Low Back Pain

Chief Complaint: A 56 year-old male presents with 1 year of low back pain.

DOMAIN A: DATA ACQUISITION

+ What are the relevant historical and physical examination findings to explore?

Relevant History:

  • How did this begin? Onset and context of symptoms?
  • Location, duration, intensity, quality, radiation, aggravating/alleviating factors?
  • Is there associated weakness, numbness, tingling, bowel/bladder dysfunction?
  • Has this ever happened before?
  • Is there a history of trauma/injury/or spine disease?
  • Has he sought care for this before, and if so, what has the workup and treatment been so far?
  • What is his work history and current working status?
  • Functional history and current functional status?
  • Family history?
  • Past Medical and Surgical History?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation
  • Range of motion of lumbar spine
  • Gait observation
  • Manual muscle testing of bilateral upper and lower extremities
  • Sensory and reflex testing of bilateral upper and lower extremities
  • Special testing: As directed by history. Lumbar facet loading challenge, FABER, thigh thrust, sacral compression test, Gillet, Yeoman, Gaenslen, Fortin finger, straight leg raise, FAIR, slump sit.

+ Challenge Question

  • What are you looking for with the FABER test?

+ Challenge Answer

  • A positive FABER test will reproduce concordant pain in the contralateral sacroiliac (SI) joint. (Contralateral from whichever lower limb is being actively moved).
 

DOMAIN B: PROBLEM SOLVING

The patient is a 56 year-old male with a past medical history of atrial fibrillation controlled with a cardiac pacemaker, who has experienced gradual onset axial low back pain without radiation. He has been out of work as an auto mechanic for the last 4 months due to the pain. A course of physical therapy recently was of no benefit. Acetaminophen and oral NSAIDs have not helped. Physical examination is grossly unremarkable.

+ What is your differential diagnosis for this patient's back pain?

  • Lumbar spondylosis, lumbar facet arthropathy, sacroiliac joint dysfunction/arthropathy, myofascial pain, discogenic pain, ankylosing spondylitis, vertebral body compression fracture, neoplastic process, infectious process, malingering.

+ What would be your next steps in workup?

  • Xray of lumbar spine
  • MRI of lumbar spine, but first would need to confirm that the patient’s pacemaker is MRI-compatible.

+ Results of your workup are as follows:

  • Xray of the lumbar spine demonstrates multilevel lumbar spondylosis, degenerative disc disease, and lumbar facet arthropathy that is worst in the L4-L5 and L5-S1 segments.
  • The patient’s cardiac pacemaker is not MRI-compatible.

+ What would be your next steps?

  • CT scan of the lumbar spine without contrast. If concern for neural impingement, I would consider a CT myelogram of the lumbar spine.

+ Your next steps lead to the following:

  • CT of the lumbar spine demonstrates mild multilevel central canal stenosis, mild-to-moderate multilevel foraminal stenosis, and moderate-to-severe facet arthropathy in the L4-L5 and L5-S1 segments bilaterally.
 

DOMAIN C: PATIENT MANAGEMENT

+ How would you manage this patient?

  • I would offer lumbar medial branch blocks and consider radiofrequency ablation of the medial branches, particularly aimed at the lower lumbar facets (L4-L5 and L5-S1). I would educate the patient on the rationale for this procedure. I would demonstrate the anatomy, purpose, and procedure using a spine model, drawing, or other educational tools. I would ensure that all questions were answered to the patient’s satisfaction. I would finally ensure that the patient feels fully autonomous regarding what he chooses to do next.
 
 

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient undergoes your recommended treatment program, but fails to receive any benefit. He continues to complain of low back pain.

+ What would be your next steps in managing this patient?

  • At this moment, it would be appropriate to discuss with the patient the option to see a fellowship-trained pain management specialist. I would discuss that I am more than happy to refer to a trusted pain management colleague for further evaluation and ideas to improve his pain. I would explain that we have exhaused all reasonable options that history, physical examination, and imaging would direct our care towards. I would express compassion and ensure that all questions are answered satisfactorily.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

This is the role-playing portion of this case, so please pretend that I’m the patient.

Patient: "Doctor, I can’t keep getting bounced around to different clinics. It seems like nobody can figure out what’s causing my pain. I had some of my wife’s hydrocodone and that really took the pain away. Can you just write me a script for that? I’ll take whatever drug tests you need me to.”

+ What is your response?

  • This is a great question. I’m so sorry that we have not been able to find an effective pain control solution for you yet. My goal is always to improve your pain and quality of life so that you can get back to doing the things you enjoy doing. Unfortunately we know from studies that opioid pain medication, such as hydrocodone, is not effective in controlling pain in the long-term. It can also lead to dependence on the medication and requiring higher doses over time, among other side effects, such as constipation, and even possibly breathing problems.
  • Patient: “I can’t work with this pain. I can’t even throw a football around. I can hardly even sit and watch TV. I don’t know why you want me to suffer. I promise I won’t abuse the medication.”

+ Your response?

  • Again, I am so sorry that your pain is so severe. Unfortunately opioid pain medication is not the most appropriate treatment option, and evidence shows that non-opioid medications can work as well as opioid medications. I would encourage trying a combination of scheduled acetaminophen, NSAIDs, topical lidocaine patch, TENS machine, and even discussing with a pain psychologist ways to modify and modulate your perception of pain so that you can feel more functional throughout the day and less inhibited by your pain. In addition, I do recommend you speak with a pain management physician, as you may qualify for other advanced procedures to treat pain beyond the scope of my expertise.
  • Patient: “You have got to be kidding me. I am not doing any of that ridiculous nonsense. I can’t work with this pain. If you’re not going to give me what I obviously need, can you at least write a letter telling the insurance company that I’m disabled and can’t work?”

+ Your response?

  • This is a great question. You may not be able to work due to your pain level. What we need to do is get a good estimate of what sorts of activity you can and cannot perform at this time. The best way to go about this is for us to request a functional capacity evaluation. Based on the results of this evaluation, we can consider a work hardening program for you, which is designed to gradually recondition your body to handle work similar to your job as an auto mechanic. I would also very much encourage consultation with a pain management specialist. I would be more than happy to facilitate each of these steps for you. What questions do you have for me regarding these steps or anything else we’ve discussed today?