I had another interesting case lately, this one is quick... but I think it's a good reminder for all of the new doctors/health professionals out there. If the presentation seems a bit wild, don't be scared to order imaging.
Patient presents with acute low back pain of 2 weeks duration and
burning into both legs. Patient walks with two crutches. When patient
had the problem last year he was never able to have the cortisone
injection because of a heart problem (stroke). The back pain was small
for some time but in the last two weeks it has been very extreme but he
has been unable to walk, drive, etc and must use crutches. Patient has
no issues controlling the bowels but notes that using the toilet is
extremely painful because of the way he must maneuver to sit. This acute
reinflammation came without warning for the patient. This time the pain
is worse than it was a year ago. Pain killers are not really helping
with the pain. When coughing or sneezing the pain is quite unbearable.
Ice on the back helps for only a few minutes. Patient is unable to sleep
due to the pain even when using pills to sleep. Burning into the legs.
Denies burning or pain in the saddle distribution, but has burning down
both legs. If patient doesn't move at all it can be a bit better for
some time but easily inflames again if he moves.
Physical Examination finds slump test so strongly positive that the patient is unable to lift either leg while seated. Straight leg raise is extremely positive bilaterally before reaching 30 degrees. Kemp is so strongly positive that patient shakes in pain. Light palpation of the spine is horribly painful for the patient even in the seated position. Moving the patient into positions for examination is excruciatingly painful. Patient states today is the best he has been walking in 2 weeks (He is using two crutches and moving very slowly). There is no neurologic deficit noted in the reflexes, sensation, or motor activation of the lower extremity.
MRI of the Lumbar Spine from 27/01/2015 finds:
Mild anterior spondylolisthesis of L5/S1.
L5/S1 discal bulging.
L3/ L4 right paracentral discal protrusion infenting on the right thecal sac & the right L4 nerve root .
Patient is sent for a new MRI of the Lumbar spine.
Patient arrives today seeming much better and is able to walk. He has brought along his MRI.
MRI Lumbar Spine 23/05/2016:
There is mild bulging of the L3 to S1
There is an abuttal of the right neural L3/L4 foramina indenting
the anterior thecal sac at L4/L5 and L5/S1.
There is an abdominal aortic
aneurysm (AP 4cm) noted with features of peripheral thrombus.
Patient's cardiologist was contacted and he was referred to him at this time.