Case: 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?
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected
Episodic/Focused Note:
Patient Information:
- Age: 42-year-old male
- Chief Complaint: Lower back pain with left leg radiation for one month.
Subjective: The patient, a 42-year-old male, presents with a chief complaint of lower back pain, which he has been experiencing for the past month. The pain occasionally radiates to his left leg.
Objective: On physical examination, the following findings were noted:
- Inspection:
- No visible deformities or abnormalities.
- Normal curvature of the lumbar spine.
- Palpation:
- Localized tenderness on the lower lumbar region.
- No swelling, warmth, or masses noted.
- No paraspinal muscle spasm.
- Neurological Examination:
- Sensory: Decreased sensation on the lateral aspect of the left leg, following the dermatomal pattern of L5.
- Motor: No focal motor deficits were observed.
- Reflexes: Patellar and Achilles reflexes were normal.
- Range of Motion:
- Limited range of motion due to pain, particularly in lumbar flexion and extension.
- Straight leg raise test elicited pain in the left leg.
- Special Maneuvers:
- Slump test was positive, reproducing the patient’s leg pain.
- The patient reports relief when sitting or bending forward.
Assessment: The patient’s symptoms, along with the physical examination findings, suggest involvement of the lumbar nerve roots, particularly L5 and possibly S1, given the radiating pain to the left leg. The pain may be neuropathic, as evidenced by the altered sensation in the L5 dermatomal distribution.
Differential Diagnoses:
- Lumbar Disc Herniation: A common cause of lower back pain with radiculopathy. MRI would be the diagnostic test of choice.
- Lumbar Spinal Stenosis: May cause similar symptoms. Imaging studies such as MRI or CT can help confirm the diagnosis.
- Piriformis Syndrome: Can compress the sciatic nerve, leading to leg pain. Diagnosis can be confirmed with clinical examination and MRI.
- Spondylolisthesis: Forward displacement of one vertebra over another. X-rays or CT scans may be necessary.
- Ankylosing Spondylitis: An inflammatory condition affecting the spine. Blood tests for HLA-B27 and imaging studies, such as X-ray or MRI, may be required.
To confirm the diagnosis and identify the underlying cause, the following diagnostic tests would be appropriate:
- MRI of the lumbar spine: To visualize disc herniation, spinal stenosis, or other structural abnormalities.
- Electromyography (EMG) and nerve conduction studies: To assess nerve function and identify areas of impairment.
- X-rays: For assessing structural abnormalities like spondylolisthesis.
- Blood tests: To rule out inflammatory conditions like ankylosing spondylitis.
The patient will be referred for MRI and EMG studies to further evaluate the underlying cause of his symptoms. Symptom management, including pain relief and physical therapy, will be initiated while awaiting test results. If red flag symptoms or signs of severe nerve compression are observed, surgical consultation may be considered.