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; www.med-ed.virginia.edu/courses/rad/ext/index.html  (To see right X Ray on the next page click on Lumber Spine and then Normal)

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?

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:   www.med-ed.virginia.edu/courses/rad/ext/index.html  To see right X Ray on the next page click on Lumber Spine and then Spondylolysis

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?

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:  http://www.aafp.org/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?

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?

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?

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?

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?

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?

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: http://www.med-ed.virginia.edu/courses/rad/ext/index.html (To see right X Ray on the next page click on Lumber Spine and then Compression Fracture

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?