Case Study #2

The patient is complaining of back pain that starts in her back and radiates down
her posterior left thigh. It has been going on for six months and gradually getting worse.
It is worse when first arising from bed and at rest.

I would first ask her what type of pain is it? Numbness and tingling can indicate
spinal stenosis as the space in the spine narrows and compresses the nerves. I would
ask if the pain goes past her left thigh farther down her leg? If it does this could indicate
spinal stenosis as the nerves being compressed go all the way down the leg.
Numbness or tingling down to the foot would point to spinal stenosis. I would ask if she
notices if it gets worse with activity? Pain during activity would indicate spinal stenosis.
But, since she says it is usually worse in the morning this may be unlikely. I would ask if
she is more comfortable in flexion or extension? Flexion would be positive for spinal
stenosis as it is taking pressure off the posterior side of the spine where the nerves are
being compressed. I would ask if there were any sudden injuries that could have caused
this? Spinal stenosis can sometimes be brought on sudden injuries such as a fracture
to the vertebrae. I would ask if she notices any weakness in her muscles? Spinal
stenosis causes the muscles to be weaker as the nerves that innervate them are being
compressed.

I would continue to ask her if the pain stops at her buttocks? If the pain does not
go all the way down her leg this would be more positive for a disc lesion. I would ask if
she has had pain before in the same area? A disc lesion can sometimes be caused by
repetitive disc spains. I would ask her what she does for her occupation or any hobbies
that would put stress on her back? Lumbar disc lesions can be caused by repetitive
mechanical stress leading to disruption and weakening of the annulus. I would ask her
how she sleeps at night, weather on her back or her stomach or on her side? Since she
has pain when she wakes up, we usually sleep with our back in extension. This would
suggest a disc lesion. I would ask if she has any back spasms? This would also
suggest a disc lesion.
 I would test her AROM and PROM in lumbar flexion and extension. Extension
would put pressure on the posterior side of the spinal column and could indicate spinal
stenosis and pain in flexion would more likely be a lumbar disc lesion as the nerves are
being stretched. I would take her through the slump test. The slump test is most
indicative of the lumbar disc lesion if she felt pain in flexion. The slump test would also
test for the myotomes. I would also have her do the valsalva maneuver which could be
positive for spinal stenosis or lumbar disc lesion. I would assess her patellar reflex and
achilles reflex.

Since it has been gradually getting worse over a period of time I would predict
that she has a lumbar disc lesion. I would also say this because spinal stenosis is more
common in patients that are over 60 and our patient is 36. She also did not mention any
numbness or tingling which is the main symptom of spinal stenosis.

The goal of treatment would be to decrease inflammation and pain, improve core
strength and decrease compression. Treatment for this patient would start with
ibuprofen to decrease swelling and lessen pain. The patient should avoid sitting for long
periods of time. She would also be prescribed at home rehabilitation with exercises
such as cat/cow to improve mobilization, core stabilizer exercises such as bird dogs,
side plank and dead bug, and exercises associated with sciatic nerve flossing. Sciatic
nerve flossing has been shown to reduce pain and inflammation and increase mobility.