1.

Back Pain
Case Scenario
Your car seems to have sprung an oil leak, so you take it to Salvu, the car mechanic
down the road. He tells you that he wont be able to deal with it till next week, as he
has been off with a backache for a few days, and has a lot of catch up work to do. As
you are a second year medical student you try to help by asking questions about the
pain: When did it start? (Last week) Was it sudden or gradual? (Sudden) What kind
of pain is it? (Was a sharp pain, but now settled to a dull ache) What exactly was he
doing when he first felt the pain? (Pushing a car that would not start) Where is the
pain exactly? (All over the lower back, but seems to be worse on the right) Does it
shoot down the leg? (Yes) Does coughing make it worse? (Yes) Does he have any
numbness or tingling in his leg or foot (Yes to both, over the lateral part of the right
leg, foot and little toe). Has he ever had pain like this before? (Yes, many years ago
after heavy lifting, went away on its own). Can he bend over to touch his toes (No,
can only bend a few inches, limited by pain in his back).
He shows you the doctors medical report which states that there is diminuition in
the spinal lumbar curve and a tilt of the trunk to the left side. He has marked
limitation of movement in the lumbar vertebral column. Raising his right extended
leg is limited by pain to 20 degrees. There is weakness in dorsi-flexion of his right
foot as well as loss of sensory perception over the dorsal aspect of the right foot.
Case Discussion
NB: In this first session I have inserted a few key images, videos and references. In the
weeks that come, you will be expected to do this yourselves.
Review Spine (Cervical) Anatomy at: Animation
See articles at BMJ
1. List the symptoms and signs in this case.
2. Where could back pain arise from?
a. Think systematically of anatomical structures from which back pain might arise.
b. Analyze carefully each of the symptoms and signs and determine which structures
in the back could be involved in producing these symptoms.
c. Identify some signs that could help you distinguish between some of the
structures that could cause pain in the back.
3. How do you explain that the pain shoots down the right leg? Image
4. Why does coughing seem to make the pain worse?
5. What movement might lessen the pain?
6. How do you explain that
a. Raising the extended leg in the recumbent position caused pain? Straight Leg
Raising
b. There was diminuition in the spinal lumbar curve and a tilt of the trunk to the left
side?
c. The back pain started when it did.
d. There was weakness in dorsi-flexion of his right foot as well as loss of sensory
perception over the dorsal aspect of the right foot.
7. Explain in anatomical terms the likely cause of his condition. Why is this condition
most common in the lumbar area? Video
8. What is the significance of the past history?
9. Explain how it would be possible to distinguish between lesions at different
vertebral levels.
10. What tests could be done to confirm the diagnosis? Would a plain X Ray, CT scan,
ultrasound or MRI of the spine be useful in this case? Review basic anatomy at
Anatomy Spine
11. Do you think that bed rest or physiotherapy could be helpful in this case? Why?
12. When might surgical treatment be indicated? What might surgery entail?
13. Your mechanic friend asks for your advise. What should you say? Back Exercises 1
Back Exercises 2
14. Would your likely diagnosis change if the patient were:
a. An 80 year old woman?
b. A 20 year old air conditioning fitter?
c. A 30 year old nursery school teacher or babysitter?
15. How common is low backpain?
16. What is the psycho-social burden of back ache?