Chapter 16 Chronic or recurring back pain

Case 16.1

History

Celine is a 43-year-old female who presented to a university teaching clinic with left-sided low back pain and leg pain, extending down to the ball of her foot. The patient had previously been a postal worker (cycling to deliver post), but had decided to terminate her employment due to constant fatigue and having to carry heavy loads all the time. Celine also mentioned that she was very depressed and that living close to her mother did not really help her stress levels. In 2004 the patient was found to have a thyroid nodule, which was removed, and although oroxine (thyroxine sodium) had been prescribed, the patient did not take it regularly. In 1983 she developed hepatitis C following a dental procedure. She is also a smoker.

Questions

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

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

Physical examination

Postural analysis demonstrated a slightly increased lumbar curve. Palpation demonstrated tightness but no trigger points within the paraspinal musculature. The lumbar range of movement was adequate with no evidence of either pain or restriction in movement in any direction. The neurologic examination revealed full sensation, good motor strength and all the lower limb reflexes were present, graded at 4 (full reflex). Examination of the sacroiliac (SI) joint region revealed tenderness on palpation along the joint line bilaterally, and the SI joint orthopaedic tests, such as SI joint compression/distraction and Gaenslen’s tests, were positive for pain. In addition, on asking the patient to perform Gillet’s motion palpation test, palpable clicking was detected suggesting hypermobility.

Questions

3. Describe the functions of the following tests:

a Gaenslen’s test

b Gillet’s motion palpation test.

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 diagnoses:

a lumbar range of movement was normal

b neurologic examination normal in the lower limb

c sacroiliac joint tests positive.

6. Celine is referred to a medical practitioner. What investigations are required? Why?

Investigations

The results of the investigations are shown in Figures 16.1 to 16.4.

Figure 16.1

Figure 16.2

Figure 16.3

Figure 16.4

Questions

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

8. Are any further investigations required?

9. What is the current hypothesis regarding the aetiology of this disorder?

10. Can this pathology be found outside the pelvic region?

Case 16.2

History

Bruce is a 56-year-old male who presents with persistent mid and low back pain of 12 weeks duration. It is generally worse through the day, and is further aggravated by exercise and weight-bearing. Some relief is reported when lying down.

He reports that he has lost weight (6 kg) over this time period, and constantly feels tired.

He has had two recent bouts of cold and ‘flu type’ symptoms which have been difficult for him to shake.

Questions

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

2. What additional questions do you need to ask Bruce?

3. a. What is the significance of pain lasting for more than 12 weeks?

b What is the significance of Bruce’s weight loss and tiredness?

c How relevant are the recent bouts of flu-like symptoms?

d What is the significance of pain on weight-bearing, relieved by rest?

Physical examination

Vitals	•Pulse rate/min	92
	•Respiratory rate/min	16
	•Blood pressure mm Hg	130/85
	•Temperature (degrees C)	36.5
HEENT	Pallor of the conjunctiva
Neck	No lymphadenopathy
Chest	No cardiomegaly, no murmurs, chest clear
Abdomen	Soft, non-tender, no masses or organomegaly
Limbs	Unremarkable
Back	There is tenderness over the spinous process of L5, and muscle guarding in the adjacent tissue
Neurological	Unremarkable

Questions

4. From the above information, can you narrow your differential diagnosis to the two most likely conditions you think this patient may be suffering?

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