Health Assessment
Back Pain
Carnel C. Jackson, DNP, RN, FNP-BC
Case Study
Chief Complaint
“I’ve been stuck on my couch all week because of this terrible pain in my back and leg.”
Patient Profile
Name: Anthony “AJ” Jackson
Age: 45
Gender: male
History of Present Illness
“AJ” is a 45-year-old man who presents with acute low back pain after lifting a heavy object about one week ago. He denies trauma,* weakness, numbness, or bowel/bladder dysfunction. He reported trying over-the-counter lidocaine patches, ibuprofen, and diclofenac gel but they have been ineffective thus far.
Surgical History
Meniscectomy (at age 22)
Medications
- Ibuprofen: 600 mg one tablet by mouth every 8 hours as needed for pain
- Voltaren Gel: 2-4 g topically every 4 hours as needed for pain over the affected area
Social History
- Construction* (decks, drywall, millwork)
- Lives alone
- Alcohol use: Rarely (1-2x per year)
- Tobacco smoke: None
- Illicit drug use: None
Family History
- Mother: COPD, Hypertension
- Father: Prostate cancer at age 52 (alive), hyperlipidemia
Review of Systems
- Constitutional: Denies chills, fever, fatigue, weight gain and/or weight loss.
- HEENT: Denies postnasal drip and sore throat. Denies blurred vision.
- Respiratory: Denies shortness of breath, cough, wheezing.
- Cardiovascular: Denies chest pain and pedal edema.
- Gastrointestinal: Denies abdominal pain, tenderness. Denies constipation, nausea, diarrhea, melena, hematochezia.
- Derm: Denies breaks in the skin, lesions and rashes.
- Neurological: Denies headaches, dizziness, headaches, tremors. Denies bladder or bowel incontinence.* Denies falls.*
- Hematologic: Denies easy bruising.
- Musculoskeletal: Low back pain with radiation down the right hamstring.*
Physical Assessment
Vitals
- Blood pressure: 134/90
- Heart rate: 92 bpm
- Respirations: 18 bpm
- Temperature: 98.2°F
- Oxygen saturation: 100%
General Survey
- General appearance: Alert, oriented to person, place, and time.
- HEENT: Moist mucous membranes.
- Cardiovascular: Normal rhythm without murmurs; normal s1 and s2;
- Respirations: Clear to auscultation bilaterally.
- Abdomen: Active bowel sounds x4, nontender to palpation, no guarding.
- Derm: Without abrasion or ulceration; color is appropriate for ethnicity.
- Neurological: No focal deficits, no signs of confusion or cognitive impairment, monofilament not performed. Bilateral patellar, Achilles and plantar reflexes intact.*
- Extremities: Right leg weakness (3/5) with extension and reported pain with resistance.* Passive range of motion is normal in bilateral lower extremities.* Patient reported worsening pain with flexion and extension of the right hip. Straight leg test positive.*
Diagnostic Testing
MRI Lumbar Spine without contrast revealed L2-L5 disc herniation
Assessment
Most likely diagnosis: Lumbar radiculopathy secondary to intervertebral disc herniation.
Treatment Plan
- Orthopedic surgery referral
- Pain management: multimodal approach
- Consider work concerns: likely will need disability forms completed
Review Questions
Click the arrow to expand the section and view the correct answers.
- Which special test is most likely to be positive for Mr. Jackson?
- Straight leg raise test
- Babinski’s reflex
- McMurray test
- Empty can test
Answer
Straight leg raise test
Feedback: The straight leg raise test is used to assess/elicit a response in those with possible nerve irritation.
- Which nerve root is most commonly affected by lumbar radiculopathy?
- L1
- L2
- L4
- L5
Answer
L5
Feedback: The L5 and S1 nerve roots are most affected in lumbar radiculopathy due to the anatomical location and flexion/extension that occurs at the most distal spine.
- A patient presents with low back pain radiating the posterior leg to the foot. The pain worsens with sitting and improves when lying down. What is the most likely cause?
- Spinal stenosis
- Lumbar radiculopathy
- Hip osteoarthritis
- Piriformis syndrome
Answer
Lumbar radiculopathy
Feedback: Lumbar radiculopathy commonly presents with radiating pain, numbness, and weakness along a specific dermatome.
- In lumbar radiculopathy, which imaging modality is considered the gold standard for diagnosing nerve root compression?
- X-ray
- MRI
- CT scan
- EMG
Answer
B. MRI
Feedback: MRI provides detailed visualization of nerve root compression, disc herniation, and spinal stenosis.
- Which of the following are indications for urgent surgical referral in a patient with lumbar radiculopathy? (Select all that apply.)
- Progressive motor weakness
- Constipation
- Mild pain relieved with NSAIDs
- Saddle anesthesia
- Cauda equina syndrome suspicion
Answer
Progressive motor weakness, constipation, saddle anesthesia and cauda equina syndrome suspicion
Feedback: Progressive motor deficits, cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction), and severe unrelenting pain are indications for urgent surgical evaluation.
- Which of the following is the first-line conservative treatment for lumbar radiculopathy?
- Surgery
- Oral corticosteroids
- Physical therapy and NSAIDs
- Epidural steroid injections
Answer
Physical Therapy and NSAIDs
Feedback: NSAIDs, activity modification, and physical therapy are first-line treatments before considering invasive interventions.
- While performing a neurological assessment, the nurse practitioner elicits the patellar reflex by striking the patellar tendon just below the kneecap. The patient’s lower leg extends briskly. Which spinal segment is primarily being tested by this reflex?
- L2–L3
- L3–L4
- L4–L5
- S1–S2
Answer
B. L3–L4
Feedback: The patellar (knee-jerk) reflex assesses the integrity of the femoral nerve and the L3–L4 spinal segments.
- When assessing for sciatica, which physical exam maneuver is most sensitive?
- Crossed straight leg raise test
- Thomas test
- Straight leg raise test
- Patrick’s (FABER) test
Answer
C. Straight leg raise test
Feedback: The straight leg raise test reproduces pain radiating below the knee, this suggests lumbosacral nerve root irritation, commonly from herniated disc.
Clinical Pearls
* All areas with asterisks are highlighted for a patient with this chief complaint.
Always ask about:
- Bowel or bladder dysfunction
- Progressive weakness
- History of cancer (consider, if undiagnosed, unexplained weight loss, night sweats, no history of cancer screenings)
- Recent trauma or osteoporosis
Physical exam:
- Observe posture and gait
- Palpate spine to assess for tenderness
- Perform ROM and Neuro exam (strength, reflexes, sensation and SLR)
Imaging:
- X-rays for trauma
- MRI is best for neurological deficits, cauda equina, tumor or infection
- CT if MRI is contraindicated or cost prohibitive
References
Hsu, P. S., Armon, C. & Levin, K. (2025). Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis. In D.C. Preston (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-etiology-clinical-features-and-diagnosis
