Chapter 15 Acute back pain

Case 15.1

History

Caitlyn is a 29-year-old woman who presents to you complaining of pain on the right side of her lower back. She had previously consulted you for mechanical pain in her neck that responded well to treatment, but has never had any other complaints.

The pain is a strong ache over the right lower back, particularly over the ‘dimple’ on the right side and into the right gluteal region. The pain is not well localised and feels diffuse. Caitlyn rates the pain severity as 8/10 on a simple analogue scale. The pain is constant and began 1 week ago after she went for her daily 3km jog. At this time, the pain came on suddenly and was sharp, but has since diminished to a ‘strong ache’. There is no radiation of the pain, and no motor or sensory phenomenon. Caitlyn has tried paracetamol, but this provided only minimal relief. The pain is not relieved by rest, although she is able to sleep normally at night. The pain is aggravated by straining on the toilet and by sneezing.

Caitlyn advises you that she first noticed a similar pain 1 year ago. The pain at this time presented as an episodic chronic dull ache in the same region over the right low back, but of a lesser severity, rated as 5/10. Since the original onset, the pain has followed a relapsing-remitting course, and seemed to peak during the middle of her menstrual cycle. The pain would last for a few days and then subside. Occasionally this has been accompanied by mild right lower quadrant abdominal pain, but not on every occasion. Recently, her menstrual cycle has become more irregular, and Caitlyn is unable to remember the date of her last menstrual period. A recent pregnancy test was negative.

Caitlyn is an otherwise healthy woman who has no previous history of medical illness and has never been hospitalised or suffered any trauma. She has been taking a pregnancy multivitamin over the last 18 months, as she is trying to become pregnant. She is not on the oral contraceptive pill and occasionally has taken Naprogesic (naproxen sodium) for menstrual pain. She eats a healthy diet and participates in regular exercise. She drinks and smokes socially, and on average consumes six standard drinks and 15 cigarettes (8mg nicotine) on weekends. Caitlyn works full time as a primary school teacher and is happy and generally stress-free. There is nothing of note in her family history, and her parents and siblings are alive and well.

Caitlyn appears to be of normal weight. She does not display any signs of acne or hirsutism. You question her on her systemic health and note that she does not have any fever, sweats or chills and has not recently lost any weight. Her appetite is normal. She has no gastrointestinal complaints and denies ever having had any sexually transmitted diseases. She has never been pregnant. She has noticed a feeling of bloating in her lower abdomen and feels a sense of pressure when she urinates or passes a bowel movement. She has noticed that intercourse has been painful in the last month. Her menstrual cycle has been irregular in the last 5 months, with delayed periods followed by spotting. Caitlyn has been trying to fall pregnant for the last 18 months without success, and has a consultation booked in 1 week with her medical practitioner to discuss further management of this issue. All other systems are unremarkable.

Caitlyn is concerned that she may have strained her back during her jogging and would like your opinion on this matter.

Questions

1. Using only this information, list the possible causes of Caitlyn’s pain. Justify your answers.

2. Why was Caitlyn asked about:

a the quality of the pain

b the nature of the onset of the pain

c pain at rest and pain affecting sleep

d the significance of sneezing and straining

e the pattern of pain

f her menstrual history

g her genitourinary history?

3. What do you need to examine in this patient?

Physical examination

General observation	Caitlyn is a healthy looking woman of average height. She is of normal body mass. She looks mildly uncomfortable but is able to move into the positions you request and can still converse appropriately. She is not pale or sweating. She does not have hirsutism, acne or digital clubbing
Vitals	•Pulse rate/min	72
	•Respiratory rate/min	18
	•Blood pressure mm Hg	120/75
	•Height (cm)	170
	•Weight (kg)	58
	•BMI	21.6
	•Temperature (degrees C)	37
HEENT	Unremarkable No uveitis, jaundice or conjunctival pallor
Chest	No cardiomegaly, no murmurs, lung fields clear
Abdomen	Inspection and auscultation The abdomen is mildly bloated; skin appears normal; bowel sounds are normal Palpation of abdomen • Left side is normal, no tenderness • There is mild tenderness over the right lower abdominal quadrant, and the possibility of a mass at the site of the ovary is noted. Palpation at this site also caused an increased sense of pressure over the bladder • There is no rebound tenderness or abdominal guarding • Kidneys not palpable
Musculoskeletal	• Gait normal • Lumbar and hip screen normal • Valsalva manoeuvre and slump test positive for pain in right sacroiliac joint and lower right abdominal quadrant, negative for lumbar pain or radiculopathy; Kemp’s test negative • Hypertonia of right gluteal muscles, right lumbar erector spinae, right psoas muscle • Right sacroiliac joint tender to palpation at sacral sulcus • Hypertonia of levator ani muscle bilaterally

Questions

4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

5. Explain the significance of the following signs, in context of your differential diagnosis:

a no clubbing of the digits

b no conjunctival pallor

c kidneys not palpable

d no rebound tenderness

e abdominal bloating

f right lower quadrant tenderness

g hypertonic right psoas and lumbar erector spinae muscles and tender sacral sulcus

h absence of acne and hirsutism.

6. Caitlyn is referred to a medical practitioner. What investigations are required? Why? What would you expect, based on the physical examination findings?

Investigations

• Urinary pregnancy test: negative.

• Full blood count: within normal limits.

• CA125: less than 35U/mL, plus no family history.

• Urinalysis: negative for blood, protein, leucocytes, bacteria, glucose; within normal limits.

• Pelvic ultrasound: right ovarian cyst, 5.2cm diameter, smooth internal capsular surface with clear contents; simple cyst, no evidence of rupture; no evidence of ectopic or uterine pregnancy.

Questions

7. What is the most likely diagnosis, based on these results? Rationalise your answer.

8. Explain the significance of the ultrasound report, in context of your differential diagnosis.

9. Are any further investigations required?

10. Why did Caitlyn have recurrent pain related to her menstrual cycle?

11. Why do simple ovarian cysts cause pelvic and low back pain?

12. Why does this patient feel pressure when she urinates or passes a bowel movement?

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