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A 65-year-old man presented with an insidious onset of right leg symptoms, which follow a period, or distance, of walking, and also occur after a period of standing, and which disappear when the patient sits down. The pain radiates down the patient posterior thigh and occasionally below the knee. The patient also complained of pain at night, especially when he slept on his stomach. Further questioning revealed that the patient had a history of back pain related to an occupation involving heavy lifting, but was otherwise in good health and had no reports of bowel or bladder impairment. The patient's past medical and surgical history is also unremarkable.

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Given the age of the patient and the history, what is your best working hypothesis?

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The best working hypothesis at this stage should at least include a vasculogenic or neurogenic cause for the patient symptoms. The patient history indicates that there may be significant degenerative changes at the spine and that activities that cause lumbar extension produce the patient symptoms. In fact, a provisional diagnosis for this patient could be made on the strength of the history—an elderly patient with root pain or paresthesia that is reproduced in the erect position and immediately disappears on sitting or bending forward. This is a classic syndrome of the elderly.

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Why do you think the patient has pain with prone lying?

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Prone lying produces an increase in lumbar lordosis/spinal extension, which in turn reduces the size of the intravertebral foramen.

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Is the pain at night a cause for concern in this patient? Why?

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Further questioning would be needed, but it would appear that the night pain the patient is experiencing is associated with the prone lying.

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Does this presentation/history warrant a scanning examination? Why or why not?

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This patient would warrant a lower quarter screening examination in view of the insidious onset of symptoms and the presence of leg symptoms.

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The physical examination revealed the following results:

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  • The patient was of a medium build. His standing posture revealed a flattened lumbar spine and slight flexion at the hips and knees, but was otherwise unremarkable.
  • Active range-of-motion tests demonstrated a capsular pattern of restriction for the spine. During spinal extension, no symptoms were reported, but closer observation revealed very little motion occurring at the lumbar spine during this maneuver.
  • When the patient was asked to perform an anterior pelvic tilt to increase the lumbar lordosis, the paresthesias into the leg were reproduced, and reversing the lordosis relieved the symptoms.
  • The distribution of the paresthesia included the lateral and medial aspect of the leg and dorsum of the foot and great toe.
  • The straight leg raise test ...

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