Is it truly the back?

Sometimes it turns out that our diagnosis at first sight may after all not be the correct diagnosis. Numerous discrepancies namely do not fit to the expected clinical picture. How can a good history help us in the case of a lower back pain? 

42-year-old lady complains of lower back pain with pain radiating over the right hip. The problems appeared spontaneously, without any known trauma. She doesn’t take any regular medication. With the exception of occasional migraine headaches, she doesn’t have any other medical problems. X-Ray of her lumbar spine and SI-joints show signs of wear. Her GP puts her on a sick leave, introduces NSAR-therapy and issues a work order for  physiotherapy

After one week physiotherapy, her complains are not getting better, instead the pain even intensifies. At the moment, the pain is most pronounced on the right side, especially when walking, the worst being the stairs. Because of the pain, sleeping on the affected side is impossible. The patient is desperate – she claims, due to physiotherapy everything has just gotten worse and that she doesn’t want to continue it anymore. Now, because of pain, she can not walk, work, or sleep.

Clinical reasoning- Method by J.Cyriax
Using the knowledge and skills of OM Cyriax, we know that, for assessing the lumbar spine, the patient’s history is crucial. Now, let’s try to put data from the history into a meaningful working hypothesis. –

The first step would be to classify the clinical picture of our patient to the appropriate clinical syndrome. Our patient’s history most closely corresponds to the image of backache. The term has no chronological meaning, but rather indicates the intensity of disco-dural interaction.

The next step is to obtain four significant informations: the size (1), the consistency (2), and the lokalisation (3) of the disc protrusion as well as assessing the risk of developing cauda equina syndrome (4). Reducibility of the protrusion, as the fifth element, may be more a domain of clinical examination.

Taking into account our patient’s history, we are considering a small nuclear posterocentral protrusion, most likely at the lower lumbar level with dural reference. In view of absent symptoms suggesting cauda equina syndrome, we can speak of a non-dangerous protrusion.

Troubled by doubts
After a careful consideration, unfortunately, the second part of the history provides us with some fundamental doubts. The pain shift coincides with our working hypothesis, as it is an internal disorder in which the rule ‘a shifting pain is a shifting lesion’ applies.

We could be dealing with a simple shift, but if we are considering the development of root pain or secondary posterolateral protrusion (SPLP), the phenomenon isn’t alarming. We even talk of a normal evolution.

The fundamentals of referred pain in OM teach that pain can be found in any part of the dermatome. It must be recognized, however, that root pain, limited exclusively to the right hip, is rather unusual.

Walking pain
The next inconsistent information is walking difficulties. Exacerbation of pain is to be expected when seated or, in the case of hyperacute lumbago, pain twinges accompanying more or less every movement.

The clinical picture of acute lumbago can be recognized at first glance. By entering the clinic, a patient is taking slow careful steps with a straightened or deviated back. As a result of a large protrusion with an intense dural interaction, each of the smallest movements in the spine triggers painful twinges. Such a patient typically moves ‘in one axis’ and gratefully declines a friendly invitation to sit down. Again, patients with lower back pain better tolerate the standing position.

What about walking the stairs?
Further concern about walking the stairs could indicate L3 root pain, where patients prefer the position in flexion, some even prefer to sleep in the armchair. In this case, walking down the stairs would be very unpleasant, ascending the stairs, on the other hand, notably less problematic. Similarly, in OM we are familiar with spondylolisthesis, where clinically the pain is present in an upright posture while walking or standing. Sitting and lying makes the pain fade away. Our patient, however, does not indicate the difference between walking up and down the stairs.

More doubt in our working hypothesis
Difficulties in walking the stairs and difficulty sleeping on the affected side are therefore further inherent unlikelihoods, that is, data from obtained patient’s history, that do not correspond to the expected clinical picture.

What now?
Considering pain at night, it is a phenomenon that can speak either in favor of the marked inflammatory activity of the affected structure or perhaps of a local compression. Last but not least, the cough is negative in our patient, which, for a cyriax therapist, is an important dural symptom.

In any case, the fact that the patient’s complaints are movement and position dependent, indicates a positive PMA-history (posture, movements, activities). This leads us to the conclusion, that we are, after all, dealing with a musculoskeletal pathology.

Puzzling clinical case
Armed with basic information, – unfortunately – with reasonable doubt in our working hypothesis, we now approach the functional examination  …

Do we have a differential diagnosis in mind?

To be continued…

MF

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