A 38 y/o male with acute low back pain and left leg pain sustained at work when lifting cabinets.
PMH/PSH: healthy, Bilateral inguinal herniorraphy @ age 25, tonsillectomy @ age 4
Fam. HX Father A&W, Mother with hypercholesteremia, CAD S/P MI, S/P CABG, 3 brothers, 1 sister A&W.
Social Hx: married, 2 children ages 2 and 5, wife works part-time as accountant. Denies tobacco use, weekend drinker (12-18 cans of beer).
ROS: occasional heartburn, takes OTC Tums or Rolaids, average twice a week. Urinary complaints are new: no dysuria, but does not feel bladder empties all the way and is going to the bathroom q 3-4 hours. Somewhat constipated: frequency decreased from 2-3x/day to once per day.
Vital signs: BP 145/88, HR 95, RR 20, Temp 36.8 0C, VAS 9/10
Posture: trunk listed to right, decrease ability to wt bear L leg.
Gait: antalgic, decrease stance time on L, unable to test heel or toe walking
Trunk ROM: decreased backward bending, (unable to stand erect/neutral), side bending R 20 0-45 0, side bending L –10 0
Neuro: DTR’s +2/4 KJ and AJ Bilaterally; down going toes Bilaterally; Motor 5/5 except L tibialis anterior. 3+/5, extensor hallucis longus 3-/5; sensation: decreased to pinprick in L L5 dermatome. Rectal wink present
SLR test: + on L @ 45 0, reproducing pain in L leg
Palpation: increase muscle tone noted in R>L lumbar paraspinals.
MRI: confirmed large left paracentral herniated nucleus propulsis at L4-5 impinging on the anterior thecal sac and compressing the L 5 nerve root. Moderate central canal stenosis, degenerative disc and joint disease L3-4, L5-S1.