case file
A previously healthy 48-year-old man presents to his primary care office with severe low back pain that began the previous day after he helped his daughter move into her college dorm. He denies any trauma or previous back injury. He describes the pain as generally “achy” and sometimes characterized as being “sharp” when he moves suddenly. The pain is located in his lower back and radiates down the back of both legs to the middle of his posterior thighs. He denies any bladder or bowel incontinence or weakness in his legs. He denies fever, chills, weight loss, or malaise. He finds it very difficult to stand for prolonged periods of time because he cannot find a comfortable position. He states that this is the worst back pain he has ever experienced. It has not been relieved with acetaminophen or ibuprofen. His past medical history is significant for hypertension, and his only medication is lisinopril daily. He does not smoke or use illicit drugs and only drinks alcohol on occasion. On physical examination, he is well developed, overweight, and in moderate discomfort. His vitals are within normal limits. On neuromuscular examination, he has moderate tenderness bilaterally in his lumbar paraspinous muscles, and his lumbar flexion and extension are limited by pain. Strength and sensation are within normal limits and are symmetrical bilaterally. He has normal and symmetric knee and ankle deep tendon reflexes. Straight leg raise testing is negative bilaterally, and gait is within normal limits.
Questions
What is the most likely diagnosis?
What is the most appropriate workup?
What is the best treatment plan?
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