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Case:Low Back Pain 001: Difference between revisions

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=History=
{{Case section|PC|A 52 year old NZ European man with chronic right low back pain, and mild radiation of pain into the right groin.  
The patient first hurt his back in his 20s playing rugby. A few years ago he reinjured it while snowboarding. His current flare of pain started after using a foam roller on his hips. In 2015 he injured his right knee running which was diagnosed as caused by a degenerative meniscal tear on MRI.


The low back pain is worse on the right, and causes sudden shocks of pain. He does not get any leg pain apart from the knee pain as above. He gets some groin pain but the back is much worse, but these seem to flare up together. The pain is worse in the mornings causing stiffness which lasts about 1-2 hours. He has found certain pain relieving stretches. He works long hours as a chef which causes discomfort.
His pain drawing is below
 
[[File:52M CLBP pain chart.PNG|300px]]
}}
{{Case section|HxPC|He first hurt his back in his 20s playing rugby. A few years ago he reinjured it while snowboarding. His current flare of pain started after using a foam roller on his hips two years ago following yet another snowboarding accident. In 2015 he injured his right knee running which was diagnosed as being caused by a complex meniscal tear with medial chondral fissuring on MRI.
 
It causes sudden shocks of pain. He does not get any leg pain apart from the knee pain as above. He gets some groin pain but the back is much worse, but these seem to flare up together. The pain is worse in the mornings causing stiffness which lasts about 1-2 hours. He has found certain pain relieving stretches.  
 
He works long hours as a chef which causes discomfort. He surfs for around two hours at a time, twice a week.


He saw an Orthopaedic Surgeon who recommended conservative management, but to proceed to anterior discectomy and fusion at L5/S1 if symptoms became unbearable.
He saw an Orthopaedic Surgeon who recommended conservative management, but to proceed to anterior discectomy and fusion at L5/S1 if symptoms became unbearable.


No pertinent contributing psychosocial factors were identified.
No pertinent contributing psychosocial factors were identified.
}}
{{Case section|PMHx|*Psoriasis
*Celiac disease.
*Right knee medial compartment osteoarthritis
*No regular medications.
}}
{{Case section|Blood|FBC, CRP, ANA, anti-CCP, RF, HLA-B27, TFTs, LFTs, HbA1c, and creatinine are all normal.


=Medical History=
Celiac antibodies are undetectable consistent with a compliant gluten free diet.
He has psoriasis and celiac disease. No regular medications.
}}
 
{{Case section|Imaging 1|Investigations done 10 months ago by the Orthopaedic Surgeon, and so they are presented before the examination.
=Blood Tests=
Inflammatory markers are normal.


=Previous Imaging=
;MRI Lumbar Spine
MR imaging done through the Orthopaedic Surgeon 10 months ago showed
*L1/2: right paracentral disc protrusion.
*L2/3: small left paracentral disc protrusion which contacts the left L3 nerve root at the lateral recess.
*L3/4 facet joint effusions
*L4/5: mild disc bulge with contact of left L4 nerve root. facet joint effusions


=Examination=
[[File:52M CLBP MRI.PNG]]|MRI Lumbar Spine Report|*L1/2: right paracentral disc protrusion.
*Mildly overweight.  
*L2/3: A tiny 3 mm left paracentral protrusion contacts the left L3 nerve root within the lateral recess, both foramina are patent. Broad based disc bulge.
*L3/4: facet joint effusions and minor spurring. Minor annular bulging.
*L4/5: mild left extra foraminal disc bulging and end plate spurring contact the extra-foraminal left L4 nerve root without compression. facet joint effusions and minor spurring
*L5/S1: broad disc bulge.
}}
{{Case section|Imaging 2|;Xray Pelvis and Right Hip
[[File:52M CLBP Pelvis XR.jpg]]|Xray Pelvis and Lumbar Spine Report|*CAM deformities of the bilateral hips with mild joint space loss.
*Facet arthrosis L3 down to S1.
}}
{{Case section|Examination|*Mildly overweight.  
*Negative straight leg raise and slump tests.  
*Negative straight leg raise and slump tests.  
*Hip external rotation restricted bilaterally
*Hip external rotation restricted bilaterally
Line 28: Line 44:
*Sacroiliac joint provocation testing positive sacral thrust, but negative distraction, compression, and thigh thrust tests
*Sacroiliac joint provocation testing positive sacral thrust, but negative distraction, compression, and thigh thrust tests
*Neurological examination is normal
*Neurological examination is normal
}}
{{Case section|More Tests no.1|;Diagnosis hip injection
*Ultrasound guided diagnostic right hip injection with 5mL 1% lidocaine done.
*Pre-procedure pain 3/10 in hip, and 7/10 in low back on NRS.
*Post-procedure pain at 30 minutes: 2/10 in hip, and 6/10 in low back
*Post-procedure pain at 60 minutes: 1/10 in hip, and 6/10 in low back
*That night the hip joint was 5/10, and low back 7/10
}}
{{Case section|More Tests no.2|;First medial branch block
*fluoroscopically guided bupivacaine injections to the right L2, L3, L4 medial branches, and the L5 dorsal root.
*Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for four hours.
*Constitutes a positive block with 100% pain relief.
[[File:52M CLBP MBB bupivacaine.PNG|400px]]


=Further Investigations no.1=
;Second medial branch block
Ultrasound guided diagnostic right hip injection with 5mL 1% lidocaine done. Pre-procedure pain 7/10 on NRS. No change post-procedure.
*fluoroscopically guided lidocaine injections to the right L3, L4 medial branches, and the L5 dorsal root, initially skipping the L2 level.
*He still felt some pain, and so further injection was done to the L2 medial branch.
*Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for two hours.
[[File:52M CLBP MBB lidocaine.PNG|400px]]


=Further Investigations no.2=
;Medial branch anatomy
*First fluoroscopically guided bupivacaine injections to the right L2, L3, L4 medial branches, and the L5 dorsal root.
<gallery>
**Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for four hours.
Lumbar-medial-branch-nerve-blocks.jpg|Oblique ViewLumbar-medial-branch-nerve-blocks2.jpg|AP View
**Constitutes a positive block with 100% pain relief.
</gallery>
*Second fluoroscopically guided lidocaine injections to the right L3, L4 medial branches, and the L5 dorsal root, initially skipping the L2 level.
}}
**He still felt some pain, and so further injection was done to the L2 medial branch.
{{Case section|Diagnosis|The diagnosis is confirmed facetogenic pain arising from the right L3/4, L4/5, and L5/S1 facet joints. He also has mild hip joint osteoarthritis which is largely asymptomatic.}}
**Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for two hours.
{{Case section|Management|*He proceeded to radiofrequency neurotomy of the right L2, L3, L4 medial branches, and the L5 dorsal root.
*He had a mild pain flare for two weeks
*At 6 week follow up he has been pain free and has been back to his usual activities of active surfing, mountain biking, and is also back to working long hours when required.
*With very strenuous activity he feels some achiness on the left side (non-RF side), but this settles after some rest.
*His hips have not been causing any pain.
*Subjectively he feels the procedure was very successful.
}}
{{Case section|Related Article|*[[Lumbar Facet Joint Precision Treatment]]}}
{{Partial case history}}


{{Header tabs}}


{{Header tabs}}
[[Category:Case Histories]]

Latest revision as of 19:00, 22 April 2022

A 52 year old NZ European man with chronic right low back pain, and mild radiation of pain into the right groin.

His pain drawing is below

52M CLBP pain chart.PNG

He first hurt his back in his 20s playing rugby. A few years ago he reinjured it while snowboarding. His current flare of pain started after using a foam roller on his hips two years ago following yet another snowboarding accident. In 2015 he injured his right knee running which was diagnosed as being caused by a complex meniscal tear with medial chondral fissuring on MRI.

It causes sudden shocks of pain. He does not get any leg pain apart from the knee pain as above. He gets some groin pain but the back is much worse, but these seem to flare up together. The pain is worse in the mornings causing stiffness which lasts about 1-2 hours. He has found certain pain relieving stretches.

He works long hours as a chef which causes discomfort. He surfs for around two hours at a time, twice a week.

He saw an Orthopaedic Surgeon who recommended conservative management, but to proceed to anterior discectomy and fusion at L5/S1 if symptoms became unbearable.

No pertinent contributing psychosocial factors were identified.

  • Psoriasis
  • Celiac disease.
  • Right knee medial compartment osteoarthritis
  • No regular medications.

FBC, CRP, ANA, anti-CCP, RF, HLA-B27, TFTs, LFTs, HbA1c, and creatinine are all normal.

Celiac antibodies are undetectable consistent with a compliant gluten free diet.

Investigations done 10 months ago by the Orthopaedic Surgeon, and so they are presented before the examination.

MRI Lumbar Spine

52M CLBP MRI.PNG

MRI Lumbar Spine Report
  • L1/2: right paracentral disc protrusion.
  • L2/3: A tiny 3 mm left paracentral protrusion contacts the left L3 nerve root within the lateral recess, both foramina are patent. Broad based disc bulge.
  • L3/4: facet joint effusions and minor spurring. Minor annular bulging.
  • L4/5: mild left extra foraminal disc bulging and end plate spurring contact the extra-foraminal left L4 nerve root without compression. facet joint effusions and minor spurring
  • L5/S1: broad disc bulge.
Xray Pelvis and Right Hip

52M CLBP Pelvis XR.jpg

Xray Pelvis and Lumbar Spine Report
  • CAM deformities of the bilateral hips with mild joint space loss.
  • Facet arthrosis L3 down to S1.
  • Mildly overweight.
  • Negative straight leg raise and slump tests.
  • Hip external rotation restricted bilaterally
  • Tenderness bilateral inguinal regions, below the right PSIS, right L3/4 articular pillar, and bilateral L4/5 articular pillars
  • Sacroiliac joint provocation testing positive sacral thrust, but negative distraction, compression, and thigh thrust tests
  • Neurological examination is normal
Diagnosis hip injection
  • Ultrasound guided diagnostic right hip injection with 5mL 1% lidocaine done.
  • Pre-procedure pain 3/10 in hip, and 7/10 in low back on NRS.
  • Post-procedure pain at 30 minutes: 2/10 in hip, and 6/10 in low back
  • Post-procedure pain at 60 minutes: 1/10 in hip, and 6/10 in low back
  • That night the hip joint was 5/10, and low back 7/10
First medial branch block
  • fluoroscopically guided bupivacaine injections to the right L2, L3, L4 medial branches, and the L5 dorsal root.
  • Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for four hours.
  • Constitutes a positive block with 100% pain relief.

52M CLBP MBB bupivacaine.PNG

Second medial branch block
  • fluoroscopically guided lidocaine injections to the right L3, L4 medial branches, and the L5 dorsal root, initially skipping the L2 level.
  • He still felt some pain, and so further injection was done to the L2 medial branch.
  • Pre-procedure pain was 50/100 on VAS, post-procedure pain at 20 minutes was 0/100, and remained at 0/100 for two hours.

52M CLBP MBB lidocaine.PNG

Medial branch anatomy
  • AP View

    AP View

The diagnosis is confirmed facetogenic pain arising from the right L3/4, L4/5, and L5/S1 facet joints. He also has mild hip joint osteoarthritis which is largely asymptomatic.

  • He proceeded to radiofrequency neurotomy of the right L2, L3, L4 medial branches, and the L5 dorsal root.
  • He had a mild pain flare for two weeks
  • At 6 week follow up he has been pain free and has been back to his usual activities of active surfing, mountain biking, and is also back to working long hours when required.
  • With very strenuous activity he feels some achiness on the left side (non-RF side), but this settles after some rest.
  • His hips have not been causing any pain.
  • Subjectively he feels the procedure was very successful.
The running commentary in this case history is either absent or has not been checked by a relevant specialist. If you would like to help please contact Jeremy
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