CASE STUDY: Diagnosis of a chronic low back pain patient experiencing radiating symptoms in the leg utilizing appropriate examination procedures and radiographs.

By: David Lincoln DC

Abstract:
Objective: The purpose of this case report is to describe the diagnosis of a patient who presented to our office with history of chronic low back pain and radiating left leg pain without resolution despite pursuing a conservative approach.

Clinical features: A 70-year-old female presented with complaints of chronic low back pain and constant left leg radiating pain that started 6 months prior. The patient reported she had been diagnosed via Lumbar MRI many years prior with a herniated Lumbar disc and Lumbar disc degeneration that caused similar symptoms, but her prior symptoms had improved with conservative care. The prior MRI was not available for review.

Case Presentation:
Patient was a 70-year-old, 5’8”, 195 lb. female who presented with a chief complaint of low back pain and left leg radiating pain. The patient’s history revealed she had a Low Back condition many years prior causing Low Back pain and radiating symptoms in her leg that an MRI revealed was caused by a herniated disc in her lumbar spine. The patient pursued chiropractic care, acupuncture, and homeopathy with a successful outcome. She then enjoyed many years without a flare-up of her radiating symptoms. Eventually, the patient stated that she suddenly started experiencing increased low back pain and radiating pain down her left leg and into her groin. No direct cause was identified for the pain, as no preceding trauma was reported. As her symptoms increased over the next several months and became severe and constant, she decided to seek out conservative approaches again. Her conservative care practitioners did not order any diagnostic imaging and treated her for sciatica and muscle tension. This was unsuccessful and the patient presented to us for evaluation, diagnosis, and case management.

Symptoms:
Low back pain: Constant 8/10-9/10 ache.
Left Leg and Groin radiating pain: Constant pain as high as 9/10 and described as aching and sharp pain.
The patient reported the following functional impairments: marked reduction in the ability to sit for prolonged periods of time; ability to walk for prolonged periods of time; weakness of the left leg; and difficulty getting up from a seated position.
Associated symptoms included: reduced ranges of motion, stiffness, and tightness.

Exam:
Patient Details:
Height: 5ft, 8in
Weight: 195 lbs.
Blood Pressure: Left: 144/95 Right: 140/95
Pulse: 77 bpm
Dominant Hand: Right
Demeanor: Alert, Oriented x 3, Cooperative

Review of Systems:
The patient denied any fever or chills, and was negative for any change in skin, head and neck, immune, cardiac, respiratory, digestive, urinary, hepatic, renal or psychiatric issues, except: numbness in the fingers of both hands.

Past Medical, Social, and Family History:
Unremarkable.

Ranges of Motion:
Lumbar Flexion: Minimal loss of motion with minimal pain (0.5-2.5/10)
Lumbar Extension: Minimal loss of motion with slight pain (2.5/10-5/10)
Left Lumbar Lateral Bending: Minimal loss of motion with slight pain (2.5/10-5/10)
Right Lumbar Lateral Bending: Minimal loss of motion with slight pain (2.5/10-5/10)

Left Hip Flexion: Within Normal Limits with slight pain (2.5/10-5/10)
Left Hip Extension: Within Normal Limits without pain
Left Hip Adduction: Minimal loss of motion with slight pain (2.5/10-5/10)
Left Hip Abduction: Slight loss of motion with moderate pain (5/10-7.5/10)
Left Hip Internal Rotation: Moderate loss of motion with moderate pain (5/10-7.5/10)
Left Hip External Rotation: Minimal loss of motion with slight pain (2.5/10-5/10)

Sensory testing:
Decreased vibratory sensation in the left and right foot; decreased pinwheel sensation and light touch sensation in the right foot.

Motor testing:
There was no evidence of visible muscle atrophy or muscle fasciculations. The patient denied experiencing any “muscle twitching” in the legs.
Muscle testing in the lower extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally, except: 4/5 muscle strength of the left hip flexors.
(Muscle Strength Rating System: x/5=Muscle Strength 0=Paralysis 1=No Movement/Minor Contraction 2=Movement w/no Gravity 3=Full ROM/Perceptible Weakness 4=Full ROM/Moderate Resistance 5=Full ROM/Maximum Strength)

Reflexes:
Reflex testing revealed: Biceps, Triceps, Brachioradialis, Patella, Hamstring, and Achilles. Deep Tendon Reflexes were present and equal bilaterally being rated at 2/4, except: bilateral Achilles 0/4 with Jendrassik Maneuver; and bilateral Patellar 1/4 with Jendrassik Maneuver. There was no evidence of clonus.
(Deep Tendon Reflexes: 0=Absent; 1=Trace/Hyporeflexia; 2=Normal; 3=Hyperreflexia; 4=Hyperreflexia with Clonus)

Orthopedic Testing:
Negative Dejerine’s Triad
Positive Left Straight Leg Raise (SLR) at approximately 50 degrees of hip flexion causing increased radiating pain into the left groin and down the thigh to the medial left knee
Negative Slump test
Positive Patrick Fabere test, left side, graded severe in severity
Positive Hip Scour test, left side, graded severe in severity

Palpation:
Lumbar Spine: Palpatory Tenderness graded 1-2/4 and Palpatory muscle spasm graded 1-3/4. Motion palpation of the Low Back revealed vertebral biomechanical dysfunctions. Palpable edema was found in the Low Back.
Left Hip: Palpatory Tenderness graded 1-2/4 and Palpatory muscle spasm graded 1-3/4. Motion palpation of the Left Hip revealed vertebral biomechanical dysfunctions. Palpable edema was found in the Left Hip.

(Tenderness Scale: 1=Tenderness on deep touch; 2=Tenderness on deep touch w/ withdrawal response; 3=Tenderness on light touch; 4=Tenderness on light touch with withdrawal response
Muscle Spasm Grading Scale: 1=Slight increase in tone; 2= Marked increase in tone; 3=Considerable increase in tone and passive movement is difficult; 4= Affected part is rigid)

Diagnostic Tests Ordered
Radiographs of the lumbar spine and left hip were ordered based on examination findings.

Images:

Image 1

Image 2

Image 3

Image 4

Imaging Results:

Left Hip Radiographs (Images 1 & 2): Degenerative osteoarthritis of the left sacroiliac joint was seen. Moderate degenerative arthritis of the left hip joint with loss of joint space and sclerosis of the acetabular roof most prominent in the superior compartment.

Lumbar Spine Radiographs (Images 3 & 4): Moderate to moderately severe multilevel degenerative disc disease most prominent at L4-5 and L5-S1 with loss of intervertebral disc space height, endplate sclerosis and hypertrophic spurring. Moderate rotatory dextroscoliosis.

Relevant Diagnosis’:
Biomechanical lesions of the lumbar spine and left hip
Intervertebral Lumbar Disc Degeneration
Osteoarthritis left Hip
Rotatory Dextroscoliosis

Discussion:
Careful assessment of the clinical presentation and potential differential diagnosis for back and leg pain patients are essential to optimize outcome results. Radiating pain down the leg can be misdiagnosed and cause treatment errors (1)(2). Simple hip tests can help distinguish patients most likely to have hip osteoarthritis from those who do not (3). Examination of all possible causes of the radiating pain should be performed to determine appropriate diagnostic imaging. Given the history of this patient’s herniated lumbar disc causing low back pain with radiating pain down the leg years prior, it is reasonable to expect some practitioners to assume the presenting condition was a flare-up of the pre-existing condition. This assumption would likely lead to inaccurate diagnosis, ineffective treatment, and even expensive and unnecessary imaging orders like a new Lumbar MRI. The patient’s history and exam findings served to determine the appropriate diagnostic imaging to order in this case. The radiographs ordered provided us with an accurate diagnosis and therefore, directly affected the diagnosis and management of this patient.

References:
1. Thorne RP, Curd JG. Radiating leg pain in the older patient. Hosp Pract (Off Ed). 1991 Mar 15;26(3):61-4, 69-72. doi: 10.1080/21548331.1991.11707713. PMID: 1900853.
2. Saito J, Ohtori S, Kishida S, Nakamura J, Takeshita M, Shigemura T, Takazawa M, Eguchi Y, Inoue G, Orita S, Takaso M, Ochiai N, Kuniyoshi K, Aoki Y, Ishikawa T, Arai G, Miyagi M, Kamoda H, Suzuki M, Sakuma Y, Oikawa Y, Kubota G, Inage K, Sainoh T, Yamauchi K, Toyone T, Takahashi K. Difficulty of diagnosing the origin of lower leg pain in patients with both lumbar spinal stenosis and hip joint osteoarthritis. Spine (Phila Pa 1976). 2012 Dec 1;37(25):2089-93. doi: 10.1097/BRS.0b013e31825d213d. PMID: 22588380.
3. Metcalfe D, Perry DC, Claireaux HA, Simel DL, Zogg CK, Costa ML. Does This Patient Have Hip Osteoarthritis?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Dec 17;322(23):2323-2333. doi: 10.1001/jama.2019.19413. PMID: 31846019; PMCID: PMC7583647.