Low Back Pain

Question 1

What key history would you obtain from a patient who complains of back pain?

Answer 1

Location
Quality
Intensity
Radiation
Context (moving furniture, bending/twisting, truama)
Timing (disturbs sleep)
Associated symptoms (especially constitutional, incontinence)
Exacerbating and alleviating factors
History of cancer
Recurrent UTIs
Diabetes 
Renal stones
IV drug use
Smoking

Question 2

What key physical exams would you perform on a patient who complains of low back pain?

Answer 2

Vital signs
Neurologic exam (especially L4-S1 nerve roots)
Back palpation and range of motion (although rarely of diagnostic utility)
Hip exam (can refer pain to the back)
Consider rectal exam

Question 3

45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. The patient is unable to tiptoe. Differentials?

Answer 3

Disc herniation
Lumbar muscle strain
Tumor on the vertebral canal

Question 4

45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. The patient is unable to tiptoe. Differentials: disc herniation, lumbar muscle strain, tumor on the vertebral canal. Workup?

Answer 4

XR - lumbar spine

MRI - lumbar spine

Question 5

45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted. Differentials?

Answer 5

Lumbar muscle strain
Disk herniation
Abdominal aortic aneurysm
Vertebral compression fracture

Question 6

45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted. Differentials: lumbar muscle strain, disk herniation, abdominal aortic aneurysm, vertebral compression fracture. Workup?

Answer 6

XR - lumbar spine

Question 7

45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g. pushing a grocery cart). Differentials?

Answer 7

Lumbar spinal stenosis
Lumbar muscle strain
Tumor in the vertebral canal
Peripheral vascular disease

Question 8

45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g. pushing a grocery cart). Differentials: lumbar spinal stenosis, lumbar muscle strain, tumor in the vertebral canal, peripheral vascular disease. Workup?

Answer 8

XR - lumbar spine
MRI - lumbar spine (preferred)
CT - lumbar spine
Ankle-brachial index

Question 9

17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not match any known distribution. He insists on requesting a week off from school because of his injury. Differentials?

Answer 9

Malingering
Lumbar spine strain
Disk herniation
Knee or leg fracture
Ankylosing spondylitis

Question 10

17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not match any known distribution. He insists on requesting a week off from school because of his injury. Differentials: malingering, lumbar spine strain, disk herniation, knee or leg fracture, ankylosing spondylitis. Workup?

Answer 10

XR - lumbar spine, knee

MRI - lumbar spine