10: 45-year-old male with low back pain

Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and recently completed a six-month steroid taper. She presents to her primary care physician after two weeks of lower lumbar back pain. She does not recall any trauma but began to feel a sharp pain after bending over to pick up laundry. The pain radiates bilaterally into her anterior abdomen. She has found no relief with over the counter NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2 region. There are no neurologic deficits and reflexes are intact. Which of the following is the most appropriate next step in management? A. Order a plain x-ray B. Order complete blood count (CBC) C. Reassess in four weeks D. Recommend conservative management E. Refer to spine specialist

A. The "red flag" in this history is that of chronic steroid use, and the concomitant risk of osteoporotic vertebral fracture; therefore, imaging is indicated. A vertebral fracture is best diagnosed with a plain x-ray (A). A CBC will not help with the diagnosis and would be indicated only if neoplasm or spinal infection was suspected (B). Referral to a spine specialist is unnecessary (E) unless a compression fracture is found on imaging and patient is deemed a candidate for surgical management, but would not be the appropriate next step at this time until imaging is done. Conservative management (D) and/or reassessment in four weeks (C) demonstrate a failure to recognize the "red flag."

Mr. Roberts is a 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension who presents lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of symptoms he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. He has never smoked. Vital signs: temperature is 38 C (100.4 F), blood pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15 breaths/minute. Given this history, which of the following physical exam maneuvers would be the most helpful in making the diagnosis? A. Abdominal palpation B. Auscultation for an abdominal bruit C. Digital rectal exam D. Pinprick sensation of the legs E. Straight leg test

C. This patient is presenting with symptoms of a genitourinary infection. In an older male patient, prostatitis may present with low back pain. This patient's symptoms—general malaise, chills, hesitancy and pain on urination—and vital signs (fever) suggest acute bacterial prostatitis. Patients with acute bacterial prostatitis will often have exquisite tenderness over the prostate on rectal exam (C). This patient could also have pyelonephritis, so assessing for costovertebral angle tenderness and collecting a urinalysis would also be appropriate in this setting. Straight leg test (E) can be performed to evaluate for radiculopathy; however, this patient does not have back pain radiating to the leg below the knee, which is a hallmark sign of radiculopathy. Abdominal palpation (A) can help determine if patient may have abdominal mass. Assessing for an abdominal bruit (B) is appropriate in older patients with back pain, however, aortic pathology is less likely in this patient, who does not smoke and who has a fever. Patients with neuropathy will often have decreased pinprick sensation of the lower extremities (D), but he does not have any numbness or burning sensation in the lower extremities which would be symptoms associated with this diagnosis.

Working at your clinic, you receive a call from a patient of yours, Mr. Smith, a 45-year-old male who was seen three days ago complaining of lower back pain. At that time he had no history of trauma, pain that improved while lying down and no neurologic deficits. He works as a truck driver. He was treated conservatively along with pharmacologic intervention with NSAIDs and muscle relaxants. He calls your office now due to only minimal improvement. And although his symptoms have not changed, he is frustrated with the slow progress, needs to get back to work as soon as possible, and is concerned this might be "something serious." Which of the following is the most appropriate next step in management? A. Ask him to double the dosage of his muscle relaxants B. Obtain a plain film x-ray C. Order an MRI D. Reassure him and schedule a follow-up appointment in a few days E. Schedule him for an appointment immediately

D. Given this clinical presentation, the likelihood of this being an episode of lumbar sprain/strain is high, and the odds of this being "something serious" (nerve root compression, malignancy, infection) is still low. The original plan is a good one, and he should be reassured to continue this course and follow up in a few days (D). No new medications (A) or imaging studies (B, C) would help, and an urgent appointment will not change the anticipated course (E). Some physicians might choose to involve a physical therapist at this time, but this option is not available for this question.

Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain that began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which additional physical exam finding would be consistent with this man's level of disc herniation? A. 2/5 strength on hip flexion B. Decreased range of motion on lumbar extension C. Decreased rectal tone D. Hypoactive ankle tendon reflex E. Positive Stoop test

D. The clinical signs presented by this patient - difficulty with heel walk and the abnormal strength of ankle plantar flexion - is consistent with nerve root impingement at the level of L5-S1. Of the answers listed, a hypoactive ankle tendon reflex (D) is also consistent with a nerve root impingement at this level. Pain with lumbar extension (B) suggests degenerative disease or spinal stenosis, and spinal stenosis is similarly suggested by a positive stoop test (E). Diminished hip flexor strength (A) suggests a lesion at the L2, L3, or L4 level and decreased rectal tone (C) suggests a cauda equina lesion.

Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely? A. Abnormal gait B. Increased pain with coughing C. Loss of ankle jerk D. Point tenderness on spinous processes E. Spasm of paraspinous muscles

E. Spasm of the paraspinous muscles (E) suggests lumbosacral sprain/strain. Increased pain with coughing (B), abnormal gait (A) and loss of ankle jerk (C) point to conditions that compress a regional nerve root, while point tenderness on the spinous processes (D) often indicates an origin in the vertebra (osteoporotic fracture, malignancy, etc.).