Case 9: Back pain

Opening scenario

Kevin Baker, a 71-year-old male; , comes to the emergency department because of back pain.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 125/80 mm Hg
• Heart rate: 68/min
• Respirations: 14/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act grumpy. You are annoyed when your back is examined because it is painful.
• When the examinee enters the room, sit on the edge of the examination chair and try to lean back as far as possible. If the examinee does not offer to recline the chair after you mention that lying down alleviates your pain, only answer in very short sentences or with “yes” and “no” where possible.
• Pretend to have back pain when the examinee feels your lower back. Tell the examinee to be careful when he/she is examining your back.
• Walk slowly and with caution because of the back pain.
• If the examinee raises your leg as part of a clinical test (straight leg test ), only pretend to be in pain if your leg is raised > 80°.
• You are not aware of the meanings of medical terms (e.g., MRI) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: When the examinee explains her/his impressions, say “I am afraid that I will become addicted to pain meds.”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have back pain.
• Location
• My lower back hurts.
• Intensity (on a scale from 0–10)
• 2/10 when I lie still, 6/10 when I bend my back or when I cough.
• Quality
• It is a stabbing pain.
• Onset
• It started yesterday.
• Precipitating events
• I do not know. I was unloading groceries from my pickup truck when it suddenly started.
• Progression/constant/intermittent
• No, it has been the same awful pain this whole time.
• Previous episodes
• I have had back pain over the years, but never like this befor ve.
• Radiation
• Sometimes I also feel the pain in my right thigh.
• Alleviating factors
• I took some Tylenol, but it did not help much. Apart from that it helps if I lie down and avoid sudden movements.
• Aggravating factors
• It gets worse when I cough or when I bend forward.
• Associated symptoms
• None.

If a patient mentions alleviating factors that can be accommodated in the examination room (e.g., by turning the lights off or down, laying the examination chair flat, or offering some water), always take the time to offer your assistance and gain valuable points in the communication and interpersonal skills component of the exam.

Review of systems specific to lower back pain

• Trauma
• No
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• No.
• Rash/skin changes (over the back)
• No
• Cough
• No.
• Pain in joints
• Apart from my back pain, no.
• Urinary problems
• No.
• Bowel problems
• No.
• Appetite
• My appetite has been normal.
• Weight changes
• No.
• Recent infections
• No.
• Tingling sensation
• No.
• Muscle weakness
• No.
• Numbness (esp. in the lower limbs)
• No.
• Erectile dysfunction
• No.

Compression of the spinal cord or spinal nerves can lead to neurological symptoms in the lower extremities!
Lower back pain with constitutional symptoms can be due to malignant or infectious causes!

Always ask about the red flags of lower back pain: fecal/urinary retention/incontinence, saddle anesthesia, progressive weakness, significant weakness localizing to a single nerve root, history or high risk of malignancy, fever, immunosuppression, or osteoporosis.

Past medical history, family history, social history

• Past medical history
• I have type 2 diabetes mellitus.
• Allergies
• None.
• Medications
• I took some over-the-counter Tylenol the past couple of days because of the back pain, and insulin for the diabetes.
  • How much Tylenol?
  • I would say three 500-mg tablets since yesterday.
• Hospitalizations
• Never.
• Past surgical history
• I had my hemorrhoids removed 3 years ago.
• Family history
• My father had prostate cancer.
• Work
• I am a retired school teacher.
• Home
• I live alone. I am divorced and have one grown-up child.
• Alcohol
• One glass of red wine on the weekend.
• Recreational drugs
• Never.
• Tobacco
• I have smoked a pack of cigarettes a day for 40 years.
• Exercise
• No.
• Diet
• I think it is pretty normal. I eat some meat, fish, and vegetables; mostly home-cooked meals.

Sexual history

• Sexually active
• Yes.
• With whom
• My girlfriend.
• Number of partners over the past year
• I slept with 2 women over the past year.
• Protection
• I always use condoms.

• Washed hands
• Used respectful draping
• Back examination
  • Inspection of the back
  • Examination of the spine
    • Spinal tenderness to palpation over L2–L4
  • Straight leg raise test (Lasegue sign)
    • Negative
• Extremities
  • Inspection of the lower extremities
• Neurologic examination
  • Focused examination of passive and active motion
  • Focused examination of sensation
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
    • Walks slowly due to back pain
  • Babinski sign

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on safer sex practices.
• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Baker, I understand that you are afraid of becoming dependent on pain medication. It is important to properly treat pain because it helps the healing process and can prevent chronic pain from developing. Let me reassure you that taking pain medication for a short period of time is very unlikely to cause an addiction. We can also prescribe you a pain medication with a low addictive potential. To ensure that you do not develop a dependence on the medication, it is important that you take the medication exactly as prescribed and that you talk to me if you feel like you require more or a different medication.”

Patient note

Differentials

1. Spinal disk herniation: Spinal disk herniation is characterized by acute-onset severe back pain that is often described as stabbing or like an electrical shock. Impingement of the adjacent nerve root leads to radiating pain in the dermatome of the nerve. As seen in this patient, the pain often increases with pressure (e.g., from coughing) and decreases when the patient changes position or lies down. Patients often have a history of less severe chronic back pain. Unlike in this case, patients also often have decreased muscle strength and sensation, decreased deep tendon reflexes, and a positive straight leg raise test. Although these symptoms are not present in this patient, his typical pain with radiation into the right thigh still makes spinal disk herniation the most likely diagnosis. Furthermore, especially in elderly patients, the straight leg test can be negative even if a spinal disk herniation is present.
2. Vertebral fractures: Vertebral fractures typically present acutely with local pain and spinal tenderness and can be caused by trauma or occur as pathological fractures (e.g., due to osteoporosis, malignancy, infection). Given this patient's history and lack of trauma, a pathological fracture is more likely. His age (> 70 years), lack of exercise, and smoking history put him at increased risk for osteoporosis, and his family history of prostate cancer and smoking history put him at risk for two cancers that commonly metastasize into the spine (prostate cancer and lung cancer). However, considering the overall small number of risk factors and the absence of other symptoms of prostate or lung cancer (e.g., weight loss, night sweats, urinary retention, cough), as well as the typical radiating back pain this patient is presenting with, spinal disk herniation seems more likely.
3. Muscle strain: Muscle strain is the most common cause of lower back pain and typically presents with acute back pain, in some cases with tenderness to palpation, following an accident or physical exertion (e.g., unloading heavy goods). Although the straight leg raise test is typically negative like in this patient, the pain does not usually radiate, making a different underlying condition more likely. Moreover, muscle strain typically presents with paravertebral tenderness instead of localized spinal tenderness.

Diagnostic studies

• Rectal examination: Damage of the nerve fibers L3–S5 (cauda equina syndrome) and S3–S5 (conus medullaris syndrome) can cause decreased rectal tone.
• MRI of the spine: to confirm spinal disk herniation and assess for signs of osteoporosis or bone metastases
• X-ray of the spine: to evaluate for degenerative and inflammatory lesions of the spine as well as signs of osteoporosis or bone metastases
• CT of the spine: to localize a vertebral fracture and assess stability
• Dual-energy x-ray absorptiometry: to calculate bone mineral density. General recommendation for women ≥ 65 years and men ≥ 70 years.

Other differentials to consider

• Degenerative spondylolisthesis
• Spinal stenosis
• Bone metastases
• Spinal epidural abscess
• Abdominal aortic aneurysm
• See differential diagnoses of lower back pain.