Case: 57-year-old Woman with Leg and Back Pain

00:00 Let's start with a case. This is a 57-year-old who presents with leg and back pain.

00:08 The pain arises around the posterior buttocks and radiates down her bilateral lower extremities and is worse on the left. On the right, she has pain in her knee which is worse with activity and better with rest, at times with swelling. On the left, she has pain radiating from her left buttocks down to her toes with some associated tingling. So here we're hearing about 2 processes; one sounds like some inflammation in the knee which may be unrelated and the second sounds like a radiculopathy.

00:40 Pain beginning in the buttocks radiating down to the toes which is suggestive of nerve root impingement in the lumbosacral spine. Let's look at the exam. The exam for this patient shows 5/5 strength in the right lower extremity, nearly 5/5 strength in the left lower extremity but testing is limited by severe pain and decreased effort in this leg. Deep tendon reflexes are 2+ and symmetric in the upper extremities.

01:09 There is no problem in the arms. In the lower extremities, there is 1+ right patellar reflex, absent left patellar reflex, and trace bilateral ankle jerks. Plantar responses are flexor bilaterally. Sensation is slightly reduced to light touch over the left lateral thigh and posterior calf, but otherwise normal vibration and proprioception are present in the bilateral lower extremities. And the gait is antalgic or painful with a left leg limp. So let's look at some of the key features here. The first is asymmetry of the deep tendon reflexes at the patella. There is absent left patellar reflex on the left and 1+ on the right. In addition, we see reduced light touch over the left lateral thigh. Each of these is supporting a focal nerve problem in the left lower extremity. Typically, these patients would be evaluated by imaging and potentially with nerve conduction study. Here, we're looking at an MRI of the lumbar spine, the sagittal section, without contrast and we see degenerative changes.

02:19 Multiple intervertebral discs throughout the lumbar spine where there is herniation of the intervertebral disc material encroaching and compressing narrowing the thecal sac in the lumbar spine. If we look at both the sagittal and the axial sections particularly at the level where this patient's symptoms are arising, you can see here the sagittal section which helps us to understand where we are and the middle and right image are the axials. We see a normal neuroforamen on the right side and on the left side of the patient's body we see severe narrowing of the neuroforamen. There's herniation of the disc laterally encroaching on the neuroforamen and nerve. We also see thickening of the ligamentum flavum posteriorly resulting in pinching of this nerve root as it exits the spinal cord.