COHF 008: 38 year old fit and healthy gentleman, who presented with an acute onset of severe lower back pain
Today, we have episode 008 where we have a 38 year-old with low back pain, after a disc herniation, just had surgery. So, this is a case study of a 38-year-old fit and healthy gentleman, who presented with an acute onset of severe low back pain. The problem was constant unremitting lower back pain, with shooting pain into the left leg from the buttock to the heel. He also reported the presence of pins and needles in his heel. Any static position aggravated his back and leg pain if sustained for over 10 to 15 minutes. There was nothing that he could do to ease his symptoms. He reported difficulty sleeping. Pathology and cancer were ruled out. He was unable to maintain any position for longer than one to two minutes. Active movements that he performed were restricted and painful in all planes, especially flexion which reproduced both back and leg symptoms. Local tenderness at the distal two joints of the lumbar spine L4 and L5 with widespread muscular spasm.
Palpation of L4-L5 elicited left leg symptoms. Neurologic tests were reflex testing. Sensory motor testing was normal and symmetrical side to side. There was evidence of significant sciatic nerve irritation when stretched. His symptoms led to believe that he had intervertebral disc prolapse at L4-L5 causing compression of the sciatic nerve root. He was immediately referred to an orthopaedic consultant. Surgical procedure was then performed to remove part of the disc and stop the compression of the nerve.
Let’s Hear From The Council!
Stimulation of the vestibular system would reflexively recruit all extensor muscles. So, with the top-down approach, we can ramp up the ability of these important stabilizing muscles before we prescribe any movement at all. Following surgery, there can be alterations to the skin local to the surgical site, and this can be a source of deafferentation or dysafferentation. So, proprioceptive stimulation to the skin can become part of the rehab, which helps the brain regain coordinative control of the area, simply because it allows the brain to see the area better. We have to improve, give the brain all the eyes that it needs to see the body, and that’s largely from the various proprioceptors and mechanoreceptors.
This is a very common injury across all populations. But in this particular situation, again being a biomechanist, what we’re trying to look at is why is this pain occurring? Why are there uneven forces that are causing this compression on the spine? So again, we’re trying to look at what’s the root cause of the situation. Some of the things that Dr. Emily had mentioned I’ll touch base on here in a minute, but something as simple again as looking at breathing. I know I’ve mentioned this a few times. Breathing is so important. It’s something we don’t think about doing, but if we don’t think about doing it and we’re doing it wrong, those muscles if they’re tight, if they’re pulling on the spine, pulling on the ribcage, that’s gonna change how your body, how your pelvic floor is gonna move.
Yeah, again this is as everyone said a pretty typical clinical case that you’ll see in day-to-day practice for me as an osteopath and physical therapist. So, in this case obviously, they’ve opted for the initial assessment they found that it was probably the best to go down the surgical route, which may or not. Given this case is hypothetical, this may or may not be the best case of action ’cause I guess what we know from looking at disc injuries on the lumbar spine is that there are a considerable amount of people who do have these asymptomatically as well. And we know with this case, they’ve obviously had an MRI to indicate a sequestration that they often have a higher rate of regression as well.
Dr. Brandon Brock
Now this is definitely a complicated case. This is what I do pretty much every day and we’re looking at traumatic brain injury here, and you gotta realize that the brain is kinda like an orchestra, you know, and you’ve got the strings section, you’ve got the percussion section, you’ve got all these different sections and they have to all be playing in sync and in tune for the whole thing to be orchestrated and sound well, and the brain is very similar. So when you’ve had some sort of concussion or traumatic brain injury or some sort of blow to the head, you can lose frontal lobe integrity, you can lose parietal lobe integrity
Dr. Emily Splichal
Alright, so this patient is clearly presenting with radiculopathy type presentation, which I often see in my office where patients do have a little back pain but their primary focus of where they’re feeling the symptoms is in the foot. So, they’ll think that it is a local presentation or nerve irritation. Because he’s seen an orthopedist and has known that he has a full sciatic nerve irritation, then that was addressed in this case. However, some things that I want the listeners to think about of where radiculopathy type pain can actually be confused or actually misdiagnosed is if a patient actually has a tarsal tunnel syndrome.
It’s kind of like everybody said, depending on how we are presented with this client. If it’s the pre-surgery kind of client coming in, it’s basically being smart enough to know when it is something that you can work with, and when it’s something that you have to refer out. The way that this patient presented it is kind of referring out to the orthopedist or the Physio Wing and working with them. My job in that position pre-surgery, if surgery is elected, is pretty much just trying to keep him comfortable and active. And him being a businessman, if he’s travelling a lot or if he has to be seated for a long period of time, just trying to get those hypertonicities and/or the adhesions down so that he’s able to actually perform his day-to-day work and not be in complete pain or highly medicated
Dr. Mark Wade
I would expect to see some postural distortion patterns of the pelvis as well as in the upper posture quadrants. Now focusing in on the pelvis and the lumbar, I would check gait for the primary purpose of seeing how his core and pelvic stability are. Most likely with this issue, we’re gonna see some movement dysfunction which will become quickly and easily apparent during gait. Next, the main exam I would look for is leg length discrepancy, just like Jeff was mentioning, non-anatomical of course, which will quickly tell me if there’s any pelvic unleveling. In my experience, we would see both of these in a situation like this.
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