Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 40-year-old computer programmer presents for a sick visit with the chief complaint of a 2-day history of low back pain. He reports the pain started after a many hours stretch of doing yard work. The pain is described as a dull, constant ache, worse with activity, better with rest, across his lower back without radiation to the legs.
He denies leg weakness, tingling or numbness in state. He's had similar pain in the past after doing extensive lifting. In considering the diagnosis of lumbar sacral strain, which of the following would most likely be noted on clinical assessment of this patient?
A: Diminished to absent lower extremity DTRs.
B: Patient report of new-onset difficulty with voiding.
C: Paraspinal muscle tenderness.
D: Positive straight leg raise test.
The correct answer is C: Paraspinal muscle tenderness. Where should we start with this question? First, determine what kind of question this is. This is an assessment question where we've been given the possible diagnosis and now need to correlate it with likely clinical findings. First, a bit of background information: the majority of adults, somewhere in the vicinity of 80% plus, will have low back pain at some time.
And nearly all of these, the pain is short-lived and will resolve without specific therapy within a month. In fact, we might think we see a lot of people in our practices with low back pain, but most people with it will self-treat and it goes away in a few weeks. We are never aware they ever had it. The diagnosis in most of these cases is lumbar sacral strain, which is what we have in this patient.
This diagnosis is actually pretty self-defining, where it's saying that the muscles and ligaments of the lumbar sacral region have been overworked or excessively taxed. On occasion, you will get a history like we do here of some marked increase in activity, particularly unfamiliar work. And that's what the patient has recently done with the yard work. We have a person who works as a computer programmer.
Likely a fairly sedentary line of work, and then did some of that, what is often referred to as unfamiliar work, and that he's also had pain like this in the past when he's done a lot of lifting. At the same time, cumulative micro-trauma, where there's not been a specific trigger event, as was reported here, is also quite common.
So, don't be surprised when you see somebody with lumbar sacral strain if they say, ‘I really don't know what the heck I did to trigger this.’ Then the next person comes in and says, ‘I know exactly what I did to trigger this.’ Risk factors for lumbar sacral strain include aging, as this is seen more in middle age and older adults than in younger adults, obesity. Maintaining a sedentary lifestyle is also a major risk factor.
The low back pain with lumbar signal strain is usually described as dull, aching feeling with no radiation beyond the LS region, and usually there is a report that the pain is worse with activity and better with rest, and a lot of times the patient will have a distinct position of comfort where they say, ‘Yeah, this is where I'm most comfortable.’ And what the patient will often tell you is, ‘I'm more comfortable lying on the floor than I am in a bed.’
So, you know, being on a hard surface is fairly comfortable. I've had patients tell me this on many occasions. Patients will also deny weakness, radiating pain, or other findings of more significant lumbar radiculopathy or other nerve root compression. Physical exam during lumbar sacral strain is notable for intact neurological function, tenderness when palpating the LS region, and often includes reduced LS range of motion.
The key part of lumbar sacral strain diagnosis is to ensure there are no red flags that could be missed, and those would be signs or symptoms of significant pathology such as lumbar radiculopathy. I'll discuss some of the issues with lumbar radiculopathy as well as intervention in lumbar sacral strain in additional podcasts.
With this information in mind, let's revisit the question and the options we've been given. A 40-year-old computer programmer presents for a sick visit with a chief complaint of a 2-day history of low back pain. He reports the pain started after a many hours stretch of doing yard work. The pain is described as a dull, constant ache, worse with activity, better with rest, across the lower back but without radiation to the legs.
He denies leg weakness, tingling or numbness and states he's had similar pain in the past after doing extensive lifting. In consideration of the diagnosis of lumbar sacral strain, which of the following would most likely be noted on clinical assessment of this patient? A: Diminished to absent lower extremity DTRs. This is incorrect given there is no nerve root compression in lumbar sacral strain, there should not be any abnormalities on the neurological exam.
Any abnormal neuro findings should trigger the diagnosis of lumbar radiculopathy or at least an investigation of that diagnosis or some other pathology that involves nerve root compression. B: Patient report of new-onset difficulty with voiding. A patient record of new-onset bladder dysfunction should trigger a serious neurological cause such as cauda equina syndrome.
As mentioned, the neuro exam should be normal during lumbar sacral strain. C: Paraspinal muscle tenderness. This is, of course, the correct answer. LS strain is characterized by intact neuro function with a normal neurological exam, but the presence of discomfort with palpation in the lumbar sacral region. D: Positive straight leg raise test. The finding of a positive straight leg raise test should again trigger a thought that there is nerve root compression consistent with lumbar radiculopathy rather than lumbar sacral strain. Option D is also incorrect.
Key takeaway: I've said this many times in these podcasts, but I'm just going to say it again. Common diseases occur commonly. In this scenario, we have a patient presenting with lumbar sacral strain, the most common reason for low back pain seen in the healthcare system. There are no red flags. He has a normal neuro exam and what we have to do is say, ‘Yes, here we have one more time, one of the most common of diseases presenting.’ This is key to clinical practice as well as NP board success.
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