Download Lumbar Spine – Case Presentation – Part 1

Lumbar Spine – Case Presentation – Part 1
History:
Benjamin Grimm is a 33 year-old male who presents with a diagnosis of ‘low back pain’ from a primary
care physician. Benjamin is scheduled to see an orthopedic surgeon tomorrow. X-rays of his lumbar spine
reveal only mild degenerative joint disease of the L4/5 – L5/S1 region. He is employed as an executive in
a fast paced advertising firm and is a father of 2 small children (3 and 2 y/o). Benjamin reports that the
only time he has been to a doctor was last year when he ruptured his Achilles tendon while playing
football at his college reunion. He is insured by an HMO, which allows him a maximum of 12 physical
therapy visits (per year) for his presenting diagnosis.
History from patient:
Benjamin reports that exactly one week ago he was returning from a business trip overseas and sat in an
airplane for 10 hours (coach class). At the conclusion of the flight, he bent over to pull his brief case from
underneath the chair in front of his and felt a ‘tug, then a warm sensation’ in his low back.
By the time he got home his back had begun to spasm, he took a couple of Doans tablets and went to bed.
The next morning he awoke feeling as though he had pulled his left hamstring. Being an avid runner, he
thought the best course of action to take would be to stretch the muscle, using his familiar ‘hurdler’s
stretch’. During the first attempt at the stretch, he heard a ‘pop’, then felt severe pain from his buttock to
his foot. He began to feel dizzy and nauseous and remained in the fetal position on the floor. The nausea
dissipated but he remained on the floor until his wife returned home to escort him to the ER. Once there,
Benjamin had x-rays taken and was sent home on Demerol and prescribed bed-rest. Benjamin followed
up with a visit to his primary care physician who changed his medication to Flexural and Naproxen and
referred him to physical therapy.
At this time, Benjamin reports a constant ‘tingling sensation, like when your foot goes asleep’ sensation
in his leg, and the outside of his foot and big toe feel completely numb. Benjamin’s low back pain and
spasm persists. Benjamin cannot tolerate sitting for more than 10 minutes and he has to switch positions
often, ‘fidgeting’ to find a comfortable position. Benjamin prefers to stand rather than sit but is most
comfortable lying down.
Benjamin reports that bending his lower back feels better while he is doing it but worse afterwards and he
does not understand why this should be so because he thought ‘stretching’ the tight back muscles was the
right exercise to do. Benjamin currently has an upper respiratory tract infection, and he says that
coughing and sneezing greatly increase his low back pain.
Objective evaluation:
General Observation: you notice when your patient arrived at the clinic that he was pacing nervously in
the waiting area. During the interview he asked to remain standing and was perspiring. He was in obvious
discomfort during the subjective evaluation.
 What information about the behavior of the pain should you obtain?
 What are the potential structures involved in this presentation?
 Describe the remaining components of your objective evaluation and the clinical relevance of each?
How will you differentially diagnose this condition?
 What information would you like to receive from the orthopedic surgeon?
Surgeon’s Report and Objective Evaluation
The following radiographs are received from the orthopedic surgeon’s office. Does this change or
confirm your previous diagnosis?
Plan The Objective Examination
Using the following outline, complete your evaluation and determine a diagnosis for the presenting
condition.
1. Name as the possible source of any part of the patient's symptoms every structure that must be
examined:
Joints under the area Joints referring into Contractile structures Other structures to
of symptoms
the
area
of underlying the area of be examined
symptoms
symptoms
1.1
Circle the most probable source(s) of the symptoms.
1.2
Will you do a neurological examination? Yes/No
1.2.1
Segmental/peripheral/central (circle)
1.2.2
Why? ________________________________________________________________
2.0
Influence Of the Symptoms of the Examination
2.1
Are the symptoms minimal/moderate/severe?
2.2
Does the subjective examination suggest an easily irritable disorder?
Local:
Yes/No
Give an example:
Referred:
Yes/No
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Local:
Activity causing symptoms________________________________________
Severity of symptoms____________________________________________
Duration before symptoms subside__________________________________
Referred:
Activity causing symptoms_____________________________________
Severity of symptoms_________________________________________
Duration before symptoms subside_______________________________
2.3.
Does the nature of the symptoms indicate caution?
Yes/No – Specify: ________________________________________________________
2.4
Does the nature of the symptoms require specific testing?
Yes/No – Specify:_________________________________________________________
2.5
Does any other aspect of the subjective examination indicate caution, e.g. severity, irritability,
stage?
Yes/No – Specify:_________________________________________________________
2.6
Are there any contraindications to any part of your examination?
Yes/No – Specify:_________________________________________________________
3.0
The Kind of Examination
3.1.
Do you think you will need to be gentle or moderately vigorous with your examination?
Local Pain
Referred Pain
Paraesthesia /
Anesthesia
Dizziness or Other
Symptoms
Short of pain
Short of symptoms
Short of symptoms
Pain or point of
increase
Pain or point of
increase
Pain or point of
increase
Pain or point of
increase
Active limit of
movement
Active limit of
movement
Partial reproduction
of symptoms
Partial reproduction
of symptoms
Active limit plus
overpressure
Active limit plus
overpressure
_______________
_______________
Sustained Repeated
Combined
Sustained Repeated
Combined
______________
_______________
3.2. At which point will you limit your objective examination?
3.3. Do you expect a comparable sign to be easy/hard to find?
3.4. Do you expect to be treating pain, resistance, or spasm?
4.0. Associated Examination
4.1. What associated factors must be examined?
4.1.1. Reasons why the joint, muscle, or other structure has become symptomatic
Specify:
______________________________________________________
4.1.2. Reasons why the disorder may occur
Specify: _____________________________________________________
Learning Objectives for Part I
The patient pulls out a list of questions from his personal organizer at the end of the session and begins to
voice the following concerns?

“What is wrong with me?”

“Do I have a pinched nerve or a slipped disc?”

“The doctor wants to give me an epidural injection, what is that?”

“Why am I going to an orthopedic surgeon do you think I need surgery?”

“How long will this take to get better?”

“When do you think I can get back to my work out, it is my only means of alleviating stress and I
am concerned about getting love handles?”

“Do you think I will be able to go on my second honeymoon with my wife next month, we plan to
go skiing?”
By addressing these questions the student should achieve the following learning objectives:
1. Discuss the behavior of this patient’s symptoms.
2. Identify the various structures that are potentially involved.
3. Describe the components of the physical examination, explaining the importance and clinical
relevance of each test performed.
4. Describe and discuss the use of medications for this patient.
5. Identify the most likely diagnosis.
6. Explain what an epidural injection is and postulate why the surgeon would suggest this method
over oral medication.
7. Identify what a ‘dural sign’ is and explain what it means.
8. Give an explanation as to why this patient may deviate away from the site of pain during flexion.
9. Suggest why this patient would have decreased symptoms in prone lying.