This topic contains 5 replies, has 2 voices, and was last updated by 
Danielle Hommer, DC August 15, 2018 at 10:57 am.
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Christopher Stepien
I have a 46 year old female with left-sided low back pain.
It’s sharp/stabby and goes up to 8/10 when provoked and down to a constant 1/10 (never 0/10).
It’s provoked by:
- twisting
- 1st thing in the AM
- end of long days
- bending forward or leaning back.
It’s relieved by rest.Exam:- SLR 86% bilaterally
- SHF 70% bilaterally
- QLF 0-3″ flat with a moderate pain arc at Left L5-S1.
- KHE 5.5″ on right with mod pull in right anterior thigh and 10″ on left with mild pull in left anterior hip.
- SLPF: full with mild left low back pain as she approaches standing neutral.
Palpation:- signfiicant adhesion in right L4-S1 ES
- mild adhesion in left L4-S1 ES
- protective tension in right psoas
MRI shows:- transtiional S1.
- L3-L4 disc bulge with mild to moderate facet arthropathy (L>R). Bone marrow edema and soft tissue edema at margins of left L3-L4 with suspected synovial cyst measuring 1.4 cm at Post Inf Margin of Left L3-L4 facet joint. Superimposed left lateral foraminal disc protrusion.
- L4-L5 left lateral/foraminal disc protrustion
- L5-S1 right-sided annular tear with associated foraminal disc protrusion.
Diagnosis:1. Annular Tear2. Moderate adhesion in low back.I treated her four times and discharged her to the orthopedic doctor. After speaking with Bill about discharging patients prematurely (leaving significant adhesion in her low back and with the prospect of surgery), I’m thinkign I want to reach back out to her.My only question is with the cyst. Because her provocative looks like disc with the pain arc in flexion, extension, and rotation (and I believe the cyst would NOT be in flexion), I believe my diagnosis is correct.Is there any way the cyst could be responsible for her provocation?
Brandon Cohen DC, CSCS
Is the pain in flexion different than the pain in extension? Its clearly disc from the other information, and could be with extension, but that could be the cyst causing trouble. I could see inflammation from irritating the cyst resulting in some of these issues.
I had a similar case back before I knew anything, and the patient had the cyst removed (it was much larger), which was great for about 6 months, and then her disc symptoms came back. I still see her to manage the disc, but her cyst related pain (in extension, and when laying down) aren’t bothersome.
Christopher Stepien
Thank you Brandon.
I missed asking her to describe the differences in the provocative movements. I’ll circle back and see what I can find.
Carl Nottoli, DC
Test passive seated extension and passive seated extension with a bias to the left side. If she points right to that spot around the cyst you found one provocative movement that the cyst is responsible for. These tend to develop when facet arthritis gets extremely inflamed and swollen. The capsule will build up fluid and form a cyst over time.
Christopher Stepien
Beautiful. This is what I was looking for. TY Carl.
Danielle Hommer, DC
Good question Chris – I have a similar situation with a patient right now as well. We’re still working through levels but this helps me be prepared as the case unfolds!
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