Case:Low Back Pain 002

31 year old male builder referred 10/12/2019 with two months of low back pain starting after he picked up a 30kg block and twisted and felt ‘pop’ in his lower back causing immediate pain

On 22/10/19 he was lifting & throwing concrete into skip bin. Referred 6-7 weeks after injury. Picked up a 30kg block and twisted and felt ‘pop’ in his lower back & immediate pain Worked on and that evening he had significant low back pain Now on ERC Severe impulse pain in the lower back and into his legs that drops him to the ground Not improving and referrer suspected a disc injury

Morning pain and stiffness Can’t comfortably hold 7/12 infant Poor sleep – best on side pillow BTKnees

More often shooting pain in the right than left leg

An engaging man not obviously in pain Could reach middle of shins; L. ext. hurt Bilateral slump test and SLR (To 50* ) caused pain in the central LS area Intact reflexes Blunting of pin prick dorsum right foot Antalgic weakness

Lumbar MRI 8 weeks post injury on 18.12.2019

No evidence of nerve root compression or displacement.
Minimal annular bulge at L4-5.
No visible annular fissure.
Mild interspinous oedema at L4-L5.

Requested F/U MRI 19/12/2019: coronal views of lumbar interspinous spaces

“Coronal and repeat sagittal views confirm interspinous ligament oedema at L4/5 rather than vessels.”

Learning point: MRI : ask for – a T2 fat suppressed Dixon coronal. Corroborate the coronal ISO in the sagittal plane. Have the sequence start posterior to the spines. A STIR will suffice but less resolution

7th January 2020 9 cm 22-gauge spinal needle advanced into the interspinous space using AP and lateral projections. 1 mL Omnipaque 300 infiltrated into the interspinous space to ensure position. A mixture of 40 mg Kenacort A and 0.5 mL 0.75% Ropivacaine was infiltrated into the L4/5 interspinous space. No immediate complications.

VAS 4-5 to 7/10
VAS 1-2/10

24th January 2020 I reviewed P today and explained to him that he used his “get out of jail card” with the successful interspinous focal steroid injection between L4 and L5 has treated the periostitis and ligament injury. Within days he had an improvement in the local pain and the impulse pain and was moving freely. He lost his impulse pain and began to move freely. Examination I saw him jog across the road today as he was running late, so I think he is moving freely. His general movements are fine without any obvious issues. He was able to bend forward and effortlessly reach just to his ankles; extension was normal. His straight leg raise was increased on the right to approximately 80 degrees limited by hamstring tightness, and on the left to 70 degrees limited by hamstring tightness. There was no tenderness to palpation in his buttocks or spinous and interspinous processes today.