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Rock Street, San Francisco

Acute low back pain in
quality inspector

Patient history

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Male patient, 32,
Indian, presented to first aid room in residence camp with severe low back pain
of rapid sudden onset, around 6 hours ago, sharp but tolerable at onset with
gradual progress into intolerable by noon, which drove patient to seek medical
attention. No specific factors provoked pain or triggered onset. Patient cannot
recall factors alleviating or worsening pain. Pain in lumbosacral area without
strict localization is constant and sharp, irradiates into thighs bilaterally.
Walking and sitting are painful, with grimace, gait is slow, painful.

NSAID injection
offered in first aid room and patient transferred for neurologist assessment.

No previous history
of backache; denies recent back injury. General medical history unremarkable.

Family history:
unremarkable.  

Non-smoker, denies
alcohol consumption.

Occupational
history:

Current position:
quality welding inspector, 4 years of employment. Routine requires frequent
climbing ladders to/from excavations, squatting (occasional, not repetitive),
walking long distances (few kilometres per day), but rather occasionally, prolonged
sitting in vehicle travelling between inspection points. No manual handling,
lifting, pulling or pushing of weights are required. Spends 1-2 hours a day at
table in office for reporting and image interpretation. Normal work shift is 10
hours, 6 days a week. No major changes to routine reported within last months. Work
load is of moderate psychological demand with strict time frames of work
completion, requiring reasonable self-pacing. Accuracy and precision of test
interpretation are mandatory. 

For the last year
patient lives in residential camp. He denies hobbies after business, preferring
sedentary life.   

Clinical examination

Alert, completely
oriented, lying on couch because of severe lumbosacral pain. Notable hyperesthesia,
does not allow touching any area of skin, screaming of pain at light touch. Back
pain irradiates to anterior aspects of both thighs. Allowed examination after IM
injected NSAID.     

Weigh 92kg

Height 168cm

BMI32.6

HEENT – unremarkable

Pulse 78BPM

BP 121/75mmHg

SpO2 98% room air

T36.4°C

No respiratory
distress. System examination – unremarkable.

Back examination –
unremarkable except superficial dermal hypersensitivity in lumbar, sacral and
gluteal areas.

Neurological
examination – unremarkable, reflexes normal, muscular strength 5/5, no sensory-motor
deficit.

Positive straight leg
raising test, no signs of cauda equina syndrome, or bladder dysfunctions.

Schober test: flexion
<5cm on pain. Forward flexion: painful, can reach knee level with fingers. Lateral flexion: can reach knee with fingers (painful). Rotation seated on couch: painful, limited. Investigations and results FBS 119 mg/dl CBC – normal WBC 10.74x103/µl RBC 5.27x106/µl HGB 15.5 g/dl ESR 5 mm/HR CRP 3.2mg/l Thyroid, renal and liver functions – normal Lumbosacral AP x-ray – unremarkable Lumbosacral MRI imaging (neurologist order) – normal Patient admitted for inpatient management of pain. Diagnosis and treatment No red flags identified to suspect serious alternative diagnosis. Possible contributing risk factors: obesity, static posture and vibration on rough terrain (while riding vehicles). Waddell signs: superficial non-anatomical tenderness, overreaction to examination – possible non-organic component of pain present. No organic changes on MRI and x-ray images (to rule out lateral disc protrusion), WBC 10.74x103/µl – possible inflammatory irritation of nerve.  Admission Dx: Radiculopathy. Discharge Dx (neurologist): Back pain. Radiculopathy. In-hospital treatment: neurologist assessment, pain control: Ketorolac 30mg IM, Blokium-B12 (Diclofenac 75mg + Hydroxicobalamine 10mg + Betamethasone 3mg) IM OD. Neurologist prescription on discharge: Blokium-B12 IM OD 3 days Tizanidine (Sirdalud) 2mg t.i.d. 2 weeks Arcoxia 90mg OD 2 weeks Nexium 20mg OD   7 days bed rest on discharge Case management, occupational health management and prevention Patient consented for communications between hospital and in-house OH service, and OH service and employer. After inpatient treatment employee was discharged with 7 days bed rest. OH service re-assessed functional capability after sick-leave. Fitness evaluated against OGUK Standards. Employee satisfied requirements of Sections 2-11 Musculoskeletal Conditions and 2-22 Medications of OGUK Guidelines.       Employee resumed to duties with OH recommendations: -       Return to work and remain active. -       Modification of daily activities: shorter work time with gradual return to normal schedule and activities, "avoid painful arcs of motion, and tasks that exacerbate back pain" (7) – climbing ladders, awkward postures, quick abrupt body movements.   -       Self-management plan and education on condition, encourage participation in treatment. Supervised exercise program. -       Weight loss advice. Fitness validity was not withdrawn. OH service considered factors that could influence return to work: -       Young age and general good health prior to acute illness – facilitate recovery. Previous fitness examination (11 months prior): elevated liver panel (<2-time fold) ALT, AST, GGT. Triglycerides 5.6mmol/l, serum cholesterol 5.6mmol/l. Medical fitness certificate issued for 2 years. -       BMI31=obesity Class I may affect treatment response. -       Early diagnosis and treatment should facilitate good treatment response. -       STarT Back Screening Tool: Total score=5, sub-score=3: medium risk of long term disability. More intensive intervention and support is required. -       Yellow flags: patient strongly believes and expects passive treatment would benefit more than active participation, inappropriate avoidance of active life, pain fear. -       Employer in-house policy on return to work determined positive attitude and support from employer and OH service. Employer was advised on work place modifications required for treatment.  Education and information most important for prevention as no specific work place modification is required.        Follow up After 2 weeks outpatient treatment employee returned to specialist revision. Lumbosacral pain markedly alleviated and remains localized, come-and-go pattern, tolerable most of the time. As coping technique employee preferred longer lunch breaks lunch and shorter work hours. General Anxiety Disorder Assessment GAD7 score: 0/21 (anxiety – none). Patient Health Questionnaire PHQ9 scored 1/27 (depression – none). Movement range: can reach mid-calf with fingers. No other movement restrictions. Taking into account medium risk of disability development and yellow flags neurologist referred patient for 6 sessions supervised group exercise program in Sports Injury Center. Arcoxia and Nexium course continued for another 2 weeks. 2 months follow-up: STarT Tool re-evaluation – total score and sub-score=1. Yellow flags blurred. Patient admitted positive effect of group and self-paced exercises. No days away from work reported. Patient still preferred self-paced longer mid-day breaks and shorter work time because of low levels of pain on some days. NSAID (Ibuprofen 400 mg) prescribed when needed for pain.   4 months follow-up: patient reported complete recovery, no symptoms of low back pain. Full range of movements. No further treatment and follow-up visits required. Importance of staying active emphasized. Employee returned to full duties.       Discussion Low back pain (LBP) is common condition. 60-80% of UK population, 90% of US population, and 50% of working population experience it at some time, peaking at age 35-55 year. 85-90% of LBP is simple or mechanical pain, nonspecific with no attribution to serious specific causes. Prolonged standing, awkward static posture, poor lifting technique, high physical job demand, repetitive movements bending are potential risk contributors, but role is poorly understood. Psychological factors can contribute to chronization and poorer outcome of treatment. In majority of cases LBP is self-limiting and recovery is expected 90% within 6 weeks. Comprehensive history with flags and physical exam allow to identify patients with serious conditions. Pain referred from other regional organs should be considered. Diagnostic triage helps to exclude alternative diagnosis: infection, injury and other specific causes. Patient risk assessment and stratification with psychological assessment (yellow flags) should be done at early contacts with health services (STarT tool). More complex care and intensive support should be considered for patients with increased risk of chronic LBP development. Imaging for simple LBP has limited application and should be performed in specialist care setting. Plain x-ray has low diagnostic yield for LBP and rarely needed for initial evaluation. MRI and CT-study could be considered in patients with progressive neurologic deficit and systemic symptoms to rule out underlying cause.     Clinical findings determine laboratory works to differentiate infection and malignancy. Patients should understand nature and ethology of pain and receive adequate reassurance, education and information to stimulate patient to maintain active life, early return to work and normal daily activities. Role of active participation in treatment and self-management should be emphasised. Patients with moderate risk should receive multidisciplinary approach to minimize long term disability, absenteeism and employment loss. Cognitive behavioural therapies, manual therapies and supervised group exercise programs benefit to overcome obstacles for recovery. Prolonged bed rest must be avoided. 2-3 days of bed rest in supine position could be offered for acute radiculopathy. Instead, activity modification is preferred to "avoid painful arcs of motion and tasks that exacerbate back pain".     Referral to physical therapy, manipulation and multidisciplinary treatment should be considered as early as 1-2 weeks(10), and offered if patient does not return to work within 6 weeks(12). NSAID at lowest effective dose should be prescribed for pain relief for the shortest reasonable time, reserving weak opioids for cases not controlled by NSAID and rescue analgesia. Opioids should be avoided for management of chronic LBP. Selective serotonin reuptake inhibitors, tricyclic antidepressants and anticonvulsants should be avoided in pharmacological management. Muscle relaxants could be considered for short course. Effectiveness of Vit B12 and steroids have not been confirmed. Thus, there is no place and role for cyanocobalamin and betamethasone in treatment of acute LBP. Paracetamol mono-therapy is ineffective and should not be prescribed. Patients, who do not improve, worsen or do not return to work within few weeks after onset and start of treatment should be reassessed and alternative reasons for LBP with alternative treatment to be considered. 

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