(1)
Princeton Spine & Joint Center, Princeton, NJ, USA
Jack is a 78-year-old retired salesman who presents with a 3-week history of left lower back pain that began without any identifiable inciting cause. Jack has a past medical history that includes coronary artery disease with two stents placed, hypertension, diabetes type II, benign prostate hypertrophy, chronic obstructive pulmonary disease, gall bladder surgery, and diverticulitis. Although his medical history is significant, Jack considers himself to be “pretty healthy all things considered.”
Jack enjoys playing golf and until 3 weeks ago was able to walk 18 holes of the golf course. Jack says that he does not “work out” but he stays active. In addition to golf, Jack occasionally goes bowling and he also goes on frequent long walks with his wife. O ne of Jack and his wife’s favorite activities is to spend an afternoon walking through a museum.
The pain in Jack’s left lower back is sharp in character. He says that the pain is 9/10 on VAS at worst and 4/10 at best. The pain does not radiate into the lower extremity. The pain is worse with prolonged standing. Twisting makes the pain much worse. Sitting is generally better than standing, but if he sits for more than 20 min, then the pain becomes worse again. Jack is very frustrated because he does not understand where the pain came from. Multiple times while talking in the office, Jack says “but I just don’t get it because I didn’t do anything” to cause the pain.
Jack has mild numbness in the bilateral feet that he says has been there for years and he says that he has been told that the numbness is from his diabetes. He does not feel weak in the legs. He went to a chiropractor a week ago and he felt better after being treated but then the pain “came right back a couple of hours later” and his primary care doctor told him to come to this office. Jack has tried taking Tylenol for the pain and says it helps “a little.” Jack has taken Aleve and finds that to be “pretty good” for the pain. Over the last 3 weeks, Jack notes that the pain has not gotten much better or gotten much worse.
For his multiple medical conditions, Jack takes many medications including Plavix for his CAD and stents. He denies any change in bowel or bladder habits. He notes that he has had back pain intermittently in the past but it has never been anywhere near this bad before or lasted this long.
Physical Examination
On physical examination, Jack is 5′9″ and 170 lb. He has a thin but muscular build. Jack exhibits some mild thoracic hyperkyphosis . He has a normal gait but he is in obvious pain when he transitions from sit to stand or from stand to sit. Jack has pain with lumbar flexion as well as lumbar extension. He has severe pain with left lumbar oblique extension but no pain with right lumbar oblique extension. He has very significant tenderness in the left lumbar paraspinals and his left quadratus lumborum muscle is particularly tender although no trigger point with a referral pain pattern is identified. His sacroiliac joints are not tender. Jack has a negative straight leg raise bilaterally and negative slump test bilaterally.
Jack has 5/5 strength in his lower extremities bilaterally. He has intact sensation to light touch except mildly decreased sensation in the bilateral feet. He has no reflexes in the patella or Achilles reflexes bilaterally. His hips have restricted range of motion bilaterally but range of motion does not produce pain. Jack’s hip flexors and knee extensors are very tight to passive range of motion testing.
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