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 Dr. 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 55-year-old man with a BMI of 40 presents with the chief complaint of low back pain for the past 2 weeks. He describes the pain as originating in the lumbar sacral region, with radiation across the left buttock associated with numbness and tingling sensation in his left leg. The pain is worse with sitting and somewhat better with standing.
He denies lower extremity weakness or a change in bowel or bladder function. He states, “I've tried ice, heat, and ibuprofen and these just take the edge off. I've had back pain like this in the past. Usually just lasts a couple of days and it's not that bad.” This history of present illness is most consistent with:
A: Lumbar radiculopathy.
B: The spinal stenosis.
C: Vertebral fracture.
D: Lumbar sacral strain.
The correct answer is A: Lumbar radiculopathy. Where should you start? First, determine what kind of a question this is. We've been given the patient's HPI and then asked what that could represent, this is actually a differential diagnosis question.
As was mentioned in previous Q&A podcast, occasional lumbar-try that again-as was mentioned in previous Q&A podcast, occasional low back pain is nearly universal in adults, while in most this condition is self-limiting and resolves in a few days. For a few, it will persist. Indeed, this patient states he's had back pain in the past that lasted a few days with less discomfort and then self-resolves.
However, now please note this patient has had 2 weeks of back pain with some concerning features suggestive of lumbar radiculopathy. Lumbar radiculopathy is caused by a compression or irritation of the root of the lumbar sacral region of the spine, and LS disc herniation is the most common cause, usually occurring after years of episodes of back pain caused by repeated damage to the annular fibers of the disc.
Risk factors for this condition include smoking, i.e. tobacco use, diabetes, overweight or obesity, male birth gender assignment, and age greater than 45 years. He has three of these risk factors for this condition: male, age, and obesity.
Lumbar disc herniation often leads to sciatica and neurological changes, as well as significant distress, as we have here. The most common sites for a lumbar sacral disc herniation are L4 to L5 and L5 to S1. And that's important to know because the resulting changes in the neuro exam are reflective of pathology in those regions.
Maneuvers like sneezing will usually result in an acute worsening of pain. Though often we'll hear of people with lumbar radiculopathy if they cause cough or sneeze, they get almost like an electric shock type of a sensation coming from their back, going over the buttock and sometimes down to the leg. Numbness or tingling in the lower extremities, usually, only present in one leg is usually reported.
In a future podcast, I'll cover the specific physical exam findings and treatment for lumbar radiculopathy. With this information in mind, let's take a look at the question and the answer choices. A 55-year-old man with a BMI of 40 presents with the chief complaint of low back pain for the past 2 weeks. He describes the pain as originating from the LS region, with radiation across the left buttock associated with numbness and tingling sensation in the left leg.
The pain is worse with sitting and somewhat better with standing. He denies lower extremity weakness or change in bowel or bladder function. He states, “I've tried ice, heat, and ibuprofen and these just take the edge off. I've had back pain in the past. It usually lasts a few days and it's not this bad.” This history of present illness is consistent with:
A: Lumbar radiculopathy. Again, this is of course the correct answer. Please note he has those multiple risk factors. As I just said, the other part of this that's key is he's had limited response to treatment that's usually helpful for a lumbar sacral strain. And this includes things like heat, ice, and NSAIDs.
The other part is lumbar sacral strain often, even without a lot of intervention, self-resolves in a number of days or maybe a week. He's been really uncomfortable all by his report for 2 weeks now. So, those are all things that should key us towards thinking of lumbar radiculopathy. I know you want the physical exam as well. So do I. At the same time, we have to remember that the clinical assessment starts with the health history and that something like 85 to 90% of the time, what we hear in the HPI will be what leads us to the final diagnosis.
B: Spinal stenosis. This is incorrect. While this condition is most often noted in adults greater than age 50, there are a few features of spinal stenosis that differ from lumbar radiculopathy. In spinal stenosis the pain is usually bilateral, and there is either an actual or perception of leg weakness that is also bilateral. Interestingly, in spinal stenosis there is commonly a report of, when standing and leaning forward, the pain is significantly less.
C: Vertebral fracture. We have a middle-aged man here without any notation of trauma given. Men, of course, due to greater bone density when compared to women, vertebral fractures and the absence of a history of recent significant trauma, it's actually quite uncommon. At the same time, the pain with vertebral fracture can be quite significant as well as radiating.
But in vertebral fracture, usually the patient will report to you there's no real position of comfort. D, this is also incorrect. The numbness and worsening of pain with cough or sneeze is not typical with the lumbar sacral strain. In addition, most episodes of LS strain resolve within days, and he's had pain for 2 weeks. Ice, heat, and NSAIDs are usually helpful in LS strain, whereas in this case this is not helping.
Key takeaway: the reasons for low back pain are in fact numerous. At the same time, learning the particulars of the risk factors in clinical presentation of the more common causes of low back pain will help hone your differential diagnosis skills, and this is critical to safe practice and NP board success.
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