A 73-year-old woman presents with a 6-month history of deteriorating gait and low back discomfort, exacerbated by walking. Examination is unremarkable except for hypo-active muscle stretch reflexes in the legs. X-rays of the lumbosacral area shows the expected degenerative changes associated with a woman of her age.
The most likely diagnosis is:
Correct Answer B: Lumbar spinal stenosis (LSS) is narrowing of the lumbar spinal canal, which produces pressure on the sciatic nerve roots (or sometimes the cord) before their exit from the foramina, causing positional back pain and symptoms of nerve root compression. LSS produces pain in the buttocks, thighs, or calves on walking, running, or even standing.
Which one of the following is consistent with spinal stenosis but not herniated vertebral disk?
Correct Answer C: Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be present in both. Pain in spinal stenosis is relieved by sitting and aggravated by standing. Pain from a herniated disk is aggravated by sitting and relieved by standing.
A 72 year old white male with known coronary artery disease complains of pain in his back and legs which is increased by standing and walking and relieved by sitting. On examination, deep tendon reflexes in his legs are 0 to 1+ bilaterally. He has mild muscle weakness of his quadriceps and 1+ pedal pulses. He is taking ibuprofen, 800 mg three times a day, and using a back brace without much relief.
Which one of the following would be most likely to relieve his symptoms?
Correct Answer D: This patient’s symptoms are typical of spinal stenosis, as they are present when he is standing and relieved by sitting. He has already failed a trial of NSAIDs and bracing. Spinal decompression surgery is now indicated. Epidural corticosteroid injection might be helpful, but not trigger-point injections. Oral corticosteroids would be helpful if he had a herniated disc. Sympathectomy and bypass surgery are treatments for vascular occlusion.
A 65-year-old male presents to your office with the complaint of a gradual onset of bilateral lower back pain that radiates to his buttocks, thighs, and lower legs. He states that the pain is worse during walking and standing and is alleviated by sitting.
This patient is most likely suffering from:
Correct Answer E: The differential diagnosis of lower back pain (LBP) for patients more than 50 years of age is substantially different from the most likely etiologies of LBP in younger patients. The history, rather than radiologic or laboratory evaluation, is usually the key to diagnosis. This elderly patient’s complaints fit the classic example of LBP caused by spinal stenosis. If the pain improved with standing, disc herniation should be considered. In a much younger male patient, ankylosing spondylitis would be a rare but possible cause of the pain. Muscle strain is very common, but usually causes pain that remains localized to the lower back area. Spondylolisthesis is also a very common radiologic finding that can cause LBP, but would not present with the pain pattern described.
Management of an open fracture should always include each of the following, except:
Correct Answer E: Open fractures predispose to bone infection, which can be intractable. Suspected open fractures require sterile wound dressings, tetanus prophylaxis, and broad-spectrum IV antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside).
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