Clinical Case #2: Ruth

(1)

Princeton Spine & Joint Center, Princeton, NJ, USA

Ruth is a 64-year-old married attorney who presents with a 7-month history of right-sided lower back and buttock pain. She is being referred to this office by her physical therapist. She had been sent to her physical therapist by her primary care doctor. After 15 sessions of physical therapy, her therapist told her that because she was not making any progress with therapy, she should see a specialist.

Ruth’s pain started without any inciting event that she can recall. She notes that the pain started insidiously and then progressively got worse to the point that in the last 4 months, Ruth has trouble performing her activities of daily living because of the intensity of the pain. Ruth’s pain is worst with standing and better with sitting. The pain is worse in the morning and also worse with transitioning from sit to stand if she has been sitting for a prolonged period of time.

Ruth’s pain does not radiate into the legs and she denies any numbness, tingling, or subjective weakness in the legs. Ruth says that she can walk about two city blocks before the pain reaches 8/10 on VAS and makes her want to sit down. She has not had any radiologic studies of her lumbar spine.

Ruth has been taking 800 mg of ibuprofen three times per day and says that this helps her pain but it upsets her stomach and she would like to stop taking it. She has tried Tylenol for the pain in the past but this has never helped her. Ruth did go to a chiropractor three times but this did not help her symptoms at all so she stopped going. Ruth notes that moist heat makes the pain feel better temporarily but then the pain keeps returning.

Ruth has a past medical history of high blood pressure that is managed with hydrochlorothiazide and otherwise does not take any medications other than the ibuprofen. Ruth notes that she does not exercise regularly and says that her hours are so long at work that it has been years since she had a regular work-out routine.

Physical Examination

On physical examination, Ruth is 5′4″ and 130 lb. Her gait is normal. She has full, pain-free trunk flexion but is restricted in trunk extension and has pain and restricted movement with right oblique extension of her lumbar spine. She has a negative straight leg raise bilaterally. Ruth’s right lumbar paraspinals are diffusely tender but no specific trigger points can be identified. Her right sacroiliac joint is tender. She has a negative FABER test.

Ruth has 5/5 strength in her lower extremities bilaterally. Her sensation is intact and her patella and Achilles reflexes are 1+ bilaterally.

Assessment and Plan

Having heard Ruth’s presentation, what does she likely have and what is the next step that you would take as her treating physician?

Ruth has chronic right lower back pain. It is helpful to review some of the pertinent points. Ruth is over 60. Her pain is axial and non-radiating. She has no neurologic signs or symptoms. Her pain is worse with standing (trunk extension) and is better with sitting (trunk flexion). On physical examination, Ruth’s pain is easily reproduced with right oblique extension of her lumbar spine. All of these important points suggest that Ruth’s pain is emanating from her facet joints.

Indeed, based on her history and physical examination, she certainly seems to have relatively classic facet joint pain. However, recall that this is a clinical assessment, and in fact it is important—some might say critical—to remember that the most likely diagnosis for Ruth’s pain based on epidemiology is discogenic pain (about 40 % of the time) followed by facet joint pain (about 30 % of the time) and then sacroiliac joint pain (10–15 % of the time).

Ruth has not had any radiologic studies of her lumbar spine yet. Based on the fact that she has had the pain for 7 months and is likely going to require interventional procedures for diagnosis and possible treatment, after a full discussion and explanation of her options, it is agreed that Ruth should first have an MRI of the lumbar spine without contrast.

Follow-Up

Ruth gets the MRI scan and returns for follow-up. Her MRI reveals multilevel facet joint arthropathy and a small central disc herniation at L5–S1. Ruth’s MRI findings are reviewed with her and it is explained to her that her MRI is essentially “average” or “normal for her age.” Another way of explaining this is to say that if one took an MRI of one hundred people who were Ruth’s age and had never had a pain in their lumbar spine and if one then compared these asymptomatic normal subjects’ MRIs with Ruth’s MRI, it would be impossible to know who has symptoms and who does not. It is important to explain to Ruth that this is not to diminish her pain or suggest that it is “made up.” Ruth’s MRI is consistent with her pain and important to consider, but in and of itself is not diagnostic of what is causing her particular pain. The MRI is, to be more succinct, one piece of the puzzle.

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