Vascular, Rheumatologic, Functional, and Psychosomatic Back Pain

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63 Vascular, Rheumatologic, Functional, and Psychosomatic Back Pain

H. Royden Jones, Jr.

Clinical Vignette

A 55-year-old lumber yard foreman with history of hypercholesterolemia, prior 30 pack-year smoking, and depression, began to experience bilateral left > right leg pain primarily precipitated with walking. The pain ceased whenever he stopped and rested for a few minutes … he did not even need to sit. With time, his pain was precipitated with significantly shorter distances, getting to the point where he could not go more than 100–150 yards without having to stop to relieve his discomfort. At rest he felt fine. He could not obtain an effective erection. This initially appeared to be a classic picture of intermittent claudication secondary to primary vascular disease.

However, all of his peripheral pulses were normal. Doppler arterial evaluation was normal. His symptoms progressed; he could not mow his lawn or take walks and he felt weak climbing stairs. Lumbar spinal MRI and EMG were normal.

He was than referred to us for a possible myopathy or spinal stenosis. His neurologic examination was perfect. All peripheral pulses were normal, and Doppler arterial studies, lumbar spinal MRI and EMG were normal.

Vascular consultants did not feel that he had peripheral vascular disease. Psychiatric consultation found no psychosomatic component. Exercise Doppler suggested mild decreased flow on the right.

A repeat examination now demonstrated his peripheral pulses were no longer present. He now had a bruit over his left femoral artery CT angiogram demonstrated severe stenosis of the proximal left femoral and iliac artery (Fig. 63-1). Angioplasty and stenting led to immediate pain relief.

Figure 63-1 Total Obstruction of Left Common Iliac Artery.

Comment: This patient had classic intermittent claudication precipitated by exercise and totally relieved by rest. This almost always implies peripheral atheromatous disease. With his initially normal peripheral arterial evaluation he was thought to have a neurologic mechanism; however, this was not confirmed.

Reevaluation demonstrated that he now had a femoral artery bruit. CT angiography identified proximal intrapelvic arterial compromise despite normal traditional techniques.

This case particularly emphasizes the importance of revisiting the history and the examination with any patient whose clinical picture is not initially confirmed by traditional studies. The neurologist must always look at potential nonneurologic mechanisms whenever forming a differential diagnosis.

Clinical Vignette

A 28-year-old milkman, who lifted many heavy milk cases daily, presented with low back pain. This had begun 1 year earlier after lifting an extra-large load, “wrenching” his back. Subsequently he noted gradually increasingly severe and eventually almost incapacitating low back pain that occasionally radiated into his buttocks and posteriorly down his right leg. He also noted increasingly more limiting early morning back and hip stiffness that gradually “loosened up” after he worked an hour.

During the previous few months, his difficulties had progressed significantly. He now felt unable to finish his daily job responsibilities. Therefore he applied for workers’ compensation.

Neurologic examination demonstrated complete loss of lumbar lordosis, significantly diminished chest excursion of only 1.5 cm (normal 3–6 cm), and mildly positive right straight leg testing. His neurologic examination was otherwise normal. An aortic diastolic murmur was presnt on cardiac examination.

Spinal and hip radiographs demonstrated typical findings of ankylosing spondylitis. These included significant sacroiliac joint sclerosis (Fig. 63-2). A serum HLA-B27 test was positive. A rheumatologist concurred with the diagnosis and began appropriate therapy.

Figure 63-2 Fusion of Sacroiliac Joints in 28-Year-Old Man with Ankylosing Spondylitis.

Comment: This patient sought care for a presumed job-related injury. Instead, a diagnosis of a serious rheumatologic disorder, namely ankylosing spondylitis, was made. If that diagnosis had not been appreciated at his age, eventually this would have led to serious spinal ankylosis with significant spinal immobility and possibly serious pulmonary compromise. Despite this early diagnosis of such a treatable condition, paradoxically this patient was disappointed with his care bacause he was no longer entitled to workman’s compensation!

The frequency of work- and accident-related back pain sometimes seems to be reaching pandemic proportions among workers performing heavy labor. Very often patients present with many potential causes for their back pain. These not only represent the classic well-defined organic mechanisms, such as lumbosacral nerve root compression, or ischemic compromise, but aditionally there may be many occupation-related symptoms wherein overt or covert psychologic factors combine to provide a confusing milieu. Secondary gain issues are commonly confounding factors. It is vital not to impugn patients’ veracity by applying pejorative labels such as “hysteric,” “a crock,” “functional,” “litiginous,” or even “having psychological overlay.” Too often, these labels have led to inadequate evaluations, and serious illness is occasionally overlooked, as initially occurred in both of the above vignettes.

Sincere physicians often encounter difficulties dealing with disingenuous patients seeking a “free ride” or a “green poultice” (Fig. 63-3). Most often secondary gain is the primary motivating factor, particularly with the perspective of a generous workers’ compensation settlement. However, the examining neurologist must carefully evaluate each patient to search for a specific neurologic or other illness, as many patients understandably look for a simple explanation for their troubles—and it is easy to blame the workplace. Often the symptoms become embellished, not uncommonly subconsciously, to prove that a “work-related injury” truly exists. Very often these patients tend to focus on their backs, seeking to prove the presence of a posttraumatic mechanically related disorder. They most definitely want to have their neurologist diagnose a specific work-related neurologic disorder as in the second vignette.

Figure 63-3 Somatoform Back Disorders.

Back pain patients may have psychosomatic features, but as with many organic disorders other primary psychologic disorders require consideration. These include depression, conversion disorder, psychophysiologic disorder, chronic pain syndrome, hypochondriasis, factitious disorder, and even schizophrenia. As the physician gains the patient’s confidence during the interview and examination, certain life stressors may become apparent, including family, job, personal issues, and inappropriate use of medications or even street drugs.

Neurologic Examination

Each patient requires a comprehensive general neurologic examination, not only to evaluate the affected extremity and back but also to confirm that other neurologic systems and anatomic structures such as joints or vessels are healthy. There are specific clinical testing means that help distinguish an organic lesion from one that is embellished or inconsistent. The straight leg raise is an excellent example. A patient with organic nerve root compression becomes uncomfortable when lying supine while the physician attempts to bring the patient’s leg to the perpendicular and is similarly affected when seated for a similar maneuver. Stretch on the sciatic nerve and its already compromised origins within the L5–S1 nerve roots initiates the discomfort. In contrast, an inconsistent response is often noted wherein individuals seeking secondary gain report pain with movement in the supine but not the seated posture.

Another example is the well-known observation that when denervation occurs with significant peripheral nerve injury, it is followed by significant muscular atrophy. Such is generally lacking in the nonorganic setting. However, the quadriceps femoris is an exception; it may undergo significant disuse atrophy without a true peripheral nerve injury. Other useful clues and testing modalities can help to verify psychosomatic back pain (see Fig. 63-3).

Evaluation

It is absolutely essential to carefully investigate patients’ concerns even when the clinician “is confident” of a psychosomatic or compensation disorder diagnosis. Too often such individuals are compartmentalized and put in the compensation diagnostic mode only to later be found to have a treatable disorder. Each of these patients needs their physicians to take their complaints with appropriate seriousness. This may mean ordering imaging studies such as MRI or, when MRI is contraindicated, CT/myelography, neurophysiologic investigations including electromyography, evoked potentials, hip radiographs, and on occasion CT angiography. Finding a symptom-specific organic lesion that can be readily treated occasionally rewards the conscientious physician and patient alike.

However, if the results of these investigations are all normal, the physician can appropriately reassure the patients that no organic mechanism is identified. When a true organic neurologic, musculoskeletal, or primary psychiatric disorder is excluded, only then should the physician consider psychologic mechanisms or secondary gain. A number of clues help in these diagnoses; perhaps the most important observation is the patient’s tendency to be “consistently inconsistent” in some features of the history or neurologic examination.

Treatment

There are many rehabilitative and behavioral interventions that are supportive as well as often therapeutic for these patients. One needs to always maintain a supportive approach with such patients, no matter what the final diagnosis. This does not depend on whether a conversion disorder is diagnosed or a very subtle hint of a lumbosacral disc protrusion is suggested. Neither requires specific therapy especially a surgical one. Appropriate management combines reassurance, rehabilitative medicine techniques, group therapy, and, in the more refractive instances, individual psychiatric intervention. An eclectic combination of various therapies often provides an improvement in long-term outcomes.

Unfortunately, some individuals with chronic low back pain are subjected to multiple surgeries for less than reasonable indications. Thus they have no chance of improving because no specific lesion such as an extruded disc has been removed. Concomitantly these surgeries, per se, are then utilized to provide justification for granting disability status per se. The patient of course feels “there must have been” an organic work-related etiology for their difficulties if a surgeon “had to operate” on them. Another subset of individuals will continue to complain until a legal settlement is reached. They are identified as having the “green poultice syndrome” (see Fig. 63-3, bottom image). This is of course dependent on gaining a financial settlement; once that is accomplished it is not uncommon to see a rapid resolution of their symptoms and ability to return to their previous activities of daily living!

Additional Resources

Hayes J. Psychosomatic back complaints. In: Nervous System. West Caldwell, NJ: Ciba; 1986:198. Jones HR. The Ciba Collection of Medical Illustrations

Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007;369:946-955.

Lindstrom-Hazel D. The backpack problem is evident but the solution is less obvious. Work. 2009;32:329-338.

Murphy PL, Volinn E. Is occupational low back pain on the rise? Spine. 1999;24:691-697.

Schultz IZ, Crook JM, Berkowitz J, et al. Biopsychosocial multivariate predictive model of occupational low back disability. Spine. 2002;27:2720-2725.

Storm PB, Chou D, Tamargo RJ. Lumbar spinal stenosis, cauda equina syndrome, and multiple lumbosacral radiculopathies. Phys Med Rehabil Clin North Am. 2002;13:713-733. ix

Tubach F, Beauté J, Leclerc A. Natural history and prognostic indicators of sciatica. J Clin Epidemiol. 2004;57:174-179.

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