A 40-year-old male presents with a two month history of low back pain. You notice that when you meet the patient he is standing so that his trunk is shifted to the left. The patient relates the injury to an incident when he was lifting a heavy box out of the trunk of his car and felt a sharp pain in his lower back. The patient initially thought that the pain would go away as it had with his previous episodes of low back pain but when it did not he went to see his primary care physician. His physician took a series of x-rays and told the patient that he had arthritis of the spine. The patient was prescribed NSAIDs but has made little improvement. Upon further questioning about his present condition, the patient reports that he has noticed over the past two months that his right leg falls asleep a lot, especially when he sits down or bends over. The symptoms are decreased when the patient is standing or when he is lying on his side (he reports that he cannot tolerate lying on his stomach). With the exception of his episodic back pain, the patient's past medical history and surgical history is unremarkable and he states that he is in good health.
Based on the history, do you think this patient's condition is neurologic, vascular, or neither? Describe the reasoning behind your decision.
It is impossible to determine at this point whether the patient has a neurologic or vascular component to his symptoms, but because of the cause-and-effect history of his symptoms it is very likely he has one or the other, or both.
Does this patient warrant a lower quarter screening examination?
This patient certainly warrants a lower quarter screening examination.
The physical examination revealed the following findings:
- Observation reveals a slight lumbar scoliosis to the left and a decreased lumbar lordosis.
- Active range of motion of the trunk is 40° of flexion, 10° of extension, 30° left sidebending, and 10° of right-side bending. Flexion and right side bending increased the patient's lower extremity symptoms. Having the patient stand erect relieves the lower extremity symptoms but makes the love back feel more uncomfortable.
- Deep tendon reflexes are normal throughout both lower extremities.
- Strength testing of both lower extremities reveals no weakness.
- There is diminished sensation to light touch on the posterolateral aspect of the patient's lower right leg.
- Straight leg raising on the right reaches 30° along with increased low back and leg pain, whereas the left leg reaches 75° and is pain-free.
- The sacroiliac stress tests were negative.
What is your working hypothesis?
There is enough data here to strongly suspect a lumbar disc ...