Case

[Fiveoboy11]

---

Members do not see this ad.

Patient is 56 y.o. male, chronic LBP (10 years) non radicular and no paresthesia. Onset can be traced to single MOI (standing on ladder drilling hole in ceiling for fan and symptoms started next day) He also has generalized aches and pains.

Eval: WNL AROM, no obvious directional preference, but he has much better tolerance to standing/walking than sitting. His posture is poor. No LE weakness. Reflexes slightly increased to patellar, achilles and FHL. I haven't felt any spasticity or clonus. He also has urinary urgency at night. Preferred sleeping position is SL in fetal. He has morning stiffness with a lot of pain in back and LE's with MM stiffness.

I thought on eval that he might have central stenosis and on f/u pt brought MRI report of L/S showing L4/5 central stenosis (mild) and mild diffuse posterior disc bulge with mild facet hypertrophy, x-ray of L/S mild disc height loss at L4/5, T/S x-ray is normal.

So...I did manipulation of mid thoracic in sitting. Gave him HEP of POE and supine hooklying on floor to reduce neural tension and told him to be aware of slumping posture to symptoms.

Avoid traction, avoid flexion/slumping, promote / and anti-inflammatories?

Seems like this may be a case of spinal cord hypersensitivity? Thoughts?

 

[facetguy]

Has he received any treatment over the years and was anything helpful? What's his body habitus? General health?

With better standing/walking tolerance than sitting, I wouldn't think central stenosis right away. His imaging studies don't seem to be that helpful. My initial thoughts would be toward discogenic pain.

 

[Fiveoboy11]

No significant benefit from Rx in past including SIJ injection, PT x 2 episodes, chiropractic.
5'11" 153lbs. He is a school teacher. Doesn't have many hobbies/recreation.

So, you think the pain is discogenic secondary to lost disc height at that level and the posterior bulge? Or not necessarily related to findings on imaging?

 

[facetguy]

No significant benefit from Rx in past including SIJ injection, PT x 2 episodes, chiropractic.
5'11" 153lbs. He is a school teacher. Doesn't have many hobbies/recreation.

So, you think the pain is discogenic secondary to lost disc height at that level and the posterior bulge? Or not necessarily related to findings on imaging?

The imaging findings may suggest an issue at that level but aren't necessarily all that helpful beyond that.

Who referred him to you, family doc or spine doc?

 

[Fiveoboy11]

I don't remember to be honest, but he has been around quite a bit.

 

[jesspt]

How long has the urinary urgency been present, and has it been worked up by a urologist or at least looked into by his PCP?

I'm with facet in that I think you need to look into the specific interventions that he has had in the past, rather than general things such as PT x 2, chiropractic, etc.

You gave him things to reduce neuromeningeal tension. Did he have a (+) slump test?

 

[Fiveoboy11]

How long has the urinary urgency been present, and has it been worked up by a urologist or at least looked into by his PCP?

I'm with facet in that I think you need to look into the specific interventions that he has had in the past, rather than general things such as PT x 2, chiropractic, etc.

You gave him things to reduce neuromeningeal tension. Did he have a (+) slump test?

SIJ injections within past year, seemed to help somewhat but temporarily. Intradiscal electrothermic therapy to lumbar spine did not help in 2005. Manipulation by Chiropractor in 2002/03 didn't help. PT interventions included core strengthening (1st episode) in/out rationale of SIJ and pelvic floor exercises secondary to urinary symptoms (2nd) episode with some benefit but not lasting (within past year). He has been diagnosed with BPH but I am not sure when the urgency symptoms started and when he was diagnosed. His symptoms are definitely not localized to SIJ or predominant there.

His slump mobility was improved by neck extension and ankle plantarflexion and worsened with opposite. Standing TL FF mobility limited 25% due to c/o posterior leg pulling with some LBP. Standing / ROM WNL pain free. I see him tomorrow so I'll let you know.

 

[HVLA]

but he has much better tolerance to standing/walking than sitting.

anytime I hear this I immediately think psoas.

 

[Fiveoboy11]

anytime I hear this I immediately think psoas.

Really? I usually find patients with diminished hip / or hip flexor mobility in those with intolerance to standing/walking, i.e. foraminal stenosis or facet hypertrophy, flexion directional preference, or h/o spinal fusion, bla bla...

 

[HVLA]

Really? I usually find patients with diminished hip / or hip flexor mobility in those with intolerance to standing/walking, i.e. foraminal stenosis or facet hypertrophy, flexion directional preference, or h/o spinal fusion, bla bla...

you ruled that out right?