Case:Low Back Pain 001

History

Past History

Blood Tests

Previous Imaging

Examination

Further Investigations no.1

Further Investigations no.2

Diagnosis

Management

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 being caused by a complex meniscal tear with medial chondral fissuring 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

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

Inflammatory markers are normal.

Investigations done 10 months ago

MRI Lumbar Spine

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 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.

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.

Medial branch anatomy

• 

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