Lower back and leg pain is a severe case with numbness and weakness in the limb; suspected lumbar stenosis.
A 38 year old man consulted me six weeks ago with LBP and serious limb signs and symptoms. He was suffering primarily from severe left cramping pain in his posterior thigh and calf. The ratio was 40 to 60; in other words, less lumbago than sciatica. That's an ominous prognosis.
It all began four weeks earlier whilst kicking a rugby ball around with his children. He complained that his thigh and ankle felt weak and wobbly. There was some improvement with his doctor's anti inflammatory medication; the radiation had also been to his foot.
His condition was aggravated by turning in bed, and sneezing which elicited stabs in the limb; standing up after sitting, and walking.
Interestingly, sitting brought relief, but afterwards it was much worse.
In these severe cases, standing is often impossible, and sitting is strictly prohibited; although not desirable, intermittent bed rest with exercise is the only alternative.
Lower back and leg pain is the biggest drain on insurance companies and keeps chiropractors in business.
EXAMINATION @ LOWER BACK AND LEG PAIN
Mr 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 stabs in his low back, particularly at lumbar vertebra 5.
Sacroiliac tests were negative.
The slump test for sciatica, left, level 3, provoked severe left calf pain but minimal back discomfort; he was on strong painkillers.
Slump test on the right provoked no back or leg pain.
Neurological testing: The achilles reflex on the left 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 giving at the knee, all on the left.
Chiropractic examination at this lower back and leg pain casefile.
He 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 jammed up 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.
L1-L2: annular tear with a bulge of the disc, with narrowing of the intervertebral foramen. No nerve root compromise.
L2-L3: Focal herniation of the disc with compromise of the nerve root on the right.
L3-L4: Lumbar Stensosis: annular tear + hypertrophic facet changes + thickening of the ligamentum flavum.
L4-L5 Lumbar Stenosis, no compromise of the nerve root.
L5-S1: Moderate facet hypertrophy. No other abnormalities.
CONSULT 1: History, examination and first treatment
Mr K could barely rise from the chair in the waiting room, known as Minor's sign, and walked with difficulty to the examination room.
The history was routine with the exception of the fact that he 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 quadriceps 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 for sciatica; it 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 treatment
Diagnosis; there is a severe disc prolapse, possibly at more than one level. However, he had no symptoms in the right leg, as expected from the MRI.
Lumbar stenosis, unlikely at his age, but with a typical trefoil shaped canal is certainly a possibility. The scan is an essential tool in the management of severe nerve impingement cases. I recommend a second opinion from a neurologist.
Treatment; 2 consultations per week for 3 to 5, followed by a
vigorous programme, and an occasional, regular treatment until the
condition has stabilised, probably for two months.
Chiropractic philosophy; an explanation of the basic tenets of our treatment and the essence of his condition.
Three important issues face us.
An explanation of the high probability of initial improvement and subsequent set back within a few months, if he never went through the rehab programme.
Subjective: Slight but definite reduction in leg pain.
Objective: Slump test for sciatica was less positive.
Assessment: Progress. Referral letter to medical doctor for an MRI.
Treatment: sideposture manipulation of L5, lying on right side.
CONSULT 3: 3rd treatment
S: Feeling better.
O: Less pain with flexion. Slump still postive in the left leg.
P: Consult with a neurologist tomorrow.
S: 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.
S: 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.
O: Ranges of motion good, guarded.
P: As before.
S: Lower back and leg pain sciatica 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.
S: 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.
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.
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 according to plan.
He is doing unbelievably well. A very positive man, he has taken the radical decision to give up smoking and lose weight simultaneously. So far so good...
Comment @ LOWER BACK AND LEG PAIN
In the management of spinal conditions like lower back and leg pain, it never ceases to amaze me how some people with very severe signs respond far quicker than expected, whilst others with minor problems continue with nagging discomfort.
Mr K had everything going against him. Seriously overweight with poor muscle tone, a smoker, and paresis corresponding to three different nerve roots, the prognosis was very poor. Unable to take time off from a sitting job, I gave chiropractic little chance; and yet within weeks he was 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 attendant freely acknowledged attendant complications. Leg pain sciatica is an extremely painful and debilitating condition.
Clinically his case is mysterious. The hernia at L2 to 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 his symptoms, and the clinical findings relate to the L5 to S1 joint where the MRI findings are least. However, the scan was taken after 4 manipulations which may have changed the findings.
and scans? I've learnt the hard way over the years. Decide to the best of one's ability from the physical exam where the problem is, and then look to the X-ray and MRI for confirmation. Not vice versa. Based on the scan I would have decided the primarily problem was at L2-L3 and would certainly not have had the success we had.
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
COMPLICATIONS OF SURGERY ...
Patients with sciatica pain (really we should talk of Sciatic pain) is a daily occurence in every chiropractic clinic. Even medical research now grudgingly admits that manipulation is the treatment of choice. But once it goes down your leg you do have to take it seriously, follow your chiropractor's instructions faithfully and do basic exercises daily, preferably for the rest of your life. Just like you brush your teeth. HELP FOR SCIATICA PAIN ...
The sacroiliac joint is frequently involved in lower back pain. In chronic cases, the joint is inclined to subluxate repeatedly. A simple set of exercises for sacroiliac joint pain, as well as general lower back pain is essential.
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. MURTAGHS GENERAL PRACTICE ...
LUMBAR FACET ARTHROPATHY causes low back pain with extension of the spine.