A forty-nine year old male presented at my office with complaints of chronic low back pain with radiation down the right leg into the foot. He states that the back pain began almost a year ago. He was treated 2-3 times a week by a chiropractor but noted no benefit after a month and discontinued care.
Seven weeks ago, after sneezing, the pain shot down the right leg. The leg pain has been constant ever since, but varies in intensity. His orthopedic surgeon diagnosed a herniated disc and prescribed muscle relaxants and anti-inflammatory medication that failed to provide any relief.
An MRI performed two days prior to his initial visit in my office shows desiccation of the L4/L5 and L5/S1 discs with apparent prolapse at L5/S1 impinging the thecal sac.
Based on the history and MRI, I had several questions (please review my blog “The Patient History” posted September 16, 2015):
- Why didn’t he respond to a month of fairly intensive chiropractic care?
- His pain radiates along the course of the femoral nerve, not the sciatic nerve. Why was he diagnosed with sciatica?
- If sneezing caused the prolapse at L5/S1, why isn’t the sciatic nerve affected and why are both discs desiccated? That takes at least a year, maybe as much as five years to show on imaging studies.
- The femoral nerve does exit from L4/L5 but that disc looks much healthier than the L5/S1 disc that supplies the sciatic nerve. Is this really a disc problem?
On examination, he had great difficulty arising from a chair (Minor’s Sign – imagine an old coal miner arising from a rocking chair) and exhibited marked antalgic posture (he leaned forward and to the left about 45 degrees) favoring the right leg to walk. Both these findings are secondary to protective muscle spasm.
