Spontaneous Low Back Pain, Radiculopathy and Weakness in a 28-Year-old
The patient is a 28-year-old male fluoroscopy technician, with a past medical history significant for athletic involvement in football, javelin and weight lifting, who spontaneously developed familiar, aching low back discomfort one week ago. He indicated that, on average, he experiences one flare-up of back pain monthly, which lasts about one week, and resolves spontaneously. This recent flare-up is not resolving as expected. Sitting is the most uncomfortable position. His employment as a fluoroscopy technician requires him to wear a lead apron in the fluoroscopy suite. He has continued to work full-duty without obvious distress, despite his discomfort.
The patient is a well-developed, well-nourished, white male, alert and oriented x3. He ambulates with a non-antalgic gait pattern and is in no obvious distress. Discogenic provocative maneuvers, including pelvic rock and sustained hip flexion, aggravate his discomfort. Dural tension signs are non-provocative. He is moderately obese.
Self-taught abdominal exercises and ibuprofen (800 mg) 3 times per day as needed.
Abdominal exercises have helped to relieve pain in the past, but he noticed abdominal exercise and "crunches" now hurt instead of help. He reports his symptoms are not improving. He has never had his spine evaluated and has never been seen by a physical therapist or chiropractor.
Initial Impression: Lumbar disc versus facet mediated back pain x 1 week; possible degenerative disc disease or herniated nucleus pulposus.
Recommendations: The patient was told to continue to utilize his ibuprofen 800 mg 3 times per day, remove his lead apron between procedures, and begin physical therapy with a spine therapist. If symptoms persist, x-rays and an MRI would be considered for further evaluation.
Re-evaluation at 1-week: Although physical therapy (with manipulation) helped to resolve the majority of his back symptoms, he developed left leg symptoms in the buttock, posterior thigh, and posterior calf downward towards the ankle and Achilles tendon. Left-side dural tension maneuvers, including straight leg raise and sitting root signs, aggravated these symptoms. Leg symptoms did not extend below the ankle or into the foot. However, leg symptoms were severe enough to interrupt sleep. Cross straight leg raise was negative. Sacroiliac joint and discogenic provocative maneuvers were not performed. Pain upon this follow-up visit was 5/10 on the visual analog scale. Pain escalated to 8/10 when exacerbated by prolonged sitting and driving. He has been removing his lead apron between injection procedures. At this point, an MRI and x-rays were ordered.
Lumbar x-rays reveal evidence of bilateral L5 spondylolysis (Figure 1), grade 2 anterolisthesis of L5 on S1, grade 1 retrolisthesis of L4 on L5 (Figure 2). The anterolisthesis measures approximately 16 cm and appears stable in flexion and extension views. There is approximately 25% loss of disc space height at L5-S1 and L4-L5.
Figure 1. L5 spondylolysis on oblique lumbar x-ray image.
Figure 2. Anterolisthesis of L5 on S1 and retrolisthesis of L4 on L5 with loss of disc space height at both levels on lateral lumbar x-ray.
Lumbar MRIs reveal a large left posterolateral inferiorly extruded disc herniation at L4-L5, which compresses and displaces the left L5 nerve root. There is bilateral facet arthropathy at L4-L5. At L3-L4 there is evidence of degenerative disc disease with a central disc bulge and mild bilateral facet arthropathy. At L5-S1 there is a spondylolisthesis associated with pars interarticularis defects at L5 bilaterally. There are Modic type 2 endplate changes. Disc desiccation is noted at L3-L4, L4-L5, and L5-S1. (Figure 3)
Figure 3. Sagittal MRI image reveals extruded disc at L4-L5, desiccation at L4-5 and L5-S1, as well as anterolisthesis of L5 on S1 and retrolisthesis of L4 on L5.
Figure 4. Axial image shows disc material compressing the left L5 nerve root in the subarticular recess.
- L4-L5 left-sided disc extrusion with left nerve root impingement and radiculopathy at L5 and possibly S1.
- Degenerative disc disease affecting L3-L4, L4-L5, and L5-S1
- L4-L5 grade 1 retrolisthesis
- L5-S1 grade 2 anterolisthesis
- Bilateral L5 spondylolysis
- L5-S1 central focal protrusion
- Left greater than right L5 exit foramenal stenosis with L5 radiculopathy
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Initial treatment included a 3-week course of physical therapy and naproxen 400 mg 2 times a day. (Instead of ibuprofen, due to a preferred b.i.d. treatment regimen.)
Re-evaluation at 2-weeks: One week later, symptoms have slightly improved, although leg pain is predominant. The patient was offered a selective nerve root block, but declined. The patient is instructed to continue the naproxen and home exercise regimen. If symptoms fail to improve, an L5 selective nerve root block may be recommended. In the future, the patient may require lumbar spine fusion.
Re-evaluation at 3-weeks: Despite some early morning discomfort, he reports he is pain free (0/10). However, he has begun to develop left leg weakness. He is faithful with his exercise regimen and naproxen usage (400 mg twice a day).
Physical Examination: He transfers to and from the exam table without difficulty or protective guarding. Left-side dural tension maneuvers, straight leg raise, and sitting root signs are provocative of the patient's familiar left leg symptoms extending below the knee. Deep tendon reflexes are 1+ and symmetrical throughout. Sensation is intact to light touch throughout. There is 3+/5 strength for left-sided extensor hallucis longus. Left-sided dorsiflexor strength is 4/5, 5-/5 strength for left-sided knee flexors, and hip abductors are 4/5. With repetitive single leg calf raises, there was definite subjective sense of weakness in the left leg compared with the right.
The patient is offered selective nerve root injections or surgical consultation, and declines both. He is instructed to continue his home exercise regimen and naproxen. If weakness progresses or pain worsens, a left L5 selective nerve root block will be performed.
Re-evaluation at 6-weeks: The patient is pain-free and has not needed NSAIDs in the past 2 weeks. He has been working closely with his physical therapist and participated in some aquatic therapy. Occasionally, when ambulating upstairs, he has a sensation that his quadriceps is somewhat tired, but he has no detectable weakness on physical examination. He does not trip or fall. Nerve root tension signs and SI joint and lumbar discogenic provocative maneuvers are negative bilaterally. Other neurological tests are normal.
At 6 month follow-up, the patient reports he has experienced no pain in more than 3 months and has returned to usual activities, including motorcycling. During the past month, he has not found it necessary to take naproxen for pain. He is also working full-time and full-duty as a fluoroscopy tech without discomfort or limitations.
Michael J. DePalma, MD
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University
Medical College of Virginia Hospitals
This case illustrates a not too uncommon story for discogenic lumbar radiculopathy, whereby a patient who experiences intermittent axial low back pain, aggravated by prolonged sitting, eventually develops lower limb radicular pain. This patient's initial presentation is consistent with discogenic low back pain perhaps related to a degenerative annular tear. His initial exam suggested involvement of an anterior column component. However, his subsequent examination after onset of left lower limb pain suggests nerve root involvement as dural tension reproduced his radicular leg pain. The acuity of straight leg raises has been shown to correlate with the presence of increased inflammatory markers at the nerve root-annular interface.
His imaging studies reveal multiple regions to explain injury of either the L5 or S1 nerve roots giving rise to his lower limb symptomatology. Given the acute onset of the leg pain after persistent central low back pain, without a clearly defined exacerbation of the leg pain with prolonged standing and walking, the L4-L5 intervertebral disc extrusion is the likely etiology for his left L5 or S1 radiculopathy or combination of both. His plain films do not suggest sacralized L5 transitional anatomy, so it is less likely that he has one single nerve root involvement presenting as the other or both.
Fortunately, for this patient, his symptoms improved with just functional restoration utilizing physical therapy to address spinal biomechanics and lower limb myotomal deficits and oral NSAID's. An appropriate additional therapeutic intervention would have been 1 to 4 therapeutic selective nerve root blocks or transforaminal epidural steroid injections. The instillation of corticosteroid along the nerve root can effectively reduce disc herniation related inflammation of the affected nerve root, while the body naturally resorbs the herniated nucleus pulposus. In addition to the diagnostic imaging studies, an electrodiagnostic evaluation could have added information about what type and the severity of the nerve root dysfunction.
Jason M. Highsmith, MD
Charleston Brain and Spine
This case describes a very favorable outcome in a patient with significant pathology. It underscores the importance of NSAIDs, activity modification and an aggressive physical therapy course as a primary course of treatment. We would expect the patient to respond within 6 weeks, if therapy was going to be effective. Fortunately, for this young man, that was the case.
However, the weakness he experienced after starting formal therapy is quite alarming. Had this patient gone for surgical consultation at that point as offered, I suspect most surgeons would have recommended a decompression and stabilization.
The fact that his back pain, radicular leg pain and strength all improved is surprising. This speaks to the benefits of therapy as well as to the patient's compliance. I would suspect weight loss played a significant role in his recovery as well.
Dr DePalma and Dr Highsmith both make excellent points regarding the case above, and I agree with both wholeheartedly. I suspect, as well, that most surgeons would have recommended a decompression and fusion procedure to this patient if he had proceeded with surgical consultation, when it was initially discussed. Dr Jason Lipetz from Long Island, New York, published an interesting case series of patients with painless weakness, all of whom got better without surgical intervention. Certainly, postponing lumbar fusion as long as possible in this young man in his 20's, who is a productive member of society, makes sense as well. He is certainly fortunate to have made a complete recovery with only conservative measures.