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A 32-year-old male presents with a four week history of severe low back pain that radiates posteriorly to the left leg as far as the ankle, which he describes as sharp and burning. Although the patient is a manual laborer with a long history of low back injuries, he reports that the latest episode of pain awoke him in the early hours of the morning. The patient was prescribed analgesics from his general medical practitioner and had tried a course of chiropractic treatment, the latter of which did not appear to help. The patient reported that coughing did not exacerbate his symptoms but that sneezing did, as did bearing down. The patient is currently off work. Apart from the periodic episodes of low back injuries, the patient's medical and surgical history was unremarkable in the patient denied having any fever or feeling unwell. Recent plain film radiographs were within normal limits as were the findings from a bone scan.

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What is your working hypothesis at this stage?

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The patient presents with the many of the findings associated with a lumbar disk injury although there appears to be no mechanism of injury.

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Does this patient warrant a lower quarter screening examination?

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This type of patient always warrants a lower quarter screening examination.

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The physical examination revealed the following findings:

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  • Observation of the trunk and pelvis appeared normal with no evidence of sciatic scoliosis.
  • Active range of motion of the lumbar spine was flexion (limited by 80% due to pain), extension (limited by 90% due to pain), right and left side bending (limited by 50% due to pain).
  • Active range of motion of the lumbar spine was flexion (limited by 80% due to pain), extension (limited by 90% due to pain), right and left side bending (limited by 50% due to pain).
  • The supine straight leg raise test was limited to 15° on the left and 20° on the right due to pain.
  • Pinprick sensation testing revealed an area of hypoesthesia of approximately 3 cm in diameter on the anterolateral aspect of the left thigh, the little toe of the left foot, and the big toe of the left foot.
  • The Hoover test was negative bilaterally.
  • The Naffziger test called an increase in low back pain as did the Milligram test (activity lifting both straight legs together while in the supine position).
  • The slump test was positive with the introduction of cervical spine flexion.
  • The foot pulses were normal bilaterally.
  • The deep tendon reflexes of the knees and ankles were normal.

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Following the physical examination, what is your working hypothesis?

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The working hypothesis for this patient would be a left posterolateral L4-5 intervertebral disk bulge/protrusion.

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