A 39-Year-Old Man With Debilitating Back Pain

Tami O. Tiamfook-Morgan, MD; Daniel M. Lindberg, MD


April 27, 2016

Physical Examination and Workup

On physical examination, the patient's temperature is 98.7°F, pulse is 75 beats/min, blood pressure is 138/69 mm Hg, and respiratory rate is 16 breaths/min. Head and neck examination findings are normal, and the lungs are clear to auscultation. Cardiac examination reveals normal S1 and S2 heart sounds, without any murmurs, rubs, or gallops. His abdomen is soft and nontender to palpation, and without any pulsatile masses. Rectal examination shows normal tone and brown, guaiac-negative stool.

Figure 1.

Figure 2.

Mild tenderness to palpation is noted in the midline lower back, at the T11-L1 levels. No significant pain is produced by flexion of the leg at the hip. The patient has normal strength and sensation in both lower extremities, and no sensory level is noted. Normal reflexes are noted in his upper and lower extremities. His gait is antalgic but without ataxia.

An anteroposterior lumbar radiograph (Figure 1) is obtained and, on the basis of the interpretation of the plain film, MRI of the spine (Figure 2) is obtained.


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