Case #3: Agust D is a 27 year old is a music producer who spends most of his time in in his studio remixing and making music. Patient has been suffering from lowback pain for the longest of time but only decided to do consultation because it is already affecting his work, thus, affecting his concentration as well. Pain is worsened by prolonged sitting or standing and is relieved by trunk flexion activities.

WHAT IS THE DIAGNOSIS OF THE PATIENT?

Low Back Pain Secondary to SpondyloLYsis

Spondylolysis is a condition in which there is a defect in a portion of the spine called the pars interarticularis (a small segment of bone joining the facet joints in the back of the spine). It is common in kids and teens, especially males and those who participate in high impact activities and one of the most common structural causes of low back pain and is readily identified and characterized in terms of its chronicity and likelihood to heal. Overstretching or overextending the spine, but not inflexion (bending inward) can lead to small cracks in the vertebrae. However, genes may play a role, wherein one may be born with thin vertebrae, which puts them at higher risk for pars fractures due to repetitive trauma to the lower back, just like our patient’s case.

WHAT FURTHER ASSESSMENT CAN BE DONE?

1) History Taking

a) Family History: Mr. August D is the youngest member of his family and apparently, his older brother, Mr. Min Junki also has spondylolysis.

b) Medications: He also mentioned that he was taking self-prescribed pain medications to keep his condition from BigHit Entertainment which is the company he is working from.

c) Differential Diagnosis: Chronic Low Back Pain, Spondylolisthesis, Lumbosacral Discogenic Pain Syndrome, Flexion Bias-Flexion Syndrome

d) Current Health Status: Mr. D stated that he was experiencing low back pain worsened with trunk extension especially when dancing, sitting throughout the day to write and produce music, and when standing for a very long time during promotions.

e) Living and Occupational Environment: Mr. D mentioned that before he became a music producer, he was a professional dancer when he was only 17 and started vigorous training on dancing when he was 10 years old. The onset of pain was when he was around 18 years old and he stopped dancing because his beautiful and clever girlfriend, Ms. Emery G., told him to focus on being a music producer instead. She was worried that dancing could harm him further. In fact, it was his girlfriend who persuaded him to consult a physical therapist.

f) Pain Assessment: The patient was experiencing low back pain since he was young. He mentioned that he experiences severe pain that spreads on his lower back. He describes the pain similar to muscle strain and worsened when performing activities that involve trunk extension and prolonged sitting and standing. He rates this as 9/10 through the visual analog scale.

2) Physical Examination

a) Palpation or Percussion of the Spine: Upon palpation slightly above the PSIS point of tenderness was observed.

b) Postural and Gait Assessment: Patient was observed to have slouched posture when sitting and walking to compensate for the pain felt when extending his trunk.

c) Range of Motion Assessment:

Trunk Forward Flexion: Limited but moderate
Trunk Extension: Greatly limited
Trunk Lateral Flexion: Limited
Trunk Lateral Rotation: Limited but moderate

3) Diagnostic Imaging

a) SPECT or CT Scan: Mr. August D's CT scan result was seen as a linear lucency or defect extending through the pars interarticularis

CT of the lumbar spine shows a defect of the pars interarticularis on the left at L5

CT of the lumbar spine showing a defect of the pars interarticularis on the left at L5

b) Plain Radiograph: Limited sensitivity compared to SPECT and CT. Mr D's images of the dense structure of the spine. Positive since the image shows “crack” or stress fracture in the pars interarticularis portion commonly involving the fifth lumbar vertebra (occasionally the fourth lumbar vertebra)

(+) Scotty dog sign: on oblique radiographs, a break in the pars interarticularis can have the appearance of a collar around the dog's neck
(+) inverted Napoleon hat sign

X-ray of the L5 showing spondylysis, decrease in disc space and bony spur formation

4) Special Tests to Rule In/Rule Out

a) Michelis' Test (Unilateral Extension): Patient performs hyperextension of the lumbar spine while standing on one leg. In a positive test, pain is reproduced. Unilateral lesions often produce pain when standing on the ipsilateral leg.

a) Straight Leg Raising Test: The patient in supine position, raises each leg with knee extended. The test is positive if pain is produced. This test is to rule out other conditions like disc herniation that also presents with LBP.

SUPPLY THE MANAGEMENT AND PATIENT EDUCATION

1) Patient Education

a) Adjust Work Environment: An ergonomic office chair is recommended in order to help Mr. Agust D maximize back support and maintain good posture while sitting and while making good music. However, we still need to measure the desk height and adjust the chair height according to Mr. D's height and comfort. We will provide an instruction pamphlet for Mr. D to take note in adjusting his work environment. (see image below)

b) Educate Mr. August D that no matter how comfortable he is at his desk, prolonged, static posture is not good for his condition. He must be reminded to stand and walk at least a minute or two every half hour

c) It is also important to inform Mr. D regarding the exercises that will be given to him. His back would hurt afterwards because his back has not yet adjusted. It should be emphasized that this is normal because it is still trying to correct the posture and will help relieve his back pain later on.

2) Pharmacological Approach

a) Nonsteroidal Anti-inflammatory Drugs

b) Corticosteroids

c) Muscle Relaxants

d) Antidepressants