LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF MEDICINE
MEDICINE 1 – CLINICAL WORKSHOP 1

TOPIC- BACK PAIN

GROUP-1

ABUTAIMA, EHAB JEHAD ABED

ADHIKARI, VICTOR
AGNAYA, ALFREDO
ALAGADAN, AURA AMOR
BAHUGUNA, MARUT
BANARAJI, ABHISHEK
BAUTOS, TANYA PAMELA
BEPARI SHAIK, ABU BAKAR
I. Case: Back Pain

Kevin Baker, a 71-year old male, comes to the emergency department

because of stabbing lower back pain. His temperature is 98.6F (37C); blood
pressure is 125/85 mmHg; heart rate is 68beats per minute; respiratory rate is
14 breaths per minute.

II: Definition of the Symptom

Back pain
 one of the most common complaints and cause of disability in
people seen in practice.
 It can result from injury, activity and some medical conditions.

 Anatomically back pain can be grouped as:

 Upper back Pain (UBP or Thoracic or Dorsal Pain) related to
the thoracic (T 1 to T 12) segments
 Low back pain ( LBP or Lumbosacral Pain) related to the
lumbosacral region (L 1-L5 + S1-S5), which may be
associated with lower extremity symptoms.

 Clinically back pain is usually classified into:

 Acute backache—Usually lasting <4 weeks of duration
- mostly due to injury, strain, or faulty
posture; symptoms such as pain, and
restricted movements often confined to
lower back, which are aggravated on
coughing, straining, or bending.
 Chronic backache—Lasting >4 to 8 weeks of duration.
- At this point it is appropriate to reassess
the patient’s symptoms and physical
findings
-perform selective investigations, evaluate
psychosocial barriers , and a surgical
referral should be considered.
 Incidence/Epidemiology
 More than 80% of the adults have had at least one episode of
back pain, and many have had recurrent episodes since
adolescence.
 Men and women are equally affected by lower back pain
 Pain can begin abruptly as a result of an accident or by lifting
something heavy, or it can develop due to age related
changes of the spine.
 Sedentary lifestyles also can set the stage for lower back
pain, especially when a weekday routine of getting too little
exercise is punctuated by strenuous weekend workout
III: History and Physical Examination Findings

Demographic Data:
Name: K.B (Kevin Baker is in initials because of confidentiality)
Age: 71 y/o
Gender: Male
Educational Attainment: College Graduate
Nationality: Filipino
Occupation: Retired School Teacher
Marital status: Divorced
Number of Children: One (1)

Vital Signs

Assessment Normal Range Interpretation

Temperature 98.6 F (37 C) 35.5 -37 C Normal
Heart Rate 68 bpm 60 – 100 bpm Normal
Respiration Rate 14 cpm 12 – 20 cpm Normal
Blood Pressure 125/80 120/80 Normal
(Reference: Kozier and Erb’s Fundamentals of Nursing)

History of Present Illness

The patient complains of a stabbing lower back pain with a scale of

2/10 when the patient lies and a scale of 6/10 when he bends his back or
when he coughs. The patient states that the pain started on the day before
the admission/consultation when he was unloading groceries from their pick
up and the intensity was the same the whole time. The patient has previous
episodes of back pain and sometimes felt radiating on his right thigh. He
stated that the pain aggravates when coughing and when bending forward.
He takes Tylenol to alleviate the pain.

Review of Systems specific to lower back

There is no trauma, skin rash/changes on his back. The patient does

not experience fatigue, no fever and cough. He does not experience other
pain apart from his complain on his lower back. No urinary and bowel
problems noted. Appetite is within normal. No noted change in weight. No
recent infections. He does not experience tingling sensation and numbness in
lower limbs. There is no muscle weakness noted.

Physical History, Family History and Social History

The patient has type 2 Diabetes Mellitus. He has no known allergies.

ok three 500 mg Tylenol since yesterday for his back pain and is taking insulin
for his diabetes. The patient has undergone hemorrhoidectomy three years
ago. His father had prostate cancer.
 The patient drinks one glass of red wine on weekends and smoked a
pack of cigarettes a day for 40 years. His diet is normal and he has no active
exercise.

Sexual History

The patient is sexually active with his girlfriend. He stated that he slept
with two women over the past year. He uses condom.

Physical Examination

The patient is annoyed when examining his back. He leans back on his
chair. He stated that lying down alleviates the pain. There is a noted spinal
tenderness to palpation over L2-L4.

Extremities
Lasegue sign (Straight leg raise test) is negative.

Neurologic Examination

The passive and active motion are normal. No noted abnormalities

upon examining the senses. Deep tendon reflexes are normal. Upon
examination of gait, the patient walks slowly and cautiously.

IV. Differential Diagnosis

Spinal disc herniation

Spinal disc herniation occurs when the gel-like center o a disc ruptures
through a weak area in the tough outer wall. It is characterized by acute-onset
severe back pain that is often described as stabbing or like an electrical
shock. Impingement of the adjacent nerve roots leads to radiating pain in the
dermatome of the nerve. Based on the radiation of the patient’s pain, his
symptoms are most likely caused by impingement of a spinal nerve root
between L2-L4. Pain often increases with pressure just like in coughing, as
seen in the patient, and decreases when the patient lies down or changes
position. Patients often have a history of less severe chronic back pain. They
also have decreased muscle strength and sensation, decreased deep tendon
reflexes, and a positive straight leg raise test. Although these symptoms are
not present in the patient, his typical pain with radiation into the right thigh still
makes spinal disc herniation the most likely diagnosis. Moreover, the straight
leg test can be negative in elderly patients even if spinal disc herniation is
present.

Vertebral Fractures due to Trauma or Malignancies

Vertebral fractures typically present acutely with local pain and spinal
tenderness. It can be caused by trauma (serious accidents or injury),
strenuous lifting in an older or osteoporotic patient, chronic usage of oral
steroids or may occur as a pathologic fracture due to osteoporosis, certain
malignancies and infections. Based on the patient’s history, there was no
trauma occurred, no strenuous activity and no usage of oral steroids.
Therefore, a pathologic fracture is more likely the patient’s case. He is at
increased risk for osteoporosis due to his age, lack of exercise and smoking
habit. Generally, osteoporosis does not become clinically apparent until
fracture occurs. His family history of prostate cancer and smoking history put
him at risk of having prostate cancer and lung cancer that usually metastasize
into the spine. However, there is the absence of other symptoms in order to
consider it as either a prostate or lung cancer such as weight loss, night
sweats, urinary retention, and cough.

Muscle Strain

Muscle strain is the most common cause of lower back pain which typically
presents with acute back pain. In some cases, there might be tenderness to
palpation following an accident or physical exertion. The straight leg test is
usually negative in patients having this. However, the pain usually does not
radiate making it less likely to be the diagnosis. Moreover, muscle strain
typically presents with paravertebral tenderness instead of localized spinal
tenderness.

CaudaEquina Syndrome

Caudaequina syndrome refers to a characteristic pattern of neuromuscular

and urogenital symptoms resulting from the simultaneous compression of
multiple lumbosacral nerve roots below the level of the conusmedullaris.
These symptoms include low back pain, sciatica (unilateral or, usually,
bilateral), saddle sensory disturbances, bladder and bowel dysfunction, and
variable lower extremity motor and sensory loss. Although there is an
abnormal gait when walking, caudaequina syndrome is less likely to be the
diagnosis since there is no bladder and bowel dysfunction.

Other differentials to consider for the case:

Degenerative spondylolisthesis
Spinal stenosis
Bone metastases
Spinal epidural abscess
Abdominal aortic aneurysm

Differential diagnosis for back pain in general:

Common

 Faulty posture
 Mechanical pain (muscle/ligamentous strain, sprain)
 Trauma/accident
 Infective (TB, i.e. Pott’s disease, epidural abscess, brucellosis)
 Lumbar spondylosis (degenerative OA)
 Spinal dysfunction (intervertebral disc prolapse, i.e. IVDP)
  Psychosocial (depression, anxiety, drug seeking behavior)
 Referred (lower cervical segments, renal calculi, pyelonephritis)
 Pelvis (in women-dysmenorrhea, pelvic inflammatory disease)

Occasional

 Infective (osteomyelitis)
 Spinal abnormalities (kyphosis, scoliosis, secondary to poliomyelitis,
Scheuermann’s disease)
 Vertebral collapse (osteoporosis, osteomalacia)
 Referred pain (cardiac –angina, MI; GI – duodenal ulcer, pancreas)
 Spondyloarthropathies (ankylosing spondylitis, Reiter’s syndrome)
 Malignancies (usually secondaries: from lungs, breast, prostate,
thyroid)

Rare

 Congenital (spina bifida, spondylolisthesis)

 Malignancies (primary: myeloma, Hodgkin’s)
 Referred pain (aorta, pulmonary embolism)
 Compensatory neurosis (legal issues, workers’ compensation)
 Caudaequina syndrome
 Paget’s disease
 Coccydynia
 Malingering

V. Red Flags

 Back pain associated with severe or progressive neurological deficit is

a medical emergency; suspect IVDP, cord compression, and vertebral
fracture. Hospitalization is indicated.
 In a patient with acute back pain who is withering with pain and
clinically unstable, suspect intra-abdominal or vascular process.
Hospitalization is indicated.
 Caudaequina syndrome - back pain with bladder or bowel
incontinence, saddle area perineal numbness, disturbed gait is an
emergent condition.
 Beware of patients, especially elderly, with weight loss, pain at rest, or
constant pain at night; significant pathology, especially malignancy,
must be ruled out.
 In elderly men, especially over age 50 with back pain, per rectal
examination is mandatory; associated PSA estimation may be
indicated to rule out prostate malignancy.
 Chronic back pain before the age of 20 years is an indication to rule out
primary spinal tumors, e.g. osteosarcoma
 INVESTIGATIONS – GENERAL
CBC, ESR, CRP :
Within normal limits i.e for CRP it should be below 3.0mg/l and for ESR should be
between 1-20 mm/hr for female and 1-30mm/hr for male.

Urinalysis :
Including causes might be shown to preclude UTI and pyelonephritis as alluded
causes entangling low back agony.

Spine X-beam :
Not valuable in mechanical pain. Required if torment is related with warnings
demonstrating increasingly major issues.

INVESTIGATIONS—SPECIFIC
Sr Calcium, Phosphorus, Alk Phosphatase, Corrosive Phosphate:
• Elevated in threat, myeloma, and hard metastasis
• Serum corrosive phosphate is normally raised in prostate carcinoma with bone
secondaries.

Sr Uric Acid:
• Elevated in gout and lymphoma
• Tophaceous gout may impersonate epidural/extra epidural contamination, sore, or
may exist together with other rheumatological issue.

PSA:
• Backache might be an unprecedented introduction of metastasized carcinoma of
the prostate
• Prostate carcinomas with set up harmful potential are bound to be recognized with
PSA edge >4.0 ng/ml.

Plasmoprotein Electrophoresis:
• Useful in the determination of plasma cell neoplasms, for example various
myeloma, and lymphoma.

Bence Jones Protein:

• May be brought up in serum and additionally urine in myeloma.

CXR:
• A singular pneumonic knob or metastatic stores, more often than not from thyroid,
or breast might be a related injury in older with easeless back pain.
US Abdomen:
• Intra-stomach issue, for example, aortic aneurysm, renal, and uterine illness are an
intermittent reason for alluded torment to thoracic or lumbar district which can be
exhibited on US of mid-region and pelvis.

CT Spine:
• CT scan is viewed as the imaging methodology of decision to assess patients for
spinal injury and vertebral breaks.

HRCT Abdomen:
• To affirm stomach US discoveries, and/or for proof of pancreatic, aortic, or pelvic
injuries.

X-ray Spine:
• MRI is noninvasive, does not include radiation, covers an enormous territory of the
spine, and can show changes inside the plate and vertebral body. It has turned into
the imaging methodology of decision in the determination of radiculopathy, spinal
rope abscesses, spinal string tumors, spinal stenosis

Bone Scans (Technetium):

• In bone secondaries, and bone disease.

Upper GI Endoscopy:
• In patients suspected with GI causes, for example gastric or duodenal ulcer.

CSF Analysis:
• To affirm CNS contaminations—bacterial,tubercular, parasitic, or viral.

Electrodiagnosis:
• Such as NCS, needle EMG inspire potential studies are normally a bit much in an
obvious radiculopathy or in patients with confined mechanical low back side effects.
These examinations are useful in the assessment of patients with appendage
torment in whom the conclusion remains indistinct, for example peroneal neuropathy
versus radiculopathy and engine neuron sickness.

Histocompatibility Antigen Test (HLA-B 27):

• In suspected spondyloarthropathies, for example ankylosing spondylitis.

Myelography, Discography, Diagnostic Specific Nerve Blockade:

• Myelography has been to a great extent supplanted by CT myelography or MRI.
• Discography or potentially nerve bar are demonstrated in particular unending back
torment patients trying to either find or cancel the accurate wellspring of back pain.

Bone Marrow Biopsy/Aspiration:

• In conditions imperceptible by traditional strategies, for example granulomatous
bone sickness,lymphomas, myelomas, and metastatic sickness.
REFERENCE:

https://www.amboss.com/us/knowledge/Case_9%3A_B
ack_pain

https://emedicine.medscape.com/article/1148690-
overview
Diagnosis: A symptom-based Approach in Internal
Medicine by CS Madgaonkar