Herniated intervertebral disc
Prolapsed intervertebral disc
Herniated nucleus pulposus
722.73 Intervertebral disc disorder with myelopathy lumbar region
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
PREFERRED PRACTICE PATTERN
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
A 40-year-old woman, employed as a nurse practitioner, presents with low back pain, left sciatica, and the following history. During the last three of her four pregnancies, she experienced left sciatica that resolved with continued low back pain. This persistent discomfort did not keep her from activities until approximately 8 months ago when she had greater pain than usual, which required 9 days of bed rest until symptoms decreased. Several weeks ago she experienced another bout of spontaneous back pain, but could not take any time off and continued to work. Pain is aggravated by sitting in a soft chair, bending, or lifting/straining activities. Pain is relieved by lying in recumbent position, sitting in a firm/straight back chair, and when walking. After about a week, the back pain diminished; however, there was a sudden onset of severe pain radiating down the left buttock, ischial tuberosity to the posterior thigh, and leg as well as the lateral aspect of the left foot.
She believes the pain started when she bent forward to lift a heavy box. There is a feeling of numbness in the left lateral foot. Presently sitting tolerance is poor, even for short durations. Driving is difficult. Pain is increased with sneezing, coughing, walking, and bending. Pain is diminished when lying supine with the left leg bent and supported by a pillow, although pain in the left leg is persistent in any position. There is a lateral shift to the left in the direction of the sciatica, which is diminished when she lies down. There is a significant flattening of the lumbar spine. There is no evidence of swelling. There is mild lumbosacral tenderness, pain at the intervertebral foramen, and no palpable step deformity. The paraspinals feel tight and in spasm.
She is able to walk tip toe, but unable to maintain plantar flexion on the left due to weakness (3-/5). She is able to heel walk on the lateral boarder of her foot, but not medial. There is mild weakness of the hamstring and gluteal muscles on the left; extensor hallucis longus is normal. Patella reflexes are equal and normal bilaterally; left ankle reflex is diminished when compared with right. Distal medial and lateral hamstring reflexes are diminished on the left. Unsustained clonus of the left ankle is noted.
Magnetic resonance image (surface coil technique) of a sagittal section through the lower lumbar spine of a patient with low back ...
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