Chief complaints:-

Patient c/o low back pain for 6 years.

History of presenting illness

Patient apparently alright 6 years back, when she started having low back pain from 6 years, insidious onset, gradually
progressive, more on standing for long duration, aggravated from 6 months.

h/o pain , sharp type, radiating to Left lower limb, insidious onset, gradually progressive, mildly relieved on
medications, no h/o diurnal variation,

h/o neurogenic claudication present, for 100 mtrs,

h/o difficulty in walking present, h/o difficulty in getting up from squatting position,

No h/o trauma present

No h/o slippage of chappals present,

No h/o cotton wool sensations,

no h/o difficulty in percieving hot and cold sensations,

no h/o bowel and bladder complaints,

no h/o difficulty in rolling over the bed, lifting head ,

no h/o cranial nerve involvement

Past History

known case of T2DM, on medication

no h/o bronchial asthma, TB, HTN.

Personal History

diet-mixed

appetite-normal,

sleep- disturbed

bowel and bladder –regular

Family history:

Not significant

GENERAL EXAMINATION:-
Moderately built and nourished.

T- normal

BP- 120/80 mm HG

RR- 16/min

Pulse- 84/min

GCS- E4V5M6

Pupils- both 3mm equally reactive to light

Cranial nerve examination

CN 1:Intact

CN 2:

Visual acuity: RE 6/6 LE 6/6

Visual fields: Normal

Color vision: Normal

Fundus: Normal

CN 3,4,6 EOM Normal

CN 5- V1 V2 V3 Normal

Sensory: Normal

Motor : Normal

Corneal reflex-

Eye Direc Consensual

t
present present
Right
eye
present present
Left eye

Jaw jerk- Present

CN 7- Normal

CN 8-
 Test Right Left

Rinne AC > BC AC > BC

Weber not lateralised not

lateralised

CN 9,10:
Uvula – Midline
Palatal movement- Normal

Gag Reflex- Normal

CN11: Normal

CN12
:
Tongue - Bulk - Normal
Deviation - No
POWER:-

tone and bulk-normal

RIGH LEF
T T
Shoulder Flexion 5/5 5/5

Extension 5/5 5/5

Adduction 5/5 5/5

Abduction 5/5 5/5

Elbow Flexion 5/5 5/5

Extension 5/5 5/5

Wrist Flexion 5/5 5/5

Extension 5/5 5/5

Hand grip 100% 100

%
Hip Flexion 5/5 5/5

Extension 5/5 5/5

Adduction 5/5 5/5

Abduction 5/5 5/5

Knee Flexion 5/5 5/5

Extension 5/5 4+/5

Ankle Dorsiflexion 5/5 4+/5

Plantar Flexion 5/5 4+/5

EHL 5/5 4+/5

Reflexes :
Superficial- present
Abdominal reflexes- present
Plantars- flexor
 Deep Tendon Reflexes : B T S K A

Right 2+ 2+ 2+ 1+
- 2+
Left- 2+ 2+ 2+ 2+ 1+

Sensory system:-

Touch – intact
Rhomberg’s sign- negative
2 point discrimination test- intact
Vibration sense- intact
Joint position sense-

Cerebellar signs:-
Dysdiadochokinesia- absent
Finger-nose test- intact
Finger-nose-finger test- intact
Knee-heel-shin test- intact
Pendular knee jerk- absent
Rebound phenomenon- absent

Other system examination:-

Cardio-vascular system- S1,S2+

Respiratory system- NVBS+, BE+
Per abdomen- soft

MRI s/o L3-L4 grade 1 listhesis with degenerative changes,

CT s/o L3-L4 Grade 1 listhesis with pars fracture

DIAGNOSIS- L3-L4 Grade 1 listhesis with pars

fracture

Case discussed with Dr. Ramesh Chandra (HOD

neurosurgery):-

Advice:- L4 L5 TLIF