CONTINUITY CLINIC CURRICULUM
Management of Low Back Pain
Objectives:
1. To develop a rational approach to the initial evaluation of low back
pain.
2. To know when to order imaging and what type.
3. To recognize and understand surgical emergencies.
4. How to follow up back pain in the outpatient setting.
CASE 1:
A 45-yo male presents to your office for evaluation of low back pain. He
states that he first noticed the pain 1 week ago while chopping wood. He
states pain mildly relieved by rest and aspirin 325 mg. No sciatica,
parasthesias or weakness. He characterizes the pain as sharp and currently
4/10. He denies weight loss. His PMHx: HTN, dyslipidemia. Physical exam
reveals an overweight male in no distress. BP 145/80, HR 85, RR 18, T 98
F. Neuro exam: +2 patellar and ankle reflexes, 5/5 motor strength with
dorsiflexion and plantarflexion of ankle and Great toe. Negative Straight Leg
test.
1. What is the differential diagnosis? What is the Straight Leg Test and
what is it used for?
2. How would you work up this patient?
3. What instructions would you send this patient home with?
4. What features of the low back pain history would prompt imaging and
what type?
5. What percent of primary care low back pain cases are caused by a
diagnosis requiring immediate imaging?
CASE 2:
A 55-yo female presents to your office complaining of a 5-day history of
low back pain, which radiates down her right leg. Pain is made worse with
coughing. No urinary complaints. PMHx: DM II, osteoporosis. She smokes
2 ppd x 40 yrs. She leads a sedentary life. On exam, she is thin and in no
acute distress. BP 130/85, HR 75, RR 20, T 98 F. Neurological exam is
significant for a positive Straight Leg test on her RLE. 4/5 motor strength of
R. ankle plantarflexion. Diminished R ankle reflex.
1. Does this woman need further workup?
She returns to your clinic 2 months later with no improvement.
2. What should be done next?
CASE 3:
A 65-yo male presents to your office complaining of a 2-day history of low
back and buttock pain. He states that today he is experiencing numbness in
his groin. He also states today he feels the urge to urinate but can’t. +20 lb
weight loss over last 4 months. PMHx: HTN, CAD, CHF. BP 145/70, HR
100, RR 20, T 99 F. Abdominal exam reveals suprapubic fullness.
Neurological exam significant for diminished sensation in perineum and
medial thighs. 4/5 strength of ankle plantarflexion and dorsiflexion.
Diminished patellar and ankle reflexes bilaterally.
1. What is the likely diagnosis and how would you proceed with the
workup? What causes this condition?
2. Who would you consult and why?
3. Would you admit this patient this patient to the hospital?
Low Back Pain – References
1. *Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363-70.
2. *Chou, Roger, et al. Diagnostic Imaging for Low Back Pain: Advice for HighValue Health Care From the American College of Physicians 1 February 2011
Annals of Internal Medicine Volume 154 • Number 3
3. Hatden JA, van Tulder MW, Tomlinson G. Systematic reviews: strategies for
using exercise therapy to improve outcomes in chronic low back pain. Ann Intern
Med 2005;142:776-86.
4. Speed C. ABC of rheumatology:lowback pain. BMJ 2004;328:1119-21.
5. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on
imaging. Ann Intern Med. 2002;137:586-97.
6. Koes BW, van Tulder MW, Thomas S. Clinical review:diagnosis and treatment
of low back pain. BMJ 2006;332:1430-4.
* Required reading