Location
Philadelphia, PA
Start Date
10-5-2021 12:00 AM
End Date
13-5-2021 12:00 AM
Description
Setting: Outpatient Pain Management
Patient: A 37-year-old female with no significant past medical history presents with low back pain and unilateral lower extremity weakness two weeks after a motor vehicle accident.
Case Description: This patient presented to the office with a chief complaint of new right sided low back pain and right lower extremity weakness. History revealed that the patient was involved in a motor vehicle accident (MVA) several weeks prior to presentation. She was the restrained driver and was hit from behind by another motorist. The patient noted that she immediately felt stiffness in her low back, but did not have any lower extremity pain or weakness at that time. Throughout the course of the day, she began to experience right-sided low back pain and continued muscle stiffness. The patient was prescribed cyclobenzaprine and methylprednisolone which initially provided mild relief. Two weeks later, the patient began developing right lower extremity weakness that was associated with recurrent falls. These symptoms necessitated the use of a cane for ambulation. Due to worsening condition, the patient was sent for an MRI of the lumbar spine by her primary physician. MRI revealed a relatively mild disc herniation at L5, and she was referred to interventional pain management for further evaluation and treatment.
Assessment/Results: Musculoskeletal exam was significant for tenderness to palpation along the right lumbar spine with radiation into the posterior right lower extremity. Gait analysis revealed right foot drop which presented as a high steppage gait with right foot inversion and plantarflexion. Neurological examination revealed impaired strength of the bilateral lower extremities, most notably in the tibialis anterior and extensor hallucis longus muscles. Right and left lower extremity motor strength were 0/5 and 4/5, respectively. Sensation was decreased along the right L5 and S1 dermatomes when directly compared to sensation on the left. The patient was subsequently diagnosed with right L5 lumbar radiculopathy secondary to disc herniation. Due to the severity of symptoms, she was immediately referred for urgent orthopedic evaluation. Repeat MRI of the lumbar spine was significant for severe L5 disc herniation with complete obliteration of the L5 nerve root. The patient was scheduled for urgent discectomy by orthopedic surgery, and is currently pending follow-up with outpatient pain management.
Discussion: Lumbar radiculopathy can present as new onset low back pain radiating to the lower extremities and is associated with both motor and sensory abnormalities. As seen in this case, lumbar radiculopathy of the L5 nerve root can present after trauma, and the patient may initially experience localized pain that later progresses to severe motor deficits.
Conclusion: Clinicians should have a high-index of suspicion for neurological involvement in patients with low back pain that develop new onset motor and sensory deficits after trauma. Acute onset and rapid progression of symptoms warrants additional imaging and urgent surgical consultation.
Embargo Period
6-10-2021
A 37-year-old female with low back pain and acute lower extremity weakness
Philadelphia, PA
Setting: Outpatient Pain Management
Patient: A 37-year-old female with no significant past medical history presents with low back pain and unilateral lower extremity weakness two weeks after a motor vehicle accident.
Case Description: This patient presented to the office with a chief complaint of new right sided low back pain and right lower extremity weakness. History revealed that the patient was involved in a motor vehicle accident (MVA) several weeks prior to presentation. She was the restrained driver and was hit from behind by another motorist. The patient noted that she immediately felt stiffness in her low back, but did not have any lower extremity pain or weakness at that time. Throughout the course of the day, she began to experience right-sided low back pain and continued muscle stiffness. The patient was prescribed cyclobenzaprine and methylprednisolone which initially provided mild relief. Two weeks later, the patient began developing right lower extremity weakness that was associated with recurrent falls. These symptoms necessitated the use of a cane for ambulation. Due to worsening condition, the patient was sent for an MRI of the lumbar spine by her primary physician. MRI revealed a relatively mild disc herniation at L5, and she was referred to interventional pain management for further evaluation and treatment.
Assessment/Results: Musculoskeletal exam was significant for tenderness to palpation along the right lumbar spine with radiation into the posterior right lower extremity. Gait analysis revealed right foot drop which presented as a high steppage gait with right foot inversion and plantarflexion. Neurological examination revealed impaired strength of the bilateral lower extremities, most notably in the tibialis anterior and extensor hallucis longus muscles. Right and left lower extremity motor strength were 0/5 and 4/5, respectively. Sensation was decreased along the right L5 and S1 dermatomes when directly compared to sensation on the left. The patient was subsequently diagnosed with right L5 lumbar radiculopathy secondary to disc herniation. Due to the severity of symptoms, she was immediately referred for urgent orthopedic evaluation. Repeat MRI of the lumbar spine was significant for severe L5 disc herniation with complete obliteration of the L5 nerve root. The patient was scheduled for urgent discectomy by orthopedic surgery, and is currently pending follow-up with outpatient pain management.
Discussion: Lumbar radiculopathy can present as new onset low back pain radiating to the lower extremities and is associated with both motor and sensory abnormalities. As seen in this case, lumbar radiculopathy of the L5 nerve root can present after trauma, and the patient may initially experience localized pain that later progresses to severe motor deficits.
Conclusion: Clinicians should have a high-index of suspicion for neurological involvement in patients with low back pain that develop new onset motor and sensory deficits after trauma. Acute onset and rapid progression of symptoms warrants additional imaging and urgent surgical consultation.