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Tip of the Iceberg
Acute Low Back Pain
Treatment plans are determined by the diagnosis. What if the diagnosis is off the mark? Is it possible that not delving deep into the patient’s history is to blame for an incorrect diagnosis?
An in-depth patient history will guide the doctor down a path of additional questions until a differential diagnosis is reached which is validated with exam findings, imaging, or other diagnostic tests. But what happens when only the tip of the iceberg regarding the patient’s history is considered? Here is what can happen.
A 50-year-old female, who injured her low back from simply bending over, presents to her doctor with acute low back pain that is constant and rated 6-7/10. No radiating symptoms, no trauma, no prior back pain history, and she is very physically active. The patient’s pain severity is not consistent with her mechanism of injury and therefore the doctor suggests that the patient’s symptoms are in her head. The doctor may have reasoned that since the injury was from simply bending over, how bad could the injury be? Can’t be more than just a muscle strain. So the patient’s symptoms are exaggerated.
3 weeks after the onset, this patient presents to my office. The patient is skeptical about “the pain is in your head” diagnosis. The history reveals that stretching and general movements increase pain and she stopped all her exercising, which typically includes; yoga, rowing, and hiking totaling about 4-5 days a week. For someone this fit and active, how can bending over cause such a disabling and painful injury?
I observed how the patient moved during the history and she demonstrated some of her exercises, stretches and yoga posses. She frequently moved with lumbar flexion. The exam revealed that her hip socket architecture causes significant lumbar disc loading with lumbar flexion, like certain yoga posses or forward bending. Further stress testing reveals that lumbar flexion, extension, right > left rotation and compression increased her low back pain. None of these tests cause radiating symptoms. Palpation of the L4 and L5 spinous process produced significant tenderness, not present at other spinal segments or the sacrum. Prone traction, slight lumbar extension (lifting the knees of the exam table) and slight right lateral deviation eliminated all her symptoms – from 6-7/10 to 0/10 pain! But when standing her symptoms returned.
Mechanical loading of the L4/L5 and L5/S1 disc are the cause of her low back pain. I demonstrated which movements, positions and loads increased and decreased her symptoms. This patient has a 2 level disc injury, not a psychological condition. The back injury was sustained after a forward bending maneuver, but her hip architecture, yoga practice and incorrect lumbar movements, conspired to create lumbar hypermobility at 2 spinal levels and eventually pain. Without an in depth history and knowledge of back mechanics and movement dynamics the patient’s pain sources would have been missed.
The diagnosis will drive the treatment plan and the diagnosis is dependent on a complete history and examination. Doing a tip of the iceberg history may lead to a missed diagnosis, incorrect treatment plan and unnecessary patient suffering.
