You are working with Dr. Lee today.

You are working with Dr. Lee today. She hands you a triage note from the nurse regarding your next patient, Mr. Payne:

Forty-five-year-old white male truck driver complaining of two weeks of sharp, stabbing back pain. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed.

Dr. Lee provides you some background information about low back pain.

TEACHING POINT

Low Back Pain Prevalence, Cost, & Duration

Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 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.

Dr. Lee continues: “There are many causes for LBP. For presenting symptoms that have a broad differential diagnosis, I find it helpful to think of systems of etiologies in which diseases or conditions can be categorized.”

TEACHING POINT

Common Causes of Back Pain

Musculoskeletal (MSK) and Non-MSK Causes of Back Pain

MSK Causes

Axial:

• Degenerative disc disease
• Facet arthritis
• Sacroiliitis
• Ankylosing spondylitis
• Discitis
• Paraspinal muscular issues
• SI dysfunction

Radicular:

• Disc prolapse
• Spinal stenosis

Trauma:

• Lumbar strain
• Compression fracture

Non-MSK Causes

Neoplastic:

• Lymphoma/leukemia
• Metastatic disease
• Multiple myeloma
• Osteosarcoma

Inflammatory:

• Rheumatoid Arthritis

Visceral:

• Endometriosis
• Prostatitis
• Renal lithiasis

Infection:

• Discitis
• Herpes zoster
• Osteomyelitis
• Pyelonephritis
• Spinal or epidural abscess

Vascular:

• Aortic aneurysm

Endocrine:

• Hyperparathyroidism
• Osteomalacia
• Osteoporosis
• Paget disease

Dr. Lee suggests, “Now, let’s look a bit more at the risk factors for mechanical low back pain that you can review with Mr. Payne during your history.”

Dr. Lee continues, “The major task in treating back pain is to Now that you have a diagnosis of disc herniation with radiculopathy for Mr. Payne, let’s discuss what would you like to do for him distinguish the common causes for back pain (95% of cases) from the 5% with serious underlying diseases or neurologic impairments that are potentially treatable.”

TEACHING POINT

Risk Factors for Low Back Pain

• Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs
• Deconditioning
• Sub-optimal lifting and carrying habits
• Repetitive bending and lifting
• Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta
• Obesity
• Education status: low education is associated with prolonged illness
• Psycho-social factors: anxiety, depression stressors in life
• Occupation: Job dissatisfaction, increased manual demands, and compensation claims

TEACHING POINT

Red Flags For Serious Illness or Neurologic Impairment with Back Pain

• Fever
• Unexplained weight loss
• Pain at night
• Bowel or bladder incontinence
• Neurologic symptoms
• Saddle anesthesia

HISTORY

You and Dr. Lee take a few minutes to review Mr. Payne’s chart:

Vital signs:

• Temperature: 98.6° Fahrenheit
• Heart rate: 80 beats/minute
• Respiratory rate: 12 breaths/minute
• Blood pressure: 130/82 mmHg
• Weight: 170 pounds
• Body Mass Index: 24 kg/m2

Past Medical History: Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control.

Past Surgical History: None

Social History: Works as a truck driver, which involves lifting 20-35 lbs 4 hours of the day, married with 2 daughters,

Habits: Quit smoking two years ago, drinks 1 to 2 beers occasionally on the weekends, no history of IV drug use.

Medication:

• metformin 500mg 2 twice daily
• glyburide 5mg 2 twice daily
• amlodipine 2.5 mg daily
• lisinopril 40 mg daily
• simavastin 40 mg daily

Allergies: No known drug allergies

After introducing yourself to Mr. Payne, you sit down across from him and begin your history, focusing on the key elements.

“Can you tell me about your back pain?”

“As I told the nurse, the pain started two weeks ago after I lifted a box at work. Right away, I got this sharp pain on the left side of my back. The box wasn’t even that heavy.

“I talked to the nurse at work; she said to ice it and to take ibuprofen. It got better after three days. But, I was playing softball with my daughter last weekend, and the pain came back. This time it was worse than before. This week, the pain is so bad I can hardly get out of bed. I get a sharp pain in my back which goes down my left leg to my ankle.”

“On a scale of 0 to 10, 10 being the worst, how severe is the pain?”

“It’s probably a 7.”

“Have you found anything that improves the pain?”

“Ibuprofen and Naproxen worked at first, but they are not helping much anymore.”

“What about positions that make things better or worse?”

“The pain is worse with any movement of my back or sitting for a long time. It is better when I lie down.”

“Have you had back pain before?”

“Yes, I have back pain from time to time. But I’m usually better after 2 to 3 days. This is the worst pain I have ever had.”

You complete your history with a review of systems and discover:

Review of Systems

Mr. Payne does not have numbness or weakness in his legs. The pain is better when he lies down. He denies urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, or weight loss. He denies any specific trauma, except for when he lifted a 10-pound box at work. He denies unrelenting night pain.

You excuse yourself from Mr. Payne to discuss your findings with Dr. Lee.

Dr. Lee walks through the steps for completing a neurologic exam in a patient with back pain.

Back Exam – Standing:

Mr. Payne has normal curvature, tenderness on palpation on the left lumbar paraspinous muscle with increase tone. Full range of motion, but has pain with movement. His gait is normal. He can walk on his heels and toes. He can do deep knee bends.

Back Exam – Seated:

Mr. Payne denies feeling pain when checked for CVA tenderness. He has no pain in his right leg with the modified version of SLR. While he does not exhibit a true tripod sign, he does complain of pain when his left leg is raised. Mr. Payne’s reflexes are 2+ and equal at the knees and 1+ at both ankles. The motor exam reveals no weakness of the muscles of the lower extremities. His sensory exam is normal.

Pulmonary Exam: His lungs are clear.

Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or gallop.

Mr. Payne’s abdominal exam is negative. His straight leg raising is positive at 75 degrees on the left and negative on the right. His FABER test is negative and sacroiliac joint is nontender. His motor exam reveals no weakness of the muscles of the lower extremities.

After finishing your exam together, you and Dr. Lee excuse yourselves from the exam room for a moment.

Dr. Lee reminds you that disc herniation, a condition which is self-limited and usually resolves in two to four weeks, remains a working diagnosis for Mr. Payne. She says, “Let’s take a few minutes, though, to discuss some conditions we still don’t want to miss.”

Now that you have a diagnosis of disc herniation with radiculopathy for Mr. Payne, let’s discuss what would you like to do for him

You and Dr. Lee now return to Mr. Payne’s exam room to talk about treatment options with him. Dr. Lee tells Mr. Payne to avoid strenuous activities but to remain active. Dr. Lee increases the dosage of naproxen to 500 mg BID to take with food. Since his pain is intense (7/10), he is given a prescription for acetaminophen with codeine to take at night, when his pain is severe. Mr. Payne declines a muscle relaxant because they usually make him drowsy. He would like to be referred to physical therapy as it was helpful in the past.

Three weeks later, Mr. Payne returns for his follow-up appointment and you discover the following:

Pertinent History

Mr. Payne has had little relief with the treatment prescribed. He is frustrated that he has been in pain for more than a month. His pain has been progressively worse. It radiates down the lateral part of his left leg and side of his left foot. This pain is worse than the back pain. He does not have any problems with bowel or bladder control and there is no weakness of his leg.

Pertinent Exam Findings

Vital signs: stable

Neurologic: Normal gait, but moves slowly due to pain; range of motion is full, with pain on flexion; SLR is positive at 45 degree on the left; motor strength intact; reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle.

Dr. Lee agrees with your diagnosis of radiculopathy of S1 nerve root with progression. She orders an MRI and sets up an appointment to see Mr. Payne after the MRI.

ne week later, Mr. Payne returns for follow-up. You review the results of the MRI report.

MRI report:

1. Moderate-size, herniated disc at L5-S1 with associated marked impingement on the left S1 nerve root and mild to moderate impingement on the right S1 nerve root. There is mild central canal stenosis.
2. Annular tear with a small central disc herniation at L4-5 causing mild central canal stenosis.

You review the findings with Dr. Lee. She agrees with your diagnosis of radiculopathy of S1 nerve root due to a large herniated disc at L5-S1.

You call Mr. Payne two weeks later to see how he is doing. He reports that he is doing quite a bit better. He went to an osteopathic physician who did some manual therapy and started him on a strict walking program. He is very encouraged and plans on losing weight through exercise and diet.

• Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
• Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not? 
• Please list 3 differential diagnoses for Mr. Payne and explain why you chose them.  What was your final diagnosis and how did you make the determination?
• What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?