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CASE STUDY
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
COLLEAGUE 1 RESPONSE
What nerve roots might be involved?
The spine, muscles, intervertebral discs, and nerves make up the back (National institute of neurological disorders and stroke, 2020). The lumbar vertebrae (L1-L5) sustain the weight of the upper body. The intervertebral discs cushion the bones while the body moves (National Institute of neurological diseases and stroke, 2020). Anterior and posterior ligaments stabilize the vertebrae, while tendons connect the muscles to the spinal column (NIH, 2020). Eleven pairs of nerves connect the spinal cord to the brain, controlling movement and transmitting impulses (National institute of neurological diseases and stroke, 2020). Lumbar and sacral nerve roots are involved in lower back pain (National institute of neurological disorders and stroke, 2020). Sciatica pain radiates along the sciatic nerve’s course from the lower back to the hips, buttocks, and legs. Sciatica only affects one side of the body (Mayo clinic, n.d.).
How would you test for each of them?
Physical exam: To test the patient’s spine, have him walk (Cleveland Clinic, 2020). Ask patient to walk on his toes and heels to test calf strength (Cleveland clinic, 2020).
Straight leg test: While resting on his back, slowly elevate each leg (from 35 to 75 degrees), noting where the pain begins. This test identifies the affected nerves and disks (Cleveland Clinic, 2020). Also, other actions and stretches can assist localize pain and test muscular flexibility and strength (Cleveland clinic, 2020).
What other symptoms need to be explored?
Low back pain that is numb, shock-like, or searing; the pain may spread to the buttocks and down to one of the legs (Mayo clinic, n.d.).
What are your differential diagnoses for acute low back pain?
Sciatica, caused by sciatic nerve compression in the lower back, buttocks, and back of one leg. It occurs when a herniated disk, bone spur or spinal stenosis compresses portion of the sciatic nerve (National institute of neurological disorders and stroke, 2020).
Leg inflammation, discomfort and numbness are caused by compression (Mayo Clinic, n.d.).
Spinal stenosis: Spinal stenosis causes low back pain by compressing the spinal cord and nerves (National institute of neurological diseases and stroke, 2020).
Spondylolisthesis, This occurs when a lower spine vertebra falls out of place, compressing spinal nerves (National Institute of Neurological Disorders and Stroke, 2020).
Osteomyelitis: Infections of the vertebrae, particularly the intervertebral discs (discitis) and the sacroiliac joints (sacroiliitis), cause low back pain (National Institute of neurological disorders and stroke, 2020).
Cauda equina syndrome a ruptured disc pushes into the spinal canal, pressing on the lumbar and sacral nerve roots bundle. Untreated, this disease can cause permanent neurological damage (National Institute of neurological disorders and stroke, 2020).
What physical examination will you perform?
Check the alignment of the back landmarks and notice the spine curves.
Palpate the paravertebral muscles.
Percuss for back pain.
Measure range of motion for forward flexion (75-90 degrees), hyperextension (30 degrees), lateral bending (35 degrees), and upper trunk rotation (30 degrees).
Examine the hips for symmetry, buttock size, and gluteal fold number and level.
Hip range of motion. Hip flexion with extended knee is 90 degrees; flexion with flexed knee is 120 degrees. 30 degrees hip hyperextension with knee extended Hip abduction is 45 degrees, adduction is 30 degrees. Internal rotation should be 40° and outward rotation 45°.
Examine muscular strength with knee flexed and extended, abduction and adduction, and with legs uncrossed (Ball, 2019).
What special maneuvers will you perform?
Specific tests include:
The National Institute of Neurological Disorders and Stroke (2020).
For detecting an infection, fracture, or bone condition. Radioactive material is delivered into the bloodstream and accumulated in the bones, especially in abnormalities. Scanner pictures can detect improper bone metabolism, blood flow, and joint disease (National Institute of neurological diseases and stroke, 2020).
Discography involves injecting a contrast dye into a spinal disc that may be causing low back discomfort. If the disc is the culprit, the fluid pressure will recreate the person’s symptoms. The dye helps CT scans show damaged tissues.
Nerve conduction studies (NCS) use two electrodes to activate a muscle’s nerve and record its electrical impulses to diagnose nerve damage (National institute of neurological disorders and stroke, 2020).
Disc rupture, spinal stenosis, and other soft tissue structures cannot be seen on conventional x-rays (National Institute of Neurological Disorders and Stroke, 2020; Friedman et al., 2010).
Magneto-resonance imaging (MRI) provides a computer-generated image of bone structures and soft tissues like muscles. Uncertainty about the cause of the pain may necessitate an MRI (National Institute of Neurological Disorders and Stroke 2020; Friedman et al. 2010).
Bone fractures, vertebral injuries, spinal spurs, malignancies, and infections can all be seen on X-ray. (National Institute of Neurological Disorders and Stroke, 2020; Cleveland Clinic, 2020; Friedman et al., 2010).