USMLE Forum Archives - USMLE Step 3 - Back Pain.
Back Pain.
drbipinsingh - 07-01-09 01:00
A 45-year-old male warehouse worker is evaluated for a back injury he experienced 4 months ago when lifting a heavy box; he has been bedridden intermittently since then. Today he is asking for a disability form to be completed so that he can be reassigned to a desk job. His back pain does not radiate and he has no lower-extremity weakness; however, he reports that both legs are completely numb. He takes over-the-counter NSAIDs but no prescription medications. He has no history of injection drug use and is otherwise healthy.
On physical examination, the temperature is normal, pulse rate is 74/min, and blood pressure is 126/82 mm Hg. The patient has exquisite diffuse lumbar and paraspinal tenderness to light palpation, with no areas of erythema or warmth; his spinal range of motion is decreased. Pressing downward on his head elicits lower back pain. Although he is able to passively extend his legs without pain when sitting down, he has back pain radiating down his right leg with a supine straight-leg-raising test. Lower-extremity motor strength is intact, and patellar and ankle reflexes are symmetric.
drbipinsingh - 07-01-09 01:00
A 45-year-old male warehouse worker is evaluated for a back injury he experienced 4 months ago when lifting a heavy box; he has been bedridden intermittently since then. Today he is asking for a disability form to be completed so that he can be reassigned to a desk job. His back pain does not radiate and he has no lower-extremity weakness; however, he reports that both legs are completely numb. He takes over-the-counter NSAIDs but no prescription medications. He has no history of injection drug use and is otherwise healthy.
On physical examination, the temperature is normal, pulse rate is 74/min, and blood pressure is 126/82 mm Hg. The patient has exquisite diffuse lumbar and paraspinal tenderness to light palpation, with no areas of erythema or warmth; his spinal range of motion is decreased. Pressing downward on his head elicits lower back pain. Although he is able to passively extend his legs without pain when sitting down, he has back pain radiating down his right leg with a supine straight-leg-raising test. Lower-extremity motor strength is intact, and patellar and ankle reflexes are symmetric.
The correct answer and explanation will be available after you answer.
Page 1
#3
Re: Back Pain.
drbipinsingh - 07-01-09 09:45 Use of Waddell's Signs
One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory.
Waddell's signs are:
1. Superficial tenderness – skin discomfort on light palpation.
2. Nonanatomic tenderness – tenderness crossing multiple anatomic boundaries.
3. Axial loading – eliciting pain when pressing down on the top of the patient’s head.
4. Pain on simulated rotation - rotating the shoulders and pelvis together should not be painful as it does not stretch the structures of the back.
5. Distracted straight leg raise - if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated (e.g. when checking the Babinski reflex).
6. Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.
7. Regional weakness - Weakness that is jerky, with intermittent resistance (such as cogwheeling, or catching). Organic weakness can be overpowered smoothly.
8. Overreaction - Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.
Page 1
