Differential Diagnosis Low Back Pain Zach Bernard William Cummins Brandon Wilbanks

Differential DiagnosisLow Back Pain

Zach BernardWilliam Cummins

Brandon Wilbanks

History

• 74 year old Male

• Chief Complaint: Pt. Has been experiencing pain for sometime now time. His best guess is that it started in the last 6 months or so. There is no history of trauma. The pain is bilateral traveling from the back down both legs and into the feet. The pt. Describes it as pain that is diffuse. The patient has been experiencing leg fatigue, numbness and weakness lately. The patient says that they really notice the pain when they stand up or begin walking, but it is quickly relieved up sitting.

Exam Findings

• Decreased ROM of Lumbar spine

• Increased pain and paresthesia when perform Extension during ROM

• S.L.R. reproduces radicular pain

• Belt test is positive in both supported and unsupported

• Decrease in sensation and strength occur upon walking

• Severely decreased mobility and flexibility of the spine

Imaging

• Plain Film X-ray: Lumbar A-P, Lateral, and Lumbosacral spot.

• Show signs of degeneration of the disk and facets.

• CT Scan

• Shows hypertrophy of the lamina, pedicles and apophyseal joints, along with a thickened ligamentum flavum. Giving it the classic cloverleaf or trefoil appearance.

• MRI

• Also allows for visualization of the trefoil appearance and is currently the preferred method of diagnostic imaging for this condition.

Differentials

• Lumbar Spinal Stenosis

• Cauda Equina Sydrome

• Centrally Herniated Discs

• Trauma

• Degenerative Spondylolisthesis

• Metastatic Disease

History

• 55 year old Black Male, 6’2’’ and a smoker

• Chief Complaint: Pt. Has been experiencing pain for the last couple of months. There is no history of trauma and patient can not explain why his back would hur. Pain stays in his low back. The patient says that nothing relieves his pain. Patients diet is high in meat and animal fat with low vegetable intake. Patient has reported having trouble urinating. A slower stream when urinating and dribbling after. Recently lost about 10 lbs with no change in diet. Also reports feeling fatigues and sick randomly.

Exam Findings

• Lumbar ROM normal

• Ortho test unable to illicit classical response

• All neruo test WNL

• Unable to elicit or elivate pain throughout exam

Imaging

• Plain Film X-ray: Lumbar A-P, Lateral, and Lumbosacral spot.

• Small amount of Degeneration.

• CT Scan

• Lumbar Area Unremarkable

• MRI

• Lumbar Area Unremarkable

Lab Tests

• CBC- Normal with slight anemia

• PSA levels are elevated > than 4 ng/ml

• EPCA-2 levels are elevated as well.

Differentials

• Prostate Cancer

• Benign Prostatic Hypertrophy

• Metastatic Disease

• Bladder Cancer

• U.T.I.

Lumbar Degenerative Disc Disease

History

How it presentsSymptomsProvocativePalliative

Examination

NeurologicalPhysicalLaboratory

Imaging

RadiographyNuclear (Bone Scan)Computerized Tomography (CT)Magnetic Resonance (MR)

Differentials

Muscle strainLigament/tendon injurySacroiliac joint syndromeLower lumbar zygapophyseal joint syndromeHip joint painCompression fractureStress reactionStress fractureSpondylolysisSpondyloarthropathyMarfan syndromeFibromyalgiaMyofascial pain syndromeDiskitisNeoplastic disease

Facet Syndrome

History

How it presentsSymptomsExamination

Imaging

RadiographyNuclear (Bone Scan)Computerized Tomography (CT)Magnetic Resonance (MR)

Differentials

Lumbosacral disc injuriesLumbosacral discogenic pain syndromeLumbosacral radiculopathyLumbosacral spine acute bony injuriesLumbosacral sprain/strain injuriesLumbosacral spondylolisthesisLumbosacral spondylolysisPiriformis syndromeSacroiliac joint injury

History

• 26 year old male 5’8” 165 lbs

• Chief Complain: Low back pain with varying intensity. Occurs mostly at night and in the morning. It usually gets better as the day goes by and as he starts to move around. It gets worse with rest. Occasionally develops low back muscle spasms. Also flexing forward eases the pain and the spasms. This has been going on for 6 months. Has experienced an occasional low grade fever and is generally fatigued. Has a loss of appetite and has loss 5lbs in the last month with out trying to lose weight.

Exam Findings

• Paraspinal muscle pain and tenderness

• Decreased ROM in lumbar and thoracic regions

• Decreased Chest expansion

• Increased thoracic kyphosis and Decreased lumbar lordosis

• low grade fever

• SLR is negative

• Lewis Gainsleins is negative

• Belt test is negative

• Amos’s sign is positive

Exam cont.

• Forester’s Bowstring sign is positive

• Lewin’s supine is positve

• Neurology tests are within normal limits

• Pt. cannot lie flat on the table

Lab Tests

• CBC-normal

• ESR-normal

• RA factor-negative

• HLA-B27-positive

• C-reactive Protien-negative

Imaging

• X-Rays performed. Lumbar AP lateral and Spot views, Thoracic A-P and Lateral

• Findings: No signs of Lumbar DDD or Thoracic DDD. Bilateral Mild sclerosis and lateral narrowing of Sacroilliac joint space. Squaring of L1 and L2 vertebrea.

• Is CT or MRI necessary?

Differentials

• Lumbar Disc Degenerative Disease

• Infection

• Tuberculous spondylitis

• Psoriatic arthritis

• Osteoarthritis

• Ankylosis spondylitis

History

• Black Male 55 years old 6’0” tall 160 lbs.

• BP 130/85 HR 70/min Resp 12/min

• Chief Complaint: Pt. has been experiencing low back pain for 3 months. He is always tired and has almost no appetite. He has lost 20 lbs in the last 3 months with no dieting. The pain is persistent especially at night and when resting. There is no history of trauma. The pain came on gradually and is unexplained. The pt. has been having to go the restroom more frequently. Pt. is also complaining of waking up at night with numbness in the hands, wrist and forearms bilaterally. Pt. also has had 3 cases of pneumonia in the last 2 years and one case of pyelonephritis 4 months ago.

Exam Findings

• Hepatomegaly

• Cachexia

• Muscle weakness 3/5 wrist extensors bilaterally 4/5 leg extension bilaterally

• Phalens test is positive

• Tinels (wrist) is positive

• Foraments cone test negative

Imaging

• Plain Film X-ray: Lumbar A-P Lateral and Lumbosacral spot, Cervical Lateral A-P lower and A-P open mouth views.

• Findings: Generalized osteoporosis, cortical thinning of the lumbar spine, L3 vertebra planna sign present. Multiple round well circumbscribed lesions of the skull are present.

Lab Tests

• CBC-Normocytic Normochromic Anemia with Rouleau, Thrombocytopenia,

• BUN Serium Creatine and Serum Uric Acid are elevated

• Hypercalemia

• Reversed A/G Ratio

• Urinary Analysis: Bence Jones Proteins, Hyperuricemia, Amyloidosis

• Bone Marrow Aspiration- Plasma cell Conc. >10 %

Differentials

• Metastis

• Lymphoma

• Multiple Myeloma

• Amyloidosis

• Plasma Cell Leukemia

• Waldenstrom macroglobuilinemia

• Carpal Tunnel Syndrome