Case:Low Back Pain 001: Difference between revisions

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=History=
=History=
The patient has right low back pain, with mild radiation into the right groin. 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.
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 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.


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.
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=Further Investigations no.2=
=Further Investigations no.2=
*First fluoroscopically guided bupivacaine injections to the right L2, L3, L4 medial branches, and the L5 dorsal root.
;First medial branch block
**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.
*fluoroscopically guided bupivacaine injections to the right L2, L3, L4 medial branches, and the L5 dorsal root.
**Constitutes a positive block with 100% pain relief.
*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.
*Second fluoroscopically guided lidocaine injections to the right L3, L4 medial branches, and the L5 dorsal root, initially skipping the L2 level.
*Constitutes a positive block with 100% pain relief.
**He still felt some pain, and so further injection was done to the L2 medial branch.
[[File:52M CLBP MBB bupivacaine.PNG|400px]]
**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.
 
;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.
[[File:52M CLBP MBB lidocaine.PNG|400px]]
 
;Medial branch anatomy
<gallery>
<gallery>
Lumbar-medial-branch-nerve-blocks.jpg|Oblique View
Lumbar-medial-branch-nerve-blocks.jpg|Oblique View
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The diagnosis is confirmed facetogenic pain arising from the right L3/4, L4/5, and L5/S1 facet joints.
The diagnosis is confirmed facetogenic pain arising from the right L3/4, L4/5, and L5/S1 facet joints.


=Management Plan=
=Management=
He will proceed to radiofrequency neurotomy of the L2, L3, L4 medial branches, and the L5 dorsal root.
*He will proceed to radiofrequency neurotomy of the L2, L3, L4 medial branches, and the L5 dorsal root.
 


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Revision as of 19:30, 6 September 2020

The patient has right low back pain, with mild radiation into the right groin. 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.

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.

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.

His pain drawing is below

52M CLBP pain chart.PNG

He has psoriasis and celiac disease. No regular medications.

Inflammatory markers are normal.

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
  • 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

Ultrasound guided diagnostic right hip injection with 5mL 1% lidocaine done. Pre-procedure pain 7/10 on NRS. No change post-procedure.

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
  • Oblique View

    Oblique View

  • AP View

    AP View

The diagnosis is confirmed facetogenic pain arising from the right L3/4, L4/5, and L5/S1 facet joints.

  • He will proceed to radiofrequency neurotomy of the L2, L3, L4 medial branches, and the L5 dorsal root.


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