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Princeton Spine & Joint Center, Princeton, NJ, USA
Natasha is a 42-year-old homemaker and mother of three children, ages 12, 8, and 4. She presents with an 11-month history of lower back pain. Natasha is being referred to this office by her primary care doctor. Natasha’s pain does not radiate into the legs. She d enies any numbness, tingling, or burning in the legs. The legs do not feel weak. The pain is described as “sharp” and is centralized around the L5–S1 level. The pain is worse with sitting. She says that going for long car rides is “very difficult” because the pain becomes extremely intense. Standing and walking around makes the pain better. In general, she feels that the more she moves, the better she tends to feel unless she does “too much.”
Natasha rates the pain as 5/10 on average on VAS. She says that she had to go on a 2 h car ride a couple of weeks ago and the pain was 9/10 on VAS by the end of the ride, and for the next few hours afterward the pain continued to be “at least an 8/10.”
Natasha says that at times the pain is only 2–3/10. Her lower back is generally more stiff and aching in the morning. As she gets moving, the pain is better, but then anytime she sits for more than a few minutes, the pain is back to a 6 or 7/10 on VAS. Lifting her 4-year-old son is very painful for her. Any activity where she has to bend forward and pick something up is painful unless she is very careful with her lifting posture.
Natasha has been to her friend who is a massage therapist and she says that massages definitely make the pain better for a few hours but then the pain always returns. She has not taken any pain medication because she does not want to “just mask” the pain with medications. She has not had any imaging studies. She has not been to physical therapy. Natasha says that she used to work out on a regular basis and take lots of different types of cardio classes but she has not done that in several years because she has been so busy with her three children.
Other than her lower back pain, Natasha is in very good general health. She has seasonal allergies and she has a history of a tonsillectomy. She does not take any medications on a regular basis.
Physical Examination
On physical examination , Natasha is 5′6″ and 125 lb and appears generally fit and in good health. Her gait is normal. She has pain with trunk flexion that is most notable at 30°. She has no pain with lumbar extension or bilateral lumbar oblique extension. Her strength is 5/5 in the lower extremities bilaterally. Her sensation is intact in the lower extremities bilaterally. She has a negative straight leg raise bilaterally. She has a negative slump test bilaterally.
Natasha’s lumbar paraspinals are diffusely tender but the tenderness is most pronounced over the bilateral L5 and S1 paraspinals. Natasha’s sacroiliac joints are mildly tender bilaterally. She has a negative FABER test bilaterally. She has brisk and symmetric patella and Achilles reflexes. She has full, pain-free range of motion of her bilateral hips. She has good overall flexibility in her knee extensors and hip flexors. She has negative Babinski and Hoffman’s reflexes bilaterally.
Assessment and Plan
Having heard Natasha’s presentation, what does she likely have and what is the next step that you would take as her treati ng physician?
Natasha has chronic lower back pain that clinically is most consistent with discogenic lower back pain. In fact, it may be said that she presents with a classic case of discogenic lower back pain. Her pain is axial, flexion biased, and worse in the morning.
While clinically Natasha seems to clearly have discogenic lower back pain, it must be remembered that from an evidence-based perspective, her chance of having discogenic lower back pain is around 40 % versus facet joint pain (15 %), sacroiliac joint pain (10–15 %), and other sources (30–35 %). Therefore, it may be said that clinically she appears to have discogenic lower back pain, whereas academically she most likely does not.
Natasha is very interested in the pathophysiology of her problem. The mechanics of her spine are explained to her as are the different potential offending pathophysiologies. Regardless of the underlying pathophysiology, she understands that her relative deconditioning over the past several years has likely contributed to her current problem. Natasha does not like medications and is not interested in any “quick fixes.” She likes the idea of physical therapy as a beginning point in her treatment and is very motivated to get started. As such, she is prescribed a 6-week course of physical therapy with a focus on extension-biased lumbar stabilization exercises.
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