Clinical Case #9: Esther

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Princeton Spine & Joint Center, Princeton, NJ, USA

Esther is a 72-year-old mother of four children and grandmother of eight who presents with a 3-week history of right lower back pain. She says that she has had intermittent right-sided lower back pain for many years, but the pain has always been mild and it had not been bothering her at all for a few months until 3 weeks ago. Three weeks ago, the pain began after taking care of her 6-month-old granddaughter. Esther says that she was lifting her granddaughter a lot on that day and felt the pain in her right lower back but kept lifting her anyway. That night, the pain in the right lower back was “pretty bad” and in the morning she had trouble getting out of bed because of the pain.

The pain in the right lower back does not radiate into the leg. She denies any numbness, tingling, or burning in the leg. The right leg does not feel weak. She rested for the first day when the pain was bad but by the second day, the pain was still “really bad” and she called her primary care doctor.

Her primary care doctor prescribed Naprosyn 500 mg twice a day and a muscle relaxer. Esther took the muscle relaxer but it made her very dizzy so she stopped taking it. The Naprosyn did not seem to help so she called her primary care doctor back the next day. At that point, her primary care doctor prescribed tramadol and told her to rest. Tramadol helped the pain a little and the pain seemed to ease up over the next week.

For the last 2 weeks, she describes the pain as 5/10 on VAS on average. The pain is worse with standing, walking, and twisting. The pain is better with resting. She has not had any imaging studies. She has not been to physical therapy or a chiropractor. The pain woke her up from sleep for the first week but in the last 2 weeks she has not been waking up with the pain. She takes tramadol 3 times a day and feels that this helps her pain significantly. She has continued to take the Naprosyn 500 mg PO twice per day although she does not know if this is helping. She denies any change in bowel or bladder and has not noticed any gait problems other than the pain while walking.

Esther is generally in good medical health. She has a history of high blood pressure and high cholesterol that are both controlled with medication and diet. She has a history of bilateral total knee replacements 4 years ago and the knees have been doing well since then. She does not exercise on a regular basis but she does enjoy walking, doing chores around her house, and taking care of her eight grandchildren. She feels that she is generally a healthy and active person.

Physical Examination

On physical examination, Esther is 5′2″ and 120 lb. She has a cervical anterior carry and thoracic hyperkyphosis. She has a normal gait. With transitions from sit to stand and stand to sit, she has obvious pain in her lower back. She has full lumbar flexion but has pai n and restricted range of motion with lumbar extension and she has severe pain with right lumbar oblique extension and mild discomfort with left lumbar oblique extension.

Esther has very significant tenderness in the right lumbar paraspinals and in her right quadratus lumborum muscle in particular. Her right sacroiliac joint is tender. She has a negative straight leg raise bilaterally and negative slump test bilaterally.

Esther has 5/5 strength in her lower extremities bilaterally except 4+/5 bilateral hip abductor strength. She has intact sensation to light touch in her lower extremities. She has brisk and symmetric reflexes in her patella and Achilles. She has negative Babinski and Hoffman’s reflexes bilaterally.

Esther’s hips have restricted range of motion bilaterally but passive range of motion does not reproduce her pain. Her hip flexors and knee extensors are very tight to passive range of motion testing.

Assessment and Plan

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

Esther is in good gen eral health and has 3 weeks of right lower back pain. While she may have a number of different pathophysiologies, at the moment all signs point to acute lower back pain caused by a muscle strain likely superimposed on underlying degenerative changes. The tramadol seems to be helping her manage her symptoms. Esther’s symptoms improved initially but have been relatively stable over the last 2 weeks.

After a discussion of the different options, it is agreed that Esther will begin physical therapy to focus on passive modalities such as soft tissue mobilization, ultrasound, and electrical stimulation as well as stretching and strengthening exercises to specifically focus on lumbar stabilization exercises, hip abductor strengthening, and hip flexor and knee extensor stretching. It is explained to Esther that it is important to not just get this pain to go away, which will likely happen anyway with a little more time given the acute nature of it and the natural history of acute lower back pain in general. However, in addition to making the pain go away, it is important for Esther to also learn a set of exercises that will make it less likely that she has these kinds of problems in the future.

Esther understands and is excited about the plan. In addition, her Naprosyn is discontinued as she does not believe it is really helping her and instead she starts Duexis (800 mg ibuprofen/26.6 famotidine) TID and is also given a compound cream consisting of cyclobenzaprine and baclofen to help with the muscle spasms.

Follow-Up

Esther returns 4 weeks later and reports that her pain is about 50 % improved. She has continued to take the tramadol and Duexis as well as to use the compound muscle relaxer cream . She is going to physical therapy and particularly enjoys the soft tissue mobilization and ultrasound treatments. She does the exercises but says that she is not sure they are helping her. She does feel a little stronger and overall more stable on her feet than before.

Esther’s physical examination is similar to her previous examinations except that now she has less tenderness in her paraspinals and her quadratus lumborum is not particularly tender. Esther is pleased with her improvement and would like to continue with the current plan. Given her improvement, this seems reasonable and so she returns to physical therapy and is instructed to only take the Duexis and tramadol when she has the pain rather than just taking it around the clock at the scheduled intervals as she has been doing.

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