Low Back Pain Case Study – A Nasty one! But a good outcome.

This is the case study of a 38- year old fit and healthy gentleman, who presented with an acute onset of severe lower back pain, an extremely common injury that will affect approximately 60% of us at one stage or another in our lives. What follows is a basic account of my management, which demonstrates the importance of a thorough assessment and a close working relationship with local Specialist Surgeons to enable the best outcome possible in the shortest space of time.

Subjective Questioning
Problem: Constant, unremitting lower back pain, with shooting pain into the left leg from buttock to heel. He also reported the presence of pins and needles in his heel.
Aggravating factors: Any static position aggravated his back and leg pain if sustained for over 10-15 minutes.
Easing factors: There was nothing that he could do to ease his symptoms.
24hrs: He reported difficulty sleeping, but no significant difference pattern to his symptoms.
Special Questions to Exclude Serious Pathology: No alterations to bladder and bowel function, no sudden unexplained weight loss, no night-time fever/ malaise, no pins and needles/ numbness in groin region, no significant loss of leg strength.
History of Problem: A sudden unexplained episode of lower back pain and leg pain, that started 8 weeks ago. He reported a history of 1-2 episodes of localised lower back pain and occasional low-grade leg pain, but nothing ever of this magnitude.
Social History: Business man, who was normally very active and enjoyed playing rugby socially and running regularly.
Past Medical History: No medical problems of note.
General health: Good. No cardiovascular nor respiratory problems, no family history of lower back pain, arthritis, diabetes, epilepsy
Drug history: Due to the severity of his symptoms, his GP had prescribed strong pain-killers and muscle relaxants.
Objective Examination Observation: Unable to maintain any position for longer than 1-2 minutes Active movements: (Patient performed) Restricted and painful in all planes, especially flexion, which reproduced both back and leg symptoms.
Passive movements: (Physiotherapist performed) severe muscle spasm prevented an accurate assessment of segmental spine movement
Palpation: Local tenderness at the distal two joints of the Lumbar spine (L4/5), with widespread muscular spasm. Palpation of L4/5 elicited left leg symptoms.
Neurological Tests: Reflex testing, sensory and motor testing was normal and symmetrical side to side. There was evidence of significant sciatic nerve irritation when stretched
Analysis of Pathology His symptoms led me to believe that he had intervertebral disc prolapse at L4/5, causing compression to the sciatic nerve root and leg symptoms. It was likely that his condition would become more serious if it was not managed quickly.
Initial Management Immediate referral to an Orthopaedic Consultant in Northampton.
Orthopaedic Consultant Assessment This gentleman was referred to a local Orthopaedic Consultant, who specialises in Spinal injury. Following an MRI our suspicion was confirmed. The scan also identified that a small part of the disc’s contents had leaked out, known as a sequestration. On discussion with the Consultant a surgical procedure was performed to remove part of the disc and stop the compression of the nerve.
Post-Operative Physiotherapy Following a brief stay in hospital (4 days), the patient was re-referred to the clinic for post-operative care. We have since been working on the following agreed goals:

1. Restoring full range of movement of spinal joints through local mobilisation, manipulation and active stretching.

2. Developing the strength and co-ordination of the local spinal muscles, which serve to protect the spine from injury. Evidence has proven a link between the education and strengthening of these muscles and a reduction in back pain. It has also been shown that these muscles will deteriorate quickly with pain and following surgery. They are best educated with a gradual specific strengthening program.

3. Restoring normal nerve movement along the length of the sciatic nerve, with nerve mobilisations and local soft tissue techniques.

Outcome
Following six weeks of Physiotherapy, this gentleman is now resuming a running program and is left with only an occasional mild buttock pain, which I am confident we can eradicate with ongoing treatment.
It is now our plan to introduce sports specific rehab to enable him to resume rugby playing in the near future.