Spontaneous Low Back Pain, Radiculopathy, And Weakness in a 28-Year-Old
A 28-year-old fluoroscopy technician 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. The patient noted that his occupation as a fluoroscopy technician requires him to sit in the most uncomfortable position and 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 walks 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 and has a past medical history significant for athletic involvement in football, javelin, and weight lifting.
The patient has been treating himself with self-taught abdominal exercises and ibuprofen (800 mg) 3 times per day as needed. The abdominal exercises have helped to relieve pain in the past, but he noticed the exercises 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.
Lumbar disc versus facet mediated back pain x 1 week; possible degenerative disc disease or herniated nucleus pulposus.
The patient was told to continue taking 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 out of 10 on the visual analog scale. Pain escalated to 8 out of 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, and 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 (Figure 3). 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 4).
Figure 3. Axial image shows disc material compressing the left L5 nerve root in the subarticular recess.
Figure 4. Sagittal MRI image reveals extruded disc at L4-L5, desiccation at L4-L5 and L5-S1, as well as anterolisthesis of L5 on S1 and retrolisthesis of L4 on L5.
- 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
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).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 at 3 Weeks
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 non-steroidal anti-inflammatory drugs (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 are 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.