A 38-year-old female presents with complaints of constant chronic central low back pain, described as having a burning and aching quality, following a fall approximately 6 months ago. Over the past six months the patient has been treated by her primary care physician, a chiropractor, and an acupuncturist but with no significant relief. The patient reports that the pain is of variable intensity but that in the last two weeks she started to develop pain in the right buttock and right hip joint region extending to the lateral aspect of the right thigh. The patient reports that the pain is minimal in the morning but, as the day progresses, the pain increases. The pain is aggravated by any sudden movements or twisting of the trunk, and with coughing and sneezing. The patient reports that she takes two analgesics prior to going to bed in order not to be awakened by low back pain during the night. The patient's past medical and surgical history is unremarkable and the patient is a non-smoker and nondrinker. Pelvic and lumbar spine radiographs performed just after the fall were reported as normal apart from ‘minimal narrowing of the L5-S1 intervertebral disk’.
Is there anything in the patient's history that gives you cause for concern? If so, what?
There are a number of issues from the history that should cause the clinician concern. These include a history of constant pain for a six month duration, the description of the pain (burning), the fact that the area of pain is expanding, pain with coughing or sneezing, and the fact that the patient has only had spinal radiographs in the presence of what appears to be a potential neurologic injury.
Does the patient warrant a lower quarter screening examination?
The patient certainly warrants a lower quarter screening examination.
What is your best working hypothesis at this stage?
The best working hypothesis at this stage would be chronic low back pain with strong likelihood of a neurologic component.
The physical examination revealed the following findings:
- An observation of the patient's posture and trunk alignment revealed nothing remarkable.
- Active range of motion of the lumbar spine was flexion (full and painless), extension (limited by approximately 10% due to slight discomfort), right and left side bending (limited by approximately 10% -- right side bending was painless while left side bending caused some low back discomfort).
- Active range of motion of both hips was normal. There was a slight reproduction of low back pain with the FABER test on the right.
- The deep tendon reflexes in the lower extremities were normal.
- Stress testing revealed no deficits throughout both lower extremities.
- Pinprick sensation and vibration sensation were normal.
- The slump test was normal.
- Right and ...
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