AMBOSS CASES:

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.

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.
o How much Tylenol?
o 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.

Focused physical examination

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

** 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.”

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