Low back pain

Question 1

Key history in low back pain

Answer 1

Location, quality, intensity, radiation, context (moving furniture, bending/twisting, trauma), 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

Key physical exam in 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 with low back pain radiating to lateral aspect of L foot
+ straight leg raise is positive
+ unable to tiptoe

Answer 3

Disk herniation
Lumbar muscle strain
Tumor in the vertebral canal

XR—L-spine
MRI—L-spine

Question 4

45 yo F with low back pain that started after she cleaned the house
+ pain does not radiate
+ no sensory deficit or weakness in legs
+ paraspinal muscle tenderness and spasm are noted

Answer 4

Lumbar muscle strain
Disk herniation
Vertebral compression fracture

XR—L-spine
MRI—L-spine

Question 5

45 yo M with pain in lower back and legs during prolonged standing and walking
+ pain is relieved by sitting or leaning forward (e.g. pushing a shopping cart)

Answer 5

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

MRI—L-spine (preferred)
XR—L-spine
CT—L-spine
Ankle-brachial index

Question 6

17 yo M with low back pain that radiates to L leg after he fell on his knee during gym class
+ loss of sensation in L foot
+ pain and sensory loss do not match any known distribution
+ insists on requesting a week off from school due to injury

Answer 6

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

XR—L-spine/knee
MRI—L-spine