Case Study: Low Back Pain - 2
Subjective - This patient is a 74 year old man who is a retired laborer and lives alone. His chief complaint is mid- and lower- central lumbar pain and pain in both posterior thighs and calves. Both pains are increased when he is standing erect or walking. These pains are decreased when he is sitting or forward trunk bending. This patient frequently develops difficulty raising his feet from the ground when he has walked more than one block. When this happens his legs become completely numb. This problem, ie. paralysis after walking, began 3 years ago but is getting progressively worse. He was referred to you by his primary care physician with a diagnosis of severe DJD of the spine. He has received no previous care for this problem. His past medical history is remarkable for a compression fracture of L4 vertebral body 20 years ago due to a motor vehicle accident. He states that he recovered from this problem but he has had back problems since then. He also has a history of COPD, and is S/P myocardial infarction X 1 with stable angina. He has recurrent bladder infections. Currently his only medication is nitroglycerin PRN. His goals are to be able to walk to and from the grocery store and do his household chores.
Objective - This patient is a thin, elderly gentleman, who stands with a forward-bent posture. He has mild atrophy of the leg muscles (anterior and posterior leg compartments) bilaterally, although calf and thigh girth are symmetrical. His range of motion is as follows: trunk FB 90% with decreased back and leg pain reported, BB 10% and increases his leg pain, SB is 15% bilaterally and is not painful, trunk rotation is 45% and not painful, LE ROM is WNL, SLR is limited by hamstring tightness at 45 degrees. Segmental motor testing shows normal motor performance except 3-/5 strength for all anterior compartment muscles (L4-5) bilaterally and 2+/5 for all posterior compartment muscles (L5-S1) bilaterally. Sensory testing shows mild decreased light touch in L4-S2 dermatomes bilaterally. His DTR's are normal except for hyperactive achilles reflexes bilaterally. He has a (+) Babinski sign bilaterally. During palpation of the lumbar spine the patient reports increased leg pain with P-A pressures over spinous process of L4-L5. The SI joint provocative tests are negative.