history: pain is better with hip and knee flexed and on back. No urinary or bowel symptoms.

Exam: weak gastrocnemius, decreased ankle reflex

Xray: normal; med-ed.virginia.edu/courses/rad/ext/index.html

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. L5-S1 disc herniation; leg pain often worse than back pain;

2. no

3. no

4. time, 4 – 6 weeks of conservative care; PT? NSAIDS, muscle relaxants, pain meds? Follow up (see article from Annals of Internal Medicine for further discussion)

Case 2:

A 13 year old male hurt his lower back 2 weeks ago while playing basketball. He says it suddenly hurt when he came down from a rebound and extended his back awkwardly. It mildly aches with ambulation and is relieved by rest. Jogging really aggravates it. Most of his pain is with extension.

Pertinent History:

Healthy, no other medical problems. Very athletic appearing boy.

Exam: pain only with extension. Good flexion. Lower extremity neuron exam normal – one leg lumbar extension more painful on right.

Xray: med-ed.virginia.edu/courses/rad/ext/index.html

Questions for Discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. Pars Interarticularis defect (spondylolysis)

2. no

3. bone scan will help determine if acute or chronic

4. and 5. rest, avoid extension or pain producing activity; goal – to be pain free before resuming sports. Xray abnormality may be permanent. May heal by fibrous union. Refer if spondylolisthesis in which vertebral body displacement is greater than 25% of the width of the vertebral body. Check lateral xray every 6 months to monitor development of spondylolisthesis. Risk of developing spondylolisthesis is greatest between ages of 9 and 14 and is greater in girls. Follow until vertebral growth is completed.

Case 3:

A 66 year old male new patient complains of new onset back pain for the last 2 to 3 months. The patient has not seen a doctor in over 15 years. There is no significant past medical history. The patient exercises regularly and doesn’t smoke. The patient has lost 10 pounds over the past few months but attributes this to his exercise regimen.

Pertinent History:

Pain with ambulation and at rest. Continual dull aching – no spasm. 1 year history of nocturia and decreased urinary stream.

Exam: normal, mild pain with flexion. Rectal: nodular prostate that is enlarged.

Xray: (afp/20020501/1834.html figure 4 only)

Questions for Discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. metastatic prostate cancer to vertebral bodies

2. yes: weight loss, change in urinary stream, age over 50, pain at rest,

3. MRI, bone scan, work up of prostate nodules

a. Determining whether metastatic bony involvement is focal or diffuse is important for the clinical decision making process. If patient has multiple painful sites, they benefit from treatment with systemic radioisotopes. If 1 or just a few painful sites, they are better served by focal external beam radiation.

4. pain meds while pursueing work up/consultation with urologist and oncologist

5. likely advanced due to bony mets

Case 4:

A 70 year old man with Groshong Catheter for chemotherapy presents to the ER with back pain. The patient was lifting boxes last night and woke up this morning with increasing pain. No history of back problems. Complete physical 3 months ago was normal. All labs (including CBC and PSA) were normal.

Pertinent history: Occasional night sweats. No lower extremity symptoms – no bowel or bladder symptoms.

Exam: point tenderness of L1 L2 spinous processes. Patient very uncomfortable. Cannot find comfortable position. Para – lumbar muscle spasm noted.

Xray:

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. osteomyelitis: staph aureus is organism in greater than 50% of cases; fever occurs inconsistently; back pain is usual presenting sx. Likely to have elevated ESR or CRP.

2. yes, age greater than 50, immunosuppresion due to chemotherapy, history of cancer, night sweats

3. MRI best shows osteomyelitis

4. Parenteral antibiotics for minimum of 6 weeks, remove Groshong catheter?

5. long course antibiotics needed, most respond, surgery necessary in a minority of patients.

Case 5:

A 41 year old female was bending over to pick her 3 year old up and felt a sudden stabbing pain in her back. The pain progressed through the day and now she can hardly move without intense pain. She state the pain is in the lower back and radiates to her hips and thighs bilaterally. No bowel or bladder symptoms are present.

Pertinent History: No history of back problems, very healthy, no meds. Annual physical 1 month ago was normal.

Exam: The patient is unable to straighten up, she leans to the right. She can hardly do exam because of pain. Lower extremity neuron exam is normal.

Xray: not done

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. low back strain/sprain with muscle spasm

2. no

3. no, at least not initially; may need to consider if pain lasts longer than 6 weeks

4. activity as tolerated, NSAIDS, muscle relaxants, ?opioids, home PT/stretching exercises when tolerated; follow up in 4 – 6 weeks. With an episode of severe low back pain, a patient working a light duty job (sitting, lifting/carrying less than 20 lb) in 0 – 3 days. See Return to Work guidelines in AFP article from 1st low back session.

5. most cases of acute back pain resolve in 4 – 6 weeks with conservative treatment.

Case 6:

A 45 year old male with insidious onset (3 – 4 months) of right lower back pain. The patient states that it feels like a constant knot. Pain is aggravated by standing or sitting for long periods.

Pertinent History: Very healthy and active. No medications. No other symptoms

Exam: good flexion and extension. Mild pain on palpation over SI joint. Patrick’s Test is positive.

Xray: SI joint arthritis on the right

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs? What is Patrick’s Test?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. Sacroiliac joint pain – OA

2. no; Patrick’s Test - Patrick's test is performed by a health care provider to evaluate people who have low back pain for sacroiliitis. The knee is flexed to ninety degrees on the affected side and the foot is rested on the unaffected knee. Holding the pelvis firm against the examination table, the affected knee is pushed towards the examination table, a maneuver which provides external rotation of the leg at the hip joint. If pain results, this is considered a positive Patrick's test and sacroiliitis is more likely. However, Patrick's test does not prove that sacroiliitis is causing the back pain, just increases the likelihood.

3. could try conservative tx and image if this fails after 6 weeks

4. NSAIDS and time. Low back stretches. If conservative treatments fail, may refer to ortho for an SI joint injection.

5. resolution or improvement with conservative tx.

Case 7:

A 71 year old male who has been a long time patient of yours complains of low back pain that has been present for 3 – 4 months. The pain is aggravated by standing for long periods. He complains of feeling stiff in the morning but feels better with activity. The patient has had improvement with the occasional use of ibuprofen or Tylenol.

Pertinent History: The patient has osteoarthritis of both knees but is otherwise healthy. He had a recent physical exam which revealed a normal prostate and PSA.

Exam: Decreased ROM on flexion and extension. Mildly flexed posture. No point tenderness, no lower extremity findings.

Xray: OA of facet joints as well as decreased intervertebral disc space. Loss of vertebral height T12 – L2.

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. Osteoarthritis

2. age over 50 but otherwise, no

3. xray may help determine if there is a compression fracture or infiltrative process of the spine or other worrisome pathology in a patient of advanced age

4. Scheduled Tylenol is a very good option in an older patient with little risk of side effect/drug interaction. NSAIDS can also be used but pick your patients cautiously in the geriatric population. Back exercises/stretching at home help. Glucosamine seems to help some patients. Pain Management for epidural injections is an option when conservative therapy fails.

5. progression, there is no cure, goal is symptom management and maintenance of an active, self-sufficient lifestyle.

Case 8:

A 42 year old male fell off a six-foot ladder and landed on his lower back. He presents 1 hour after the injury in acute pain.

Pertinent History: No other symptoms besides pain. No medications. No medical problems. Complete physical 6 months ago was normal.

Exam: extremely point tender over spinous processes and para lumbar muscle area between L2 – L5. No lower extremity symptoms or signs. Cannot flex or extend.

Xray: fracture of transverse processes

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. Fracture of transverse processes.

2. significant trauma only

3. yes, due to history of significant trauma

4. rest, pain medications, time, close followup

5. bony callous formation at the fracture site, healing, no casting/splinting needed unless for pain control.

Case 9:

An 86 year old female was on her daily walk and felt sudden sharp pain in her lower back causing her to fall. She was able to get up and get help. Her neighbors bring her in and she is in a lot of pain. No lower extremity pain.

Pertinent History: OA of left hip. She does not take estrogen or calcium but does exercise regularly. Complete physical 1 month ago was normal. She is normally a very active and vibrant lady.

Exam: Can hardly do because of pain. Very tender throughout lumbar soft tissue and bony structures. Increased pain with standing and walking, some relief when lying supine.

Xray:

Questions for discussion:

1. What is the diagnosis?

2. Are there any red flag signs?

3. Is imaging indicated?

4. How should this patient be treated?

5. What is the expected course of this illness?

Answers:

1. lumbar compression fracture

2. yes – age, trauma (fall), otherwise no. Note, in severe osteoporosis, even minimal trauma may cause a fracture, ie, sneezing.

3. yes, though serial xrays may be necessary as the injury can take days to weeks to show up on xray; MRI is imaging of choice if there are neurologic signs/sx involved.

4. rest, pain control – sometimes hospitalization is necessary. Consider miacalcin for pain relieving properties as well as for treatment of osteoporosis. Consider bisphosphonates. Calcium supplementation. Lumbar corset brace helps with pain control. PT after acute phase. Vertebroplasty is an option in those who don’t respond to conservative therapy.

5. severe pain acutely which gradually lessens. Some may have chronic pain from such injuries. Important to maintain the patient’s functioning as best as possible. Women diagnosed with a compression fx have a 15% higher mortality. There is an increased risk of subsequent fractures of all types. Don’t forget to assess the elderly pt for fall risk in order to avoid future compression fractures.

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