This topic contains 7 replies, has 2 voices, and was last updated by Christopher Stepien October 24, 2018 at 11:07 am.
October 16, 2018 at 3:17 pm #4892
20 YO Female:
- Bilateral posterior distal thigh symptoms (2″ above knee crease)
- sharp and pins/needles
- 7/10 when provoked, 3/10 24 hours after activity
- P+: exercise (squats, lunges, scissor kicks on back), running >1miles, after 3 sprints, worse as the day goes on (24 hours after activity), going up stairs (“feels like pulled muscle”)
- P-: rest
- division 1 lax player on scholarship at Villanova who missed past 2 seasons due to “hamstring pulls”.
- Onset – Aug 2017, no cause, progressive.
- Had LB soreness for years, she ignored it and got adjusted.
- Felt C/Cx trying to adjust spine by twisting to left.
- L4-S1 tiny bulges (superimposed central protrusion at L5-S1).
- Grade 1 retrolisthesis L5-S1.
- Grade 1 Retrolisthesis impinging on S1 Nerve roots
- SLR R – 93 deg – moderate bilateral LB and right C/Cx tightness (R LB Sx started at 40 deg) – increase with DF
- SLR L – 85 deg – mod C/Cx smptoms – increase with DF
- SHF R – 92% – mild bilateral LB pull
- SHF L – 100% – mild tightness 1″ below ASIS
- QLF – 0-3.5″ flat – whole right plantar foot went tingly after 20 seconds
- KHE R – 13.5″ with mild tightness proximal thigh
- KHE L – 14″ mild tightness proximal thigh
- SLPF – 100% with mild tightness bilateral posterior thigh into calf
- Observation: Left quad hypertrophied compared with right.
- Palpation: Moderate adhesion in lumbar erectors
- Lunge: Right toe land/off with significant knee adduction.
- Retrolisthesis with S1 NR involvement
- MOD Adhesion
Lots of low back flare-up with lumbar flexion.
I’m working to respect MRIs more than I have been.
1. Can tiny bulges (I haven’t seen MRI b/c they haven’t brought to me yet) cause these symptoms? Or Can a retrolisthesis do this? I imagine it could, but wanted to confirm.
2. If YES to retrolisthesis, is it because the vertebra is literally pushing into the NR?
3. The MRI says nothing about degenerative or traumatic. I imagine this is degenerative. Would this be observable on the MRI if I had it?October 16, 2018 at 4:31 pm #4894
Eric Lambert, DCParticipant
I’ve had multiple retrolisthesis patients not have symptoms unless a disc bulge or joint degeneration was present. I’d get my hands on that MRI to see what’s it really looks like. I’d suspect more the disc bulge and load causing the symptoms. But I’m interested in what other guys say.October 16, 2018 at 9:40 pm #4895
Keith Puri, DCParticipant
I often say conditions do not read textbooks so technically anything is possible. That said, to answer your questions –
1. I would be more suspicious of the superimposed central protrusion at L5-S1 being the primary pain generator than the tiny bulges at L4-5 or the retrolisthesis at L5-S1.
2. I am not certain a grade 1 retrolisthesis at L5-1 would have enough accessory motion to impinge both traversing S1 Nerve roots.
3. In the absence of trauma, don’t tiny disc bulges and a central protrusion assume some degree of degeneration has already occurred?
In reviewing her case, I question the relevance of the L5-S1 retrolisthesis in relation to the central protrusion. Did the central protrusion create local instability and contributed to the retrolisthesis or was it vice-versa? Flexion and extension XR’s may help rule to in/out the presence of instability and relevance of the retrolisthesis.October 17, 2018 at 5:30 am #4896
Good feedback. I’ll gather more info and report back in. TY Eric and Keith.October 17, 2018 at 6:29 am #4897
Carl Nottoli, DCParticipant
I like Keith’s feedback of flex/ext X-rays to rule out instability. You could also test her standing extension and seated passive extension to see if that illicits any symptoms.
My suspicion is that it’s a combination of L5/S1 retrolisthesis + the central disc protrusion.
She’s only 20 years old and this has been a progressive condition! Make sure you are keeping this frame in mind and the patient understands that this is bigger than her Lax career. This may be the difference between living with manageable symptoms and having a spinal fusion before she’s 40.
She has good tests already which is also another red flag. Keep us updated.October 17, 2018 at 9:11 am #4898
Seth Schultz, DCParticipant
Can tiny bulges (I haven’t seen MRI b/c they haven’t brought to me yet) cause these symptoms? Or Can a retrolisthesis do this?
Given her age, it’s possible the protrusion could illicit those symptoms. A 20 yo likely has a thick, well-hydrated disc. So, her protrusion could still illicit a lot of symptoms on top of the sheer force the retrolisthesis causes during LB flexion. Also, the fact that she gets sx @ 40 degrees during Rt SLR makes me think the protrusion is playing a major part in her problem. More so than the report leads you to believe.
Out of curiosity, did the radiologist measure the size of the protrusion?October 17, 2018 at 11:53 am #4899
Brandon Cohen DC, CSCSParticipant
Are sx worse on right or left?
Does she have a painful arc during the SLR on the right, or do they increase from 40 on? If there is a painful arc, what might cause that?October 24, 2018 at 11:07 am #4900
Her father is a PI lawyer.
He came into the office with the MRIs to look at with me. The disc was clearly desiccated and bulging more than a tiny protrusion.
I’m confident this was not the retrolisthesis, but the disc.
With that said, this is the 2nd time in 2-3 months that I expressed the gravity of the situation to a 20 YO female, only to have her parents become mildly disgruntled with my communication.
I don’t think I did anything wrong – I think I’m just rubbing up against the current healthcare paradigm and how most doctors underweight MRI findings.
Next time, I will probably tell the patient to bring both of her parents in before I communicate to all of them, so it’s all out in the open.
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