LOWER BACK AND LEG PAINCASEFILE: LUMBAR STENOSIS(Keywords: LOWER BACK AND LEG PAIN, chiropractic help, leg pain sciatica, complications of surgery HISTORYMR K, a 38-year old man consulted me six weeks ago (29 May) with low back pain and leg pain. He was suffering primarily from severe left leg cramping pain (posterior thigh and calf). The ratio of low back pain/ leg pain = 40/60%. More LEG pain than BACK pain.The pain began four weeks earlier whilst kicking a football around with his children. He complained that his leg felt weak and wobbly. There was some improvement with his doctor's anti inflammatory medication (Diclofenac) - the pain had also been in the foot. The pain was aggravated by turning in bed, sneezing (stabbing pain in the leg), standing up after sitting, and walking. Interestingly, sitting brought relief. EXAMINATION @ LOWER BACK AND LEG PAINMr K is an obese man with a large belly. He reeked of tobacco.Forward flexion provoked pain in the back of the left calf muscle. Extension of the back increased the pain in his low back, particularly at L5. Sacroiliac tests were negative. The Slump test (left) (level 3) provoked severe left calf pain but minimal back pain (he was on strong painkillers). Slump test on the right provoked no back or leg pain. Neurological testing: The Achilles reflex (L) was totally absent. There were no sensory changes. There was marked weakness in three separate myotomes: Heel and toe raising were both weak. The quadriceps was weak. (all on the left). CHIROPRACTIC EXAMINATION @ LOWER BACK AND LEG PAINMr K walked with a marked limp associated with the weakness in his left leg. There were no fixations in the sacro-iliac joints, but L2 and L5 were fixated on motion palpation. The L5 joint was tender on deep palpation.There were no obvious piriformis or hip pathologies. Muscle tone was generally poor. The lumbar lordosis was increased.
MRI (10 June)- taken after the 4th manipulation.
RADIOLOGIST'S REPORT @ LOWER BACK AND LEG PAIN
Mr K could barely rise from the chair in the waiting room (Minor's sign) and walked with difficulty to the Examination Room. The History was routine with the exception of the fact that Mr K had more pain in the left leg than the back, and that his leg "collapsed" regularly under his weight. He was unsure whether this was due to pain or frank weakness. The Examination was unusual in only one respect: There was weakness in three distinct myotomes. The Gastrocnemius, Extensor Hallucis Longus and Quadruceps Femoris are supplied by three different nerve roots. The reproduction of leg pain, with no back pain, is not that unusual in the Slump test, just served to confirm a serious nerve impingement syndrome. Contrary to our usual policy (because he was in so much pain) he immediately received the first Treatment at the first consultation. CONSULT 2: Report of findings and second treatmentDiagnosis: Severe disc prolpase, possibly at more than one level. Possible lumbar stenosis, unlikely at his age. MRI is essential. Recommend a second opinion from a neurologist.Treatment: 2 treatments per week / 3-5 weeks, followed by a vigorous programme, and an occasional, regular treatment until the condition stabilised (probably 1/6 weeks). Chiropractic philosophy: An explanation of the basic tenets of Chiropractic. Three important issues:
Objective: Slump test less positive. Assessment: Progress. Referral letter to medical doctor for an MRI. P: Treatment: sideposture manipulation of L5, lying on right side. CONSULT 3: 3rd treatmentS: Feeling better.O: Less pain with flexion. Slump still postive in the left leg. A: Progress. P: Consult with a neurologist tomorrow. CONSULT 4S: 10% less leg pain.O: Slump 3 is now negative. A: MRI reports a hernia on the RIGHT at L2-3. And lumbar stenosis in the mid and lower lumbar spine. Copy of the MRI requested. P: Continued adjustment of L5-S1 joint, lumbar roll technique. Neurologist is guardedly positive about chiropractic. Diagnosis given: Lumbar stenosis. CONSULT 5S: 50-80% less pain. Left leg feeling stronger, less "giving".O: Range of motion of the spine improving, less pain. A: Progress better than expected. Patient in new job, unable to take leave, and recommended bed rest. Has lost 3kg, and trying to smoke less. P: Add adjustment of L2, lumbar roll, lying Left-side-down. First of rehab exercises. CONSULT 6S: Improving.O: Ranges of motion good, guarded. A: Excellent. P: As before. CONSULT 7S: Lower back and leg pain still improving.O: Slump 7 completely negative. Forward bending is guarded but painfree. Patient not limping. A: Definite improvement in the strength of the muscles in the left leg. Able to lift big toe off the ground. P: First exercise for stability of the pelvis. CONSULT 8S: Slight setback yesterday, no obvious cause. Back to 50% less pain.O: Flexion mildly painful again. Slump 7 still negative. A: Not unexpected slight relapse with all the sitting. P: As before. Chiropractic adjustments. Holiday 2weeks. CONSULT 9:Mr K has almost no pain. He found swimming very beneficial, the leg is no longer collapsing at all, feeling much stronger.Gentle bilateral mobilisation. No true manipulation. More rehab exercises. CONSULT 10:In three weeks time. Advised wife to join him in a consult over the future. The importance of regular walking, healthy diet... behind every great man sits a great woman pulling the strings, and making sure things go to plan.CONSULT 11Case in progress.COMMENT @ LOWER BACK AND LEG PAINIn the management of spinal conditions like lower back and leg pain, it never ceases to amaze how some people with very severe conditions, respond far quicker than expected, and others with minor problems continue with nagging pain. Tis mystery all...Mr K had everything going against him. Seriously overeweight with poor muscle tone, a smoker, muscle paresis corresponding to three different nerve roots, unable to take time off from a sitting job, and within weeks is much improved. He is taking the poor long-term prognosis seriously, and doing his best to improve his health. He's exercising, trying to smoke less, and losing weight. A month ago he was on the verge of major invasive surgery for spinal stenosis, with all the attendent freely acknowledged complications of surgery ... Leg pain sciatica is an extremely painful condition. Clinically his case is mysterious. The hernia at L2-3 on the right appears to be an incidental finding. All his symptoms are on the left. The spinal stenosis at numerous levels explains the weakness in the quadriceps muscle and the great toe dorsi-flexor, but most of symptoms, and the clinical findings relate to the L5-S1 joint where the MR findings are least. However, the MRI was taken after 4 manipulations which would have changed the MRI findings. The proof of the pudding is in the eating. He has no pain in the left leg, no back pain, and the strength of the muscles in his left leg is much improved. The test for a pinched nerve is now negative. Careful management in the future is vital to ensure that he doesn't just have a relapse in a couple months, and end up under the knife anyway.
COMPLICATIONS OF SURGERY ... MURTAGHS GENERAL PRACTICE
It's encouraging to find a general medical textbook, widely used in Australia, that is pro-chiropractic. There is now strong medical research confirming that manipulation is the treatment of choice for acute and chronic lower back and leg pain.
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