FMcase 10

Case 10
45-year-old male presenting with low back pain - Mr.

Payne
Author: Shou Ling Leong, M.D., Penn State College of Medicine
Learning Objectives:
Understand the differential diagnosis for low back pain. 1.
Develop physical exam skills in evaluating low back pain. 2.
Develop the skills in the diagnosis and treatment of low back pain. 3.
Recognize the red flags or alarming symptoms for serious causes for low
back pain.
4.
Order imaging studies when indicated. 5.
Prescribe appropriate treatment for back pain. 6.
Refer refractory back pain for consultation and surgical intervention. 7.
Summary of Clinical Scenario:
Mr. Payne, a 45-year-old white male truck driver, presents with two weeks of
back pain and a tingling sensation down his left leg after lifting a 10-pound box.
Serious causes of lower back pain are excluded by history. Physical exam reveals
straight leg-raising (SLR) is positive at 75 degrees on the left. Mr. Payne is given
a provisionary diagnosis of back pain with radiculopathy and sent home for
conservative treatment with physical therapy. At follow up, three weeks later, Mr.
Paynes pain is now radiating down the lateral part of his left leg and the side of
his left foot. At this point, physical exam reveals positive SLR at 45 degrees on
the left, and reflexes are absent at the left ankle and 1+ at the right ankle. An
MRI is ordered, which depicts a large herniated disc at L5-S1. He is referred to
the pain clinic for consultation and possible selective S1 nerve root injections.
During a phone call two weeks later, Mr. Payne happily reports that the cortisone
injection was a big success. His pain is much improved and he has gone back to
work part-time. After a few months of improvement, Mr. Paynes pain flares up
again and he develops weakness of his left foot. A repeat MRI shows progression
of the disc herniation. He elects for surgery, which relieves his pain.
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Key Findings
from History
Pain worse with movement and sitting, improves
while lying down
Pain radiates down the leg/numbness
No history of trauma
No problem with bowel or bladder control
No dysuria/frequency
No fever or chills
Key findings
from Testing
MRI
Herniated disc at L5-S1 with associated
impingement on the left S1 nerve roots and
mild-moderate impingement on the right S1 nerve
root.
Mild central canal stenosis.
Annular tear with small central disc herniation at
L4-5 with mild central canal stenosis.
Final
Diagnosis
Low back strain with herniated disk.

Case Highlights:
This case contains a detailed explanation of performing a complete neurological
exam of lower extremities, illustrates the use of Evidence Based Medicine to
determine when imaging studies are warranted in lower back pain, and discusses
the use of conservative management for lower back pain while reserving surgery
as the treatment of last resort.
Key Teaching Points
Knowledge:
Low Back Pain
Etiology
Mechanical (97%)
No primary inflammatory or neoplastic cause
Risk Factors
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Prolonged sitting, with truck driving having the highest rate of LBP, followed
by desk jobs.
Deconditioning.
Suboptimal lifting and carrying habits.
Obesity is a possible risk factor, but the evidence is limited and inconsistent.
Causes
Lumbar strain/sprain (70%)
Age related degenerative joint changes in the disks and facets (10%)
Herniated disc (4%)
Osteoporotic fracture (4%)
Spinal stenosis (3%)
Visceral (2%)
No primary involvement of the spine
Usually involves internal organs
Pyelonephritis and kidney stones
Non-mechanical (1%)
Epidemiology
Low back pain (LBP) is the fifth most common reason for all doctor visits.
In the US, lifetime prevalence of LBP is 60-80%.
The direct and indirect costs for treatment of LBP are estimated to be $100
billion annually.
Fortunately, most LBP resolves in two to four weeks.
Summary of the causes of back pain by categories
Category Diseases/Conditions
Congenital Scoliosis, kyphosis, spondylolysis
Traumatic Lumbar strain, compression fracture
Metabolic
Osteoporosis, hyperparathyroidism, Paget's disease,
osteomalacia
Infectious
Pyelonephritis, osteomyelitis, discitis, herpes zoster,
spinal or epidural abscess
Inflammatory
Ankylosing spondylitis, sacroiliitis, rheumatoid
arthritis
Neoplastic
Multiple myeloma, metastatic disease, lymphoma,
Leukemia, osteosarcoma
Degenerative
Disc herniation, osteoarthritis, facet arthropathy,
spinal stenosis
Vascular Aortic aneurysm, diabetic neuropathy
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Category Diseases/Conditions
Visceral
Prostatitis, PID, ovarian cyst, endometriosis, kidney
stones, cholecystitis, pancreatitis
Radiologic findings associated with LBP
Spondylolysis
Disc-space narrowing
Spinal instability
Spina bifida occulta
Prognosis
Most cases of low back pain are acute in onset and resolution, with 90%
resolving within one month and only 5% remain disabled longer than 3
months.
For patients who are out of work greater than 6 months, there is only 50%
chance of them returning to work; this drops to almost zero chance if
greater than 2 years.
Patients who are older (>45) and patients who have psychosocial stress
take longer to recover.
Recurrence rate for back pain is high at 35 to 75%.
SKILLS
History:
Fever, constant pain, even at rest, pain at night, and unexplained weight
loss require extra attention to rule out uncommon, but serious underlying
non-mechanical causes of pain, such as infection or malignancy.
Questions to ask regarding low back pain
Location, quality, duration, radiation
Is the pain constant or remitting
Exacerbating circumstances (active vs. passive motion, day vs. night)
Palliative circumstances (medication, positioning-sitting, lying, standing)
What has the patient tried to relieve the problem (what worked, what
didn't)
Intensity of the pain: Severity scale 1-10
History of similar problem
Review of Systems
Constitutional symptoms
Fever, nausea, vomiting
Unexplained weight loss
Neurologic symptoms
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Numbness
Tingling
Muscle weakness
Incontinence
Urinary symptoms
Frequency
Dysuria
Pertinent history
Recent illness
History of trauma
Patient's occupation
History of back injury, cancer, diabetes, etc.
Relevant Past Medical History
Current medications and allergies
Disc herniation
Classically, disc herniation is associated with exacerbation when sitting or
bending, and relief while lying or standing
Other symptoms
Increased pain with coughing and sneezing
Pain radiating down the leg and sometimes the foot,
Parasthesias
Muscle weakness, such as foot drop.
Physical Exam:
Standing
Inspection
Look for posture, contour, symmetry
Check for lordosis, kyphosis, scoliosis
Slight scoliosis may be more easily visualized during lumbar flexion.
Have the patient stand with their feet and hands together, like they
are about to dive off a diving board, bending forward toward their
toes. Look out across the back to see if the shoulders are level.
Palpation
Identify muscle spasm, vertebral fracture, or infection by checking for any
tenderness, tightness, rope-like tension, or inflammation in the paraspinous
muscles or tenderness over bony prominences.
Range of Motion (ROM)
Lumbar Flexion (normal is 90 degrees)
The best measure of spine mobility.
Restriction and pain during flexion are suggestive of herniation,
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osteoarthritis, or muscle spasm.
Lumbar Extension (normal is 15 degrees)
Pain with extension is suggestive of degenerative disease or spinal
stenosis.
Lateral motion (normal is 45 degrees)
Most patients should be able to touch the proximal fibular head of the
knee.
Pain on the same side as bending is suggestive of bone pathology,
such as osteoarthritis or neural compression.
Pain on the opposite side of bending is suggestive of a muscle strain.
Gait
Ask the patient to walk on heels and toes.
Expect normal gait, even with disc herniation.
Difficulty with heel walk is associated with L5 disc herniation.
Difficulty with toe walk is associated with S1 disc herniation.
Stoop Test
Have the patient go from standing to squatting position.
In patients with central spinal stenosis, squatting will reduce the pain.
However, asking the patient to run is not part of a back exam and may
cause discomfort to the patient who is already in pain.
Sitting
Costovertebral angle (CVA) tenderness,
Suggests pyelonephritis.
Modified straight leg raise (SLR) test
Raise each leg by extending the knee from 90 degrees to straight.
If the pain is functional, the action is possible without difficulty.
If the pain is due to structural disease, the patient will instinctively exhibit
the "tripod sign" by leaning backward and supporting himself with his
outstretched arms on the exam table.
Neurological exam
Most neuropathic back pain is due to impingement of L4, L5, and S1 nerve
roots.
Deep Tendon Reflexes
Grading Reflexes:
0 No evidence of contraction
1+ Decreased, but still present (hyporeflexic)
2+ Normal
3+ Increased (hyper-reflexic)
4+ Clonus: Repetitive shortening of the muscle after a single
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stimulation
Decreased patella reflex implies nerve impingement at the L3-L4
level.
Decreased Achilles reflex implies nerve impingement of L5-S1 levels.
Hyper-reflexia is a sign of upper-motor neuron syndrome associated
with spinal cord compression.
Muscle Strength
Rating Scale:
0/5 No movement
1/5 Barest flicker of movement of the muscle, though not
enough to move the structure to which it's attached.
2/5 Voluntary movement, which is not sufficient to overcome
the force of gravity. For example, the patient would be able to
slide their hand across a table but not lift it from the surface.
3/5 Voluntary movement capable of overcoming gravity, but not
any applied resistance. For example, the patient could raise
their hand off a table, but not if any additional resistance were
applied.
4/5 Voluntary movement capable of overcoming "some"
resistance
5/5 Normal strength
Range of motion
Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you
push down on his thigh
Hip Abduction (L 4, 5, S1): Ask the patient to push his legs
apart while you push them together
Hip Adduction (L 2, 3, 4): Ask the patient to push his legs
together while you push them apart
Knee Extension (L 2, 3, 4): Ask patient to extend his knee while
you push it down.
Knee Flexion (L 5, S1, S2): Ask the patient to flex his knee while
you push against it.
Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up
while you push it down.
Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot
down while you push it up.
Decreased strength implies nerve impingement of the associated
nerve in parenthesis.
Sensation
Test for sharp and light touch along the dermatonal distribution of the
great toe (L5), lateral malleolus and posteriolateral foot (S1).
Supine
Abdominal Exam
Auscultation: Check for abdominal bruit, looking for abdominal aortic
aneurysm.
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Palpitation: Check for abdominal tenderness (on all patients, not just female
patients), pelvic tenderness (PID), pulsatile mass, unequal femoral/brachial
pulses (abdominal aortic aneurysm), or any general tenderness indicating
visceral pathology.
Rectal Exam
To be done only on patients with red flags or alarm symptoms.
Bleeding or rectal mass can be signs of cancer with metastasis to the spine
causing back pain.
Decreased tone can indicate disc herniation and/or cauda equina syndrome.
Passive Straight Leg Raise (SLR or Lasegues sign)
The normal leg can be raised 80 degrees. If a patient raises their leg <80
degrees, they have tight hamstrings or a sciatic nerve problem.
To differentiate, raise the leg to the point of pain, lower slightly, then
dorsiflex the foot.
If there is no pain with dorsiflexion, the patients hamstrings are tight.
The test is positive if pain radiates down the posterior/lateral thigh.
This radiation indicates stretching of the nerve roots (specifically S1 or L5)
over a herniated disc and will most likely occur between 40 and 70
degrees.
Pain will not occur until the leg is lifted at least 30 degrees.
Pain earlier than 30 degrees is suggestive of malingering.
Pain in the opposite leg during a straight leg raise is suggestive of root
compression due to complete disc herniation.
The ipsilateral straight leg raise test has a sensitivity of 0.80 and a
specificity of about 0.40.
Thus, a negative test makes a herniated disc unlikely, but a positive test is
nonspecific.
Crossed Leg Raise
Asymptomatic leg is raised.
Test is positive if pain is increased in the contralateral leg; this correlates
with the degree of disc herniation.
Cross SLR test is much less sensitive (0.25) but is highly specific (about
0.90).
Thus, a negative test is nonspecific, but a positive test is virtually diagnostic
of disc herniation.
FABER Test: Flexion, Abduction, and External Rotation
The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain
from sacroiliitis).
The test is performed by flexing the hip and placing the foot of the tested
leg on the opposite knee. Pressure is then placed on the tested knee while
stabilizing the opposite hip.
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The test is positive if there is pain at the hip or sacral joint or if the leg cant
lower to the point of being parallel to the opposite leg.
The FABER test should done on all patients suspected of having sacroiliac
pain, not just in the elderly patients. Sacroiliitis can occur in the young
population as well.
Pelvic Compression Test
Performed by forcibly pressing together the hips
A positive test elicits pain in the sacroiliac joint.
Muscle Atrophy: of quadriceps and calf muscles.
Lack of atrophy, despite patient's complaints of long-term weakness,
suggests malingering.
Nerve Root Impingement Syndromes
Reflex
Pin-Prick
Sensation
Motor
Examination
Functional
Exam
L3
Patellar
tendon
reflex
Lateral thigh and
medial femoral
condyle
Extend
quadriceps
Squat down and
rise
L4
Patellar
tendon
reflex
Medial leg and
medial ankle
Dorsiflex ankle Walk on heels
L5
Medial
hamstring
Lateral leg and
dorsum of foot
Dorsiflex great
toe
Walk on heels
S1
Achilles
tendon
reflex
Posterior calf,
Sole of foot, and
lateral ankle
Stand on toes
Walk on toes
(plantarflex
ankle)

Differential Diagnosis:
More Likely
Lumbar strain
Pain worse with movement and sitting that improves while lying down is
suggestive of a mechanical cause of back pain, such as a lumbar strain.
Disc herniation
Pain worse with movement and sitting that improves while lying down is
suggestive of a mechanical cause of back pain, such as a disc herniation.
Pain with radiation down the leg and numbness indicate nerve involvement,
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such as in disc herniation.
Spinal stenosis
Degenerative arthritis
Less likely
Serious medical conditions that should be excluded:
Cauda equina syndrome
Results from spinal compression of the cauda equina, resulting from a large
mass efect (such as an acute disc herniation or a tumor) causing pain
radiating down the leg and numbness of the leg.
This is a true emergency and decompression should be performed within 72
hours to avoid permanent neurologic deficits.
Red flags signaling cauda equina include:
Urinary incontinence or retention
Saddle anesthesia
Anal sphincter tone decreased or fecal incontinence
Bilateral lower extremity weakness or numbness
Progressive neurologic deficits
Malignancy
More commonly seen in patients over 50
Dull, throbbing back pain
Localized to the affected bones
Progresses slowly
Increases with recumbency or cough
Red flags signaling cancer include:
History of cancer
Unexplained weight loss >10 kg within 6 months
Age over 50 years or under 17 years old
Failure to improve with therapy
Pain persists for more than 4 to 6 weeks
Night pain or pain at rest
Infection
Red flags signaling infection include:
Persistent fever (>100.4 F), fever/chills
Risk factors for spinal infection such as
Recent bacterial infection, particularly bacteremia (urinary tract
infection, cellulitis, pneumonia)
History of IV drug abuse
Immune suppression (steroids, transplant, or HIV).
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Vertebral Fractures
Cause pain which may be aggravated with movement.
Red flags signaling fractures include:
Prolonged use of corticosteroids
Mild trauma over age 50 years
Age greater than 70 years
History of osteoporosis
Recent significant trauma at any age (car accident, fall from
substantial height)
Previous vertebral fracture
Significant herniated nucleus pulposus
Red Flags
Major muscle weakness (strength 3 of 5 or less)
Foot drop
Other, less common causes that should be considered based on the
history and physical
Gastrointestinal diseases such as pancreatitis, cholecystitis and ulcers
Usually associated with other abdominal symptoms.
Pyelonephritis
The lack of fever and urinary symptoms makes pyelonephritis less likely.
Ankylosing spondylitis
Chronic, painful, inflammatory arthritis primarily affecting the spine and
sacroiliac joints, causing eventual fusion of the spine
It is often seen in patients 15-40 years old
Associated with morning stiffness and achiness over the sacroiliac joint and
lumbar spine.
Spondylolisthesis
Describes the anterior displacement of a vertebra or the vertebral column in
relation to the vertebrae below
Occurs at any age.
It causes aching back and posterior thigh that increases with activity or
bending.
Prostatitis (men) and pelvic inflammatory disease and endmetriosis
(women)
Can cause referred LBP, suggested by evidence of infection in the history
and physical exam.
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Studies:
In the absence of red flags or findings suggestive of systemic disease,
diagnostic testing, especially imaging,imaging,imagis not indicated until
after 4 to 6 weeks of conservative treatment.
Ordering tests too early is not only cost ineffective, but can also cause harm
to the patients.
CBC and sedimentation rate
Should be ordered if tumor or infection is suspected.
Plain x-ray
Spine film can expose a patient to radiation.
Especially concerning in young women because radiation to the
ovaries in a single plain radiograph of the lumbar spine is equal to
getting daily CXR for more than a year.
Spine films lack specificity and have a high rate of false-positive for causes
of low back pain.
However, it is relatively inexpensive and easily accessible with a quick
turnaround time for the results.

Guidelines for plain films Criteria for lumbar films
Agency for Health Care Policy
and Research (AHCPR)
Deyo series
Age <20 and >70
History of trauma
Strenuous lifting in patient with
osteoporosis
Prolonged steroid use
Osteoporosis
History of cancer
fever/chills/weight loss
Pain worse when supine or severe
at night (spinal fracture, tumor or
infection)
Age over 50
Significant trauma
Neuromotor defect
Weight loss of 10 pounds
Ankylosing spondylitis
Drug or alcohol abuse
History of malignancy
Fever of 100 degrees
Fahrenheit
Revisit without
improvement or financial
compensation
Computed Tomography (CT scan)
CT scans expose patients to contrast materials that have renal toxicity.
Routine imaging with CT or MRI is not associated with improved outcomes,
but can identify abnormalities that are unrelated to the patient's back pain.
This can cause anxiety and could lead to more testing and possibly
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unnecessary intervention.
Magnetic Resonance Imaging (MRI)
Not associated with clinical benefit in randomized trials.
Early MRI is not associated with improved outcomes in patients with acute
back pain or radiculopathy (Level 2/mid-level evidence).
Indications for MRI include:
Neurological deficit
Radiculopathy
Progressive major motor weakness
Cauda equina compression (sudden bowel/bladder disturbance)
Suspected systemic disorder (metastatic or infectious disease)
Failed 6 weeks of conservative care. (However, 75% of herniated
discs improve with 6 weeks of conservative therapy.)
Some recommend that in the absence of red flags, it is reasonable to
obtain an imaging study after one month of symptoms if surgery is
being considered.
Management:
Acute low back pain (0-3 months)
Conservative therapy
General measures:
Apply local therapy (heat/cold) as tolerated.
Maintain good posture and practice good lifting techniques at all time.
Call the clinic if there is no relief or if the pain increases, progression of
neurologic deficits, development of problem with bowel or bladder control.
Pharmacologic
First line medications:
Non-steroidal anti-inflammatory drugs (NSAIDs)
A systematic review of randomized controlled studies found
strong evidence that NSAIDs and muscle relaxant are helpful in
the treatment of LBP.
Acetaminophen
There is conflicting evidence about the superiority of NSAIDs to
acetaminophen.
Muscle relaxants
The various NSAIDs and muscle relaxants are equally effective,
while some muscle relaxants are more sedating.
Opioids
Second- or third-line option for treatment of back pain.
There is little evidence regarding the benefits and harms of opioid use
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in LBP.
Corticosteroids
No studies support the use of oral steroids in patients with LBP.
Activity level
Avoid strenuous activities but to remain active
Bed rest is not more effective than continuation of activities of daily living.
Prolonged bed rest may contribute to muscle atrophy, cardiovascular
deconditioning, bone mineral loss, and reinforcement of illness behavior.
Physical Therapy
Tailored physical therapy is slightly more effective for acute back pain
compared to patients who just stay active.
At 4 weeks, patients who received physical therapy had 10-point
improvement in a 100-point disability score compared to the control group.
There is great variation in physical therapy because various interventions
(exercises, traction, massage) and different modalities (heat, ice,
ultrasound) may be used.
Spinal manipulation is safe and can help in the short term.
There is limited evidence in the use of acupuncture in the treatment of LBP,
with some studies showing that it is not beneficial.

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Case 10

45-year-old male presenting with low back pain - Mr.

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