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  #1  
Old 03-16-2012
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Rheumatology/Orthopedics Best initial step for back pain?

A 48-year-old man is evaluated in the office for back pain of 1 month's duration. He describes the pain as an ache that has been slowly worsening and is only partially relieved with acetaminophen. He is most comfortable lying down and least comfortable sitting or moving. He has not had any recent trauma or previous back pain. He has not had weight loss, fever, chills, numbness or weakness in his legs, or problems with bowel or bladder function. His only other medical problems are hypertension and osteoarthritis of the knees, for which he takes hydrochlorothiazide and acetaminophen, with occasional ibuprofen.

On physical examination, vital signs, including temperature, are normal. He has mild lumbar paravertebral tenderness and spasm. Neurologic examination, including muscle strength, deep tendon reflexes, and sensation, is normal. The straight-leg-raising test is normal.

Complete blood count and metabolic panel performed in the office 3 months ago were normal.

Which of the following is the best initial management plan for this patient?

A Analgesics and strict bed rest
B CT scan of the lumbosacral spine
C MRI of the lumbosacral spine
D Physical therapy
E Symptomatic treatment
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Old 03-16-2012
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D Physical therapy - It is lumbar sprain, characterized by paraspinal tenderness.
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Old 03-16-2012
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I think its case of Spinal stenosis, bcoz pt is most comfortable when hez lying down and least comfort when sitting or moving, therz no any Hx of trauma, no wt loss, so for Spinal stenosis dx First test iz MRI, do MRI (C)
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c) MRI...is the answer
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D Physical therapy
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this pts has signs of both lumbosacral strain and lumbar spinal stenosis. So doing MRI of the lumbar spine will help make a definitive diagnosis. So my ans. is C.
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I also say Physical Therapy

Sounds more like strain than spinal stenosis; failure of PT to alleviate the symptoms would be an indication to then go to MRI. Also, insurance companies and medicare mostly will not approve an MRI until the patient has failed PT.
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Old 03-17-2012
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Quote:
Originally Posted by tyagee View Post
A 48-year-old man is evaluated in the office for back pain of 1 month's duration. He describes the pain as an ache that has been slowly worsening and is only partially relieved with acetaminophen. He is most comfortable lying down and least comfortable sitting or moving. He has not had any recent trauma or previous back pain. He has not had weight loss, fever, chills, numbness or weakness in his legs, or problems with bowel or bladder function. His only other medical problems are hypertension and osteoarthritis of the knees, for which he takes hydrochlorothiazide and acetaminophen, with occasional ibuprofen.

On physical examination, vital signs, including temperature, are normal. He has mild lumbar paravertebral tenderness and spasm. Neurologic examination, including muscle strength, deep tendon reflexes, and sensation, is normal. The straight-leg-raising test is normal.

Complete blood count and metabolic panel performed in the office 3 months ago were normal.

Which of the following is the best initial management plan for this patient?

A Analgesics and strict bed rest
B CT scan of the lumbosacral spine
C MRI of the lumbosacral spine
D Physical therapy
E Symptomatic treatment
ans is E.
dx is lumbosacral sprain.why?paravertebral tenderness along with negative SLRT.
for those saying spinal stenosis, i disagree because it has not been mentioned that pain relieves on flexion. any back pain will get relieved by lying down[resting] and increase with moving.

here is excerpt from qbank..
Diagnostic imaging techniques are indicated in individuals with “red flags” for serious underlying disease, including
  • fever,
  • chills,
  • weight loss,
  • history of malignancy,
  • injection drug use,
  • trauma, or
  • indolent course.
[personally, i think of h\o abscess,tumor,trauma as red flags ..]

***not physical therapy..
Physical therapy is an appropriate adjuvant but is not an appropriate initial treatment. Clinical trial evidence has shown that beginning back exercises immediately actually delays recovery.....

so, everyone agrees?:sorry:
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Old 03-17-2012
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Quote:
Originally Posted by tyagee View Post
ans is E.
dx is lumbosacral sprain.why?paravertebral tenderness along with negative SLRT.
for those saying spinal stenosis, i disagree because it has not been mentioned that pain relieves on flexion. any back pain will get relieved by lying down[resting] and increase with moving.

here is excerpt from qbank..

Diagnostic imaging techniques are indicated in individuals with “red flags” for serious underlying disease, including
  • fever,
  • chills,
  • weight loss,
  • history of malignancy,
  • injection drug use,
  • trauma, or
  • indolent course.
[personally, i think of h\o abscess,tumor,trauma as red flags ..]

***not physical therapy..
Physical therapy is an appropriate adjuvant but is not an appropriate initial treatment. Clinical trial evidence has shown that beginning back exercises immediately actually delays recovery.....

so, everyone agrees?:sorry:

good questions.
i was thinking of lumbar osteoarthritis, as pt has a history of osteoarthritis.
can you plz explain, why it is a sprain ( there is not a hx of trauma,heavy lifteing etc) will appriciate your response. thanks.
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