A 46-year-old woman comes to the office to follow up on back pain. The patient was involved in a motor vehicle collision 2 weeks ago and was transported to the emergency department due to back pain. Imaging revealed a bulging disc at L4-L5, with no nerve root impingement, and she was released with a prescription for naproxen. Since then, the patient has had only partial relief of pain; it is rated as 7 on a scale of 0-10 in severity and radiates to her right hip and thigh. Medical history is notable for hypothyroidism and irritable bowel syndrome. Vital signs are normal. BMI is 27 kg/m². Examination shows tenderness in the right paraspinal region at the L4 level. Lower extremity motor strength and reflexes are normal, and straight-leg raising test is negative. The patient states, "My back is going to ruin my life. My mother lost her job due to back pain, and now I just know I'm going to lose my job, too." Which of the following is most predictive of poor long-term functional status in this patient?

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Explanation: 11ec2b69_c0a7_697d_8f63_5103b2f1ecf1_MD0005_00 This patient has acute low back pain and paraspinal tenderness, findings consistent with lumbosacral strain. Acute low back pain spontaneously resolves in most patients. Initial management emphasizes measures to provide temporary pain relief, such as nonsteroidal anti-inflammatory drugs, heat, massage, and spinal manipulation. Only a small number of patients (ie, <20%) with acute low back pain go on to develop chronic pain. However, certain factors (yellow flags), including the following, are associated with poor prognosis and an increased risk of long-term disability: Maladaptive pain coping behaviors Psychosocial comorbidities High level of functional impairment Maladaptive pain coping behaviors include, as in this patient, catastrophizing (ie, assuming the worst possible outcome) and poor expectation of recovery. In most cases, patients with low back pain are simply advised to maintain normal activity, with gradual introduction of a regular exercise program as pain improves. However, patients at high risk for extended disability should be considered for additional interventions, including education, occupational ergonomic assessment, and supervised physical therapy. (Choice A) Minor, nonspecific abnormalities on imaging (eg, bulging discs) are common, both in patients with low back pain and in asymptomatic patients. In the absence of more specific clinical features (eg, radiculopathy with progressive neurologic deficits), these features have little to no impact on prognosis. (Choice B) Localized tenderness in the paraspinal tissues is common in acute lumbosacral strain and is not associated with poor prognosis. In contrast, midline point tenderness suggests an alternate etiology (eg, vertebral compression fracture, vertebral osteomyelitis), which could adversely impact prognosis. (Choice D) Pain referred to the buttocks, hips, and thighs is common in patients with benign lumbosacral strain. It does not indicate radiculopathy or suggest an unusually poor prognosis. (Choice E) The use of opioid analgesics in acute low back pain is associated with an increased risk of prolonged pain and disability. Nonsteroidal anti-inflammatory drugs are not associated with a worse prognosis. Educational objective: Only a small number of patients with acute low back pain develop chronic pain and long-term disability. High-risk features (yellow flags) for prolonged disability include maladaptive coping behaviors, psychosocial comorbidities, and a high level of functional impairment. Maladaptive coping behaviors include catastrophizing (ie, assuming the worst possible outcome) and poor expectation of recovery. References: Yellow flags as predictors of rehabilitation outcome in chronic low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/30024205)

A 46-Year-Old Woman Comes to the Office to Follow Up