A 63-year-old woman comes to the office due to back pain. The patient works as a postal carrier, and the pain started 2 days ago while she was lifting a heavy package on the job. She has had no lower extremity weakness or sensory symptoms. The patient was treated for a urinary tract infection a month ago. She smokes a pack of cigarettes daily. The patient reports "I am tired of the heavy lifting I've been doing for 30 years." Temperature is 36.7 C (98.1 F), blood pressure is 120/76 mm Hg, and pulse is 80/min. Physical examination shows paravertebral tenderness localized to the L3 level on the right side. There is no tenderness over the spine. Lower extremity strength is 5/5, and deep tendon reflexes are 2+ and symmetric. Babinski sign and straight-leg raising test are negative. Which of the following is the most likely diagnosis in this patient?

Question

A 63-year-old woman comes to the office due to back pain.  The patient works as a postal carrier, and the pain started 2 days ago while she was lifting a heavy package on the job.  She has had no lower extremity weakness or sensory symptoms.  The patient was treated for a urinary tract infection a month ago.  She smokes a pack of cigarettes daily.  The patient reports "I am tired of the heavy lifting I've been doing for 30 years."  Temperature is 36.7 C (98.1 F), blood pressure is 120/76 mm Hg, and pulse is 80/min.  Physical examination shows paravertebral tenderness localized to the L3 level on the right side.  There is no tenderness over the spine.  Lower extremity strength is 5/5, and deep tendon reflexes are 2+ and symmetric.  Babinski sign and straight-leg raising test are negative.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d505_6438_bc81_dff6fe597c42_MD0003_00 This patient developed acute low back pain while lifting a heavy object. Lower extremity strength, sensation, and reflexes are intact and straight-leg raising test is negative, suggesting a lumbosacral strain (LSS). LSS is the most common cause of back pain and is often triggered by twisting, lifting, or physical exertion. Acute LSS can occur at any age; risk factors include obesity, spinal deformity (eg, scoliosis), degenerative spinal changes, and muscle weakness/deconditioning. LSS is generally marked by pain in the lumbar paravertebral muscles that does not radiate below the level of the knee. Straight-leg raising testing is usually negative (no exacerbation of pain when the hip is flexed with knee extended and foot dorsiflexed), and lower extremity neurologic examination (eg, strength, reflexes, sensation) is typically intact. Most cases improve spontaneously and are treated symptomatically with heat, nonsteroidal anti-inflammatory drugs, nonbenzodiazepine muscle relaxants, and early mobilization. Therefore, no additional work-up is usually needed. (Choice A) A herniated intervertebral lumbar disc generally causes acute low back pain with radiation into the foot (lumbosacral radiculopathy); straight-leg raising testing is usually positive, and lower extremity neurologic deficits (eg, dorsiflexion weakness) are often present. (Choice C) Malingering is often suspected when a patient has pain in a nonanatomic distribution, tenderness to light palpation over a broad region, and a change in neurologic examination while distracted. (Choice D) Cancer frequently metastasizes to the spine due to slow blood flow through the vertebral plexus, which allows deposition of malignant cells. However, spinal tumors generally cause vertebral pain (not in the paraspinal muscles) that is worse at night and not relieved by rest. In addition, other systemic signs of malignancy (eg, weight loss, fatigue) are often present. (Choice E) Osteoporotic compression fractures can occur in postmenopausal women during heavy lifting or twisting. However, tenderness is generally localized to the vertebral bodies rather than the paraspinal muscles. (Choice F) Spinal epidural abscess can cause low back pain. However, it is unlikely to present acutely during heavy lifting, and lower extremity radicular symptoms are often present due to compression of the nerve roots. Educational objective: Lumbosacral strain is the most common cause of acute back pain. It is often triggered by twisting, lifting, or physical exertion. The pain and tenderness are localized primarily to the lumbar paraspinal area, but pain may radiate to the buttocks, hips, and thighs. Straight-leg raising test and neurologic examination are typically normal. References: Diagnosis and treatment of acute low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/22335313)

A 63-Year-Old Woman Comes to the Office Due to Back