Problem: Today I had a 62 year old man present with severe low back and leg pain. On taking his history, he stated that his low back hurt worse first thing in the morning and again late at night. He also stated that his pain was increased with slightly bending over say the sink to wash dishes or shaving. He also stated that his low back and leg pain was decreased by sitting down. On questioning, he stated that when he shops he needs to lean over a shopping cart. And while shopping his pain can be relieved if he sits down for a few minutes. I ask him if his pain immediately goes away while sitting or does it take a few minutes to historically differentially separate vascular claudication from stenosis. He has a past history of MRI study showing 2 bulging disc and has had 2 lumbar epidural injections with little success. You know God gives you the right to have more than one thing going on at a time an I think this patient has taken him up on that idea. After taking his history, I have a theory that he had two primary problems 1) lumbar stenosis and 2) degenerative facet syndrome. I feel that his bulging disc may in fact be a red herring and not causing his problems. I did a complete and thorough examination including posture exam, orthopedic test, neurological test, palpatory exam, spinal exam, range of motion and digital muscle weakness exam. Next I completed a surface NCV and EMG of his spine and lower extremities. I ordered X-rays of his lumbar with obliques at the hospital and compared them to his recent MRI films. Discussion: On imaging he in fact does have both soft tissue and bony stenosis. The lumbar canal was narrowed to 9mm at L4 and L5. Since he did not have any pain with a straight leg raiser or well leg raiser and was able to tandom walk heel/toe with no other neurological deficits, I concluded that his bulging disc were red herrings. Spinal stenosis, a narrowing of the spinal canal, which places pressure on the spinal cord or nerve roots. If the stenosis is located on the lower part of the spinal cord it is called lumbar spinal stenosis. Stenosis in the upper part of the spinal cord is called cervical spinal stenosis. While spinal stenosis can be found in any part of the spine, the lumbar and cervical areas are the most commonly affected. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. In the lumbar spine, symptoms often increase when walking short distances and decrease when the patient sits, bends forward or lies down. Cervical spinal stenosis may cause similar symptoms in the shoulders and arms. In some patients the pain starts in the legs and moves upward to the buttocks; in other patients the pain begins higher in the body and moves downward. Treatment: I started him on phisotherapy including Interferrential current (IFC) for 15 minutes along with hot pads. I also started him on ultrasound over the lumbar paraspinal muscles and facets. I started him on DTS Decompression Traction; Cox Flexion/Distraction; and chiropractic manipulative therapy. If he does not improve in two weeks then I will send him for lumbar facet injections. I feel he will ultimately need the facet injections. However if he needs facet injections I want them to be done under floro guidance at the hospital or surgery center. I am also talking to him regarding his overall health and his future health goals and life expectancy. If he develops neurological deficits then I will immediately refer him back to the neurosurgeon for surgical decompression.
Dr Greg Millar
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