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Ms Q is a 46-year-old female with a past medical history significant for depression, gastroesophageal reflux, and a motor vehicle accident 7 years ago. Over the last 3 years she has developed worsening low back pain that she feels is limiting her ability to carry out her activities of daily living. She works as a heavy equipment operator at a local factory. She denies fevers, chills, weight loss, and bladder or bowel habit changes. She denies radicular pain and numbness or weakness in her legs. Her vital signs include a blood pressure of 128/65, heart rate of 72 bpm, respiratory rate of 16/min, and temperature of 37.2°C. She is seeing you for the first time for pain control and is requesting opioid medication.

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1. What is your differential diagnosis?

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2. What are the key elements of the history and physical examination?

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3. What diagnostic evaluation should be done for this patient?

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4. What are the best treatment strategies for her pain?

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Answers

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Summary: This is a 46-year-old female with a history of depression, motor vehicle accident, and an occupation that involves heavy machine operation presenting with nonspecific low back pain that appears to be chronic in nature.

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  1. Subacute, nonspecific low back pain is the most likely diagnosis. Less likely etiologies include neoplasm, infection, and fracture.

  2. Obtaining information to rule out neoplasm, infection, and fracture is key. A history of bacteremia or other disseminated infection as well as immunosuppression may heighten your suspicion for infection. Inquiring about fevers and chills is thus important. In addition, a history of unexplained weight loss or known malignancy may increase your concern for a neoplasm or complication of a malignancy. A recent history of trauma as well as risk factors for osteoporosis would increase your concern for fracture.

  3. Physical examination should focus on location of tenderness on examination—percuss over each spinous process. True tenderness over the spine itself raises concern for neoplasm, infection, or fracture. Muscle tenderness is most likely seen in nonspecific back pain as well as fibromyalgia, myositis, and chronic muscle strain. A straight leg raise, performed with the patient supine, with the knee in full extension is considered positive for nerve root compression if contralateral radiation of pain is elicited.

    Numerous guidelines provide recommendations about diagnostic evaluation. The focus is primarily on identification of patients who are at high risk for pathology such as tumor, infection, and fracture. None of the guidelines advocate routine use of imaging, especially at the initial evaluation. Imaging is recommended primarily for those patients who exhibit red flags, such as fever, weight loss, or bowel or bladder incontinence. If red flags do exist, a plain film can be diagnostic of fracture, but for evaluation of infection and malignancy, MRI is typically advocated.

  4. Because there are no ...

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