NURS 6512 Discussion: Assessing Musculoskeletal Pain Discussion Paper
Patient Information.
The patient is a 42-year-old male who reports to the health facility.
Chief complaint.
The man complains of lower back pain that he has been experiencing for the past one month.
History of Presenting Illness
A forty-two-year-old male patient was well until about a month ago when he started experiencing lower back pain. He describes the pain as being located in his lower back region, a problem that began about a month ago and radiating to his left leg. It would be important to describe the character of the pain. Knowing whether it is a pounding, stabbing or sharp pain goes a long way in establishing a diagnosis.
The timing of the pain would also be important. It is worse during the day, at night or after completion of certain task. It would be important to highlight any exacerbating and relieving factors of the pain. Asking the pain to gauge the severity of his pain in accordance to the pain scale numbered one to ten would also be important to note while taking the history of the patient.
It is vital to look out for other associated symptoms commonly accompanying lower back pain. Weakness, numbness or any tingling sensation in the legs is important to note. It is vital that the patient points out the specific regions, if any, where he is experiencing weakness, numbness or a tingling sensation (Hartvigsen et al., 2018). Any associated fever along with the back pain would be critical to note as it would be an indicator of an infection. Problems controlling bowel and bladder movements are other commonly associated symptoms of lower back pain that are important to ask about and note.
Nerve roots involved
A lumbar radiculopathy also referred to as sciatica occurs following involvement of the nerve roots responsible for formation of the sciatic nerve. The nerve roots exiting from the lower lumbar and upper sacral regions involve L4, L5, S1, S2 and S3 (Berthelot et al., 2018). Lower back pain is usually the commonest presentation of a lumbar radiculopathy. The pain is often radiating to the back of the leg with sciatica commonly affecting one side of the body.
Testing for the nerve roots
To test for the L4 nerve roots, one would test the loss of sensation in the dermatome supplied by L4. This includes the area around the thigh, knee, leg and foot anteromedially. It is important to also conduct the straight leg raise test, the femoral nerve stretch test, the knee reflex and to test the power of the muscle involved in ankle dorsiflexion to test for the credibility of the L4 nerve root.
The test for the L5 nerve root involves testing for the presence or absence of sensory sensation in the dermatome area supplied by L5. This area includes the buttocks, posterior and lateral aspects of the thigh, lateral part of the leg, dorsum of the foot, medial half of the sole including the first, second and third toes. It would also be advisable to conduct the straight leg raise test and test for the power of the muscle on hip abduction, dorsiflexion at the ankle, ankle eversion and extension of the big toe.
Testing for the S1 nerve roots involves testing for sensory loss in the dermatome area supplied by S1 (Tampin et al, 2020).. This includes the area around the lateral aspect of the foot, the heel and majority of the area of the sole. It would be important to carry out the straight leg raise test, ankle reflex and test for power of muscles involved in extension of the hip, knee flexion, plantarflexion at the ankle joint and ankle eversion.
Testing for dermatomes is usually done using a pin and cotton wool. The patient is asked to close their eyes and give response after stimulation by various stimuli. Dermatome testing should be conducted on specific dermatomes and the results compared with the opposite side. The pin prick test involves gently pricking the patient with a pin and asking for the patient’s feedback whether it is a sharp or a blunt pain. Light touch sensation test involves rubbing a piece of cotton wool against a specific area on the skin.
The straight leg raise test is a neurodynamic test conducted to asses mechanical movement of the neurological tissues and their sensitivity to mechanical stress (Parashkevova et al., 2019). Testing is conducted on both lower limbs with the normal limb being assessed first. Patient lies in a supine position with the hip medially rotated and the knee extended. The physician then elevates the patient’s limb by the posterior ankle with the knee maintained in full extension continuously until the patient complains of discomfort at the back or posterior surface of the leg.
The femoral nerve stretch test is a test used to asses the sensitivity to stretch of the soft tissue located at the dorsal aspect of the leg. The patient is asked to lie down while the physician lies on the affected side to stabilize the pelvis and hinder any anterior rotation using one hand. The physician then proceeds to extend the hip while maintaining the knee at flexion. The physician can encompass a few alterations to the test position to be able to pick out the nerve involved.
Differential Diagnosis
Some of the causes of lower back pain include: sciatica, lumbar herniated disc, piriformis syndrome and arachnoiditis (Thompson et al., 2020). Sciatica often arises from a herniated disc. This results in compression of the nerve roots of the sciatic nerves that runs from the lower back down to the lower limbs. Patients will normally present with lower back pain that is normally radiating to the back of the leg. A burning sensation, muscle weakness and bladder and bowel incontinence are among other presentations.
A lumbar herniated disc is a ruptured disc at the lower back normally arising as a result of a tear resulting in consequent pushing out of the nucleus out of the spinal disc. The protruding disc pushes against a spinal nerve resulting in severe pain, numbness and in some instances weakness. The pain is exacerbated by standing, coughing or sneezing and there is consequent reduction of reflexes at the knee and ankle joint.
Piriformis syndrome results from compression of the sciatic nerve by the piriformis muscle. It results in associated pain radiating to the lower leg, tingling and numbness in the gluteal region. Arachnoiditis, an inflammation of the arachnoid covering the spinal cord nerves, can also result in lower back pain radiating to the legs as the commonly affected nerves are in that region.
The Agency of Healthcare and Research and Quality lists back pain as a common occurrence affecting eight out of every ten individuals. It further goes to highlight that back pain can range from a dull, constant ache to a sudden, sharp pain (Herman et al., 2019). Acute back pain lasts a few days to weeks becoming chronic if it persists for a duration longer than three months. Over the counter medication and adequate rest are the remedies for most back pain with medical attention required if back pain persists.
Physical Exam.
Any physical exam begins with inspection. It is important to note the shape of the spine. Appreciate the normal curvature of the spine. The absence of lumbar lordosis is commonly associated with lower back pain. Palpation is the next step. Palpating the spinal region to elicit any tenderness helps to prove or rule out pain from the vertebra. Palpation of the para-spinal region to elicit tenderness proves muscle involvement. The next step is to conduct specialized tests.
Special manoeuvres.
Provocative tests are done to elicit any tenderness and pain. If these tests are positive, there is likelihood that the irritation on the nerve is as a result of mechanical interference resulting from a vertebral bone or herniated disc. Some of the special manoeuvres include the straight leg raise test, the tripod sign and femoral stretch test. Neurological exam including motor, sensory and reflex exam can also be done. The major nerve roots examined are L4, L5 and S1 as they are the commonly affected nerve roots.
References
- Berthelot, J. M., Laredo, J. D., Darrieutort-Laffite, C., & Maugars, Y. (2018). Stretching of roots contributes to the pathophysiology of radiculopathies. Joint Bone Spine, 85(1), 41-45. https://doi.org/10.1016/j.jbspin.2017.01.004
- Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., & Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356-2367. https://doi.org/10.1016/s0140-6736(18)30480-x
- Herman, P. M., Broten, N., Lavelle, T. A., Sorbero, M. E., & Coulter, I. D. (2019). Health care costs and opioid use associated with high-impact chronic spinal pain in the United States. Spine, 44(16), 1154-1161. https://doi.org/10.1097/brs.0000000000003033
- Parashkevova, P., Deleva, R., Mincheva, P., & Andreev, A. (2019). A Study on Use of Neurodynamic Tests among Neurorehabilitation Professionals. Journal of IMAB–Annual Proceeding Scientific Papers, 25(1), 2438-2442. http://dx.doi.org/10.5272/jimab.2019251.2438
- Tampin, B., Slater, H., Jacques, A., & Lind, C. R. (2020). Association of quantitative sensory testing parameters with clinical outcome in patients with lumbar radiculopathy undergoing microdiscectomy. European Journal of Pain, 24(7), 1377-1392. https://doi.org/10.1002/ejp.1586
- Thompson, J., Merrill, R. K., Qureshi, S. A., & Leven, D. M. (2020). Compression of the S1 Nerve Root by an Extradural Vascular Malformation: A Case Report and Discussion of Atypical Causes of Lumbar Radiculopathy. International Journal Of Spine Surgery, 14(1), 96-101. https://doi.org/10.14444/7013