This topic contains 4 replies, has 3 voices, and was last updated by Anthony Moreno June 21, 2018 at 2:09 pm.
June 20, 2018 at 1:11 pm #5376
Ladies and Gentlemen,
Had a new patient today Referred to me by massage therapist after months of chiropractic and massage treatment. MRI was done yesterday and single image is below:
Male 36 Y/O, Radiating lumbar pain to left butt cheek and down to toes at certain times, Deep, sharp, intolerable (20% of day), VAS 8/10.
PRO: Bending, climbing, standing and walking
ID Lumbopelvic examination was extremely limited due to pain and range.
Clearly this is a significant disc herniation/extrusion, has anyone had luck treating this severe? I’ve diagnosed with a suspected disc injury prior to seeing this image, which was sent after initial exam, My gut says this is severe enough beyond conservative care. Please any input is appreciated.
And I appreciate knowing that the ID system led to a proper primary diagnosis. This case is straight forward, but here in the Quad Cities, this patient could have gone to 5 DC’s before someone took a film, and 5 more before an MR.
Attachments:You must be logged in to view attached files.June 20, 2018 at 1:45 pm #5378
Adam Holen D.C.
Good work on diagnosing the disc injury without the images. What concerns me is the “intolerable” aspect (20% of the day). That is a massive herniation and 8/10 is severe. Does he have any neurological deficits? (strength, sensation, reflex). If it’s causing enough compression to compromise those functions, he is likely an orthopedic referral sooner rather than later. However, I’m curious as to what the level 1 tests were (ROM, Sx LQI) and how much relevant adhesion he has. If his QLF (and/or other tests) is severely limited with lots of adhesion, you may be his best first option and be able to help a significant amount. But again, that depends on more of the case details. Also, if he lays down or rests does that improve his symptoms (8/10 to a 5-6/10?) or is massage the only thing that’s helped?June 20, 2018 at 4:57 pm #5379
Thanks for your quick response.
Tests are as follows:
SLR left= 41% (Low back to hamstring 4/10), SLR right=76% (hamstring 1/10) dorsiflexion exacerbated each side at same locations with left VAS 8/10.
SHF left=100%, none SHF right=92.5% s: low back 2/10
QLF: 1,1,1,0,1 S: feels good to flex. States, “this feels good and has been doing this at home.”
KHE left=100% s: slight jamming feeling 1/10, KHE right=100% s: same as left
SLPF: 0% (29 inches) s: left lumbar pain 5/10, increased as he flexed.
Adhesion: left erector spinae.
Previous diagnosis was piriformis syndrome (left side), which palpates with mild to moderate adhesion.
Palliative are massage, changing positions and thats about it. Laying on stomach and back at night forces a change after approx. 1 hour.
No positive neuro deficits.
Anthony MorenoJune 21, 2018 at 9:11 am #5397
Carl Nottoli, DCParticipant
That’s a massive sequestration! If I had to guess without seeing the patient myself, I would say he will need surgery first. It’s great he doesn’t have any neurological deficits…yet.
Some factors to consider is the pain level he has to endure on a daily basis, how much it effects work and family, and how willing he is to let conservative care work.
I had a patient like this years ago. I did about 4 treatments and he had some positive change, but had to go back to work. As soon as he did it flared up worse. I sent him for surgery. I followed up with him the week after and he said he was feeling much better and I haven’t heard from him since.
In hindsight I would’ve sent him for surgery sooner and really hammered home the importance of his follow up with me because the adhesion is what is causing the herniation due to poor function.June 21, 2018 at 2:09 pm #5398
Thanks for the response Carl, and I will see you this weekend.
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