CASE PRESENTATION

• MODERATOR – DR THOMAS KISHAN

• PRESENRER – DR SWAMY O G R
SPINE CASE
• Demographic details
• Name : ALI ATEF AHMED MD KHAN
• IP Number: 10669899
• Age: 38 y
• Gender: male
• Residence : DUBAI , ARABIA
• Profession : MANAGER
• Education ; GRADUATE
HOPI

• Patient was apparently alright 1 years back, when he

developed low backache which was insidious in onset,
gradually progressive

• Associated with tingling sensation to his Left leg

• Pain was dragging in nature
• Radiating from lower back to back of the thigh till the left
foot and the toes
• Pain increases on trying to maintain an upright posture
• Pain reduces when he stoops forward
• Patient develops pain and tingling sensation or heaviness in
both lower limbs more so in the left.
• Pain becomes so severe that he has to take rest for a minutes
• Then the symptoms settle down temporarily and allow him
to walk further the same distance
• Pain increase with coughing and sneezing
• Patient is having difficulties in performing his activities of
daily routine
• Patient is having disturbed sleep
• Difficulty in sitting cross legged or squatting due to pain
• No history of…
• Significant trauma
• Constitutional symptoms (fever, loss of weight)
• Burning micturition
• Other joint pains
• Morning stiffness
• Lifting of heavy weights
• Not a known case of ...

• Diabetes
• Hypertension
• Tuberculosis
• Asthma
• Epilepsy
• Hypothyroidism
• Past history : no significant past history
no h/o of any hospital admissions , previous medications
• Personal history : not significant
• Bowel and Bladder habits normal
• Sleep disturbed
• Appetite normal
• No h/o allergies
• Mixed diet
• Not a known alcoholic or a smoker
• Family history : not significant
 Conclusion
• 38 year old male with low backache with left radicular pain since 1
years, which reduces on bending forward. The pain is of significant in
nature altering his sleep and ADL.
• No history of trauma/lifting weights, constitutional symptoms
• No complains of muscle weakness or bowel bladder involvement

• Ddx
• Lumbar Canal stenosis
• Degenerative Disc Disease
• Spondylolisthesis
• General examination
• Moderately built and nourished
• Conscious to time place & person
• No pallor /icterus /cyanosis/clubbing/lymphadenopathy/edema
• Pulse 86/min
• Blood pressure 110/80 mmHg right upper-limb
• Gait
• Patient is having a gait with forward stoop
• Patient able to walk on toes
• Has difficulty in walking on heels

• Attitude
• Patient lies on the bed with mild discomfort with his hands by the
side of his trunk and legs in neutral position
Spine examination
• Examined the patient from front, back,side and the patient
being in supine prone and in sitting position

• Inspection :
• Head is central in position with both the shoulders being at the
same levels
• Chest and the rib wall appears to be normal
• Natural Lordosis of the cervical region maintained
• Thoracic Kyphosis is well maintained
• Lumbar lordosis seems to be lost
• Inspection ( contd)
• No deformity of the back. No step sign
• Paraspinal muscle appear to be taut
• NO evidence of scoliosis or step off deformity
• List towards right side
• Both shoulders, scapular spine, inferior angle of the scapulae and the
PSIS appear to be at the same level
• No e/o low lying hairline
• No webbing of neck
• No presence of any swelling, sinuses engorged veins scar marks or any
skin markers
• Palpation
• Inspectory findings are confirmed
• No evidence of local rise of temperature
• Bony landmarks appear to be normal
• Paraspinal muscles appear to be taut
• Spinous process
• Defects – absent
• Thickening/deformity – absent
• Alignment – appears normal
• Tenderness – present over the L4 L5
Superficial tenderness
Thrust tenderness
Twist / Rotatory tenderness

• Tenderness at Lumbar triangle of Petit tenderness absent

MOVEMENTS

SPINE MOVEMENT DEGREE INFERENCE

CERVICAL FLEXION 0 - 50

EXTENSION 0 – 40 NOT ASSOSICATED WITH PAIN /

SPASM
LATERAL FLEXION 0 – 30 (B/L)

LATERAL ROTATION 0 - 60

THORACIC ROTATIONS 0 - 50 NOT ASSOSICATED WITH PAIN /

SPASM
LUMBAR FLEXION 0 – 40 PAINFUL AND RESTRICTED TO 30

EXTENSION 0 – 40 PAINFUL AND RESTRICTED TO 20

LATERAL FLEXION 0 – 30 PAINFUL AND RESTRICTED TO 10

MEASUREMENTS
• Illio occipital distance – 38 cm
• Illio costal distance -15 cm
• Chest expansion - 6 cm
MEASUREMENTS

MUSCLE WASTING RIGHT LEFT

Arm circumference 29cm 29cm

Forearm circumference 23cm 23cm

Thigh circumference 53cm 52cm

Calf circumference 36cm 35cm

Special tests
TEST FINDINGS

STRAIGHT LEG RISING TEST POSITIVE POSITIVE

WELL LEG RISING TEST/CROSSED SLRT /FRAJERSZTAJN POSITIVE POSITIVE

TEST
LASEGUE’S TEST / BRAGARD’S TEST POSITIVE POSITIVE

MODIFIED LASEGUE’S TEST/ KERNIG’S TEST POSITIVE POSITIVE

BOWSTRING SIGN OF MCNAB POSITIVE POSITIVE

FEMORAL NERVE STRETCH TEST/REVERSE SLRT POSITIVE POSITIVE

• Test for SI Joint
• Patrick/Fig of 4 test - positive
• Pelvic compression test – positive
• Pelvic distraction test – positive
NEUROLOGICAL EXAMINATION

Higher Mental Functions:

• Conscious
• Well oriented to time, place and person.
• Speech, Memory & Intelligence– Normal.

Cranial Nerve Examination:

• Cranial nerves – examination of cranial nerves Normal.
MOTOR EXAMINATION:
PARAMETER LIMB REGION RIGHT LEFT

BULK UPPERLIMB ARM Equal on both -

sides
FOREARM Equal on both -
sides
LOWER LIMB THIGH - Reduced

CALF - Reduced

TONE UPPER LIMB NORMAL NORMAL

LOWER LIMB NORMAL NORMAL

PARAMETER REGIONS RIGHT LEFT

POWER – UPPER C5- SHOULDER 5/5 5/5

LIMB ABDUCTORS
C6 – ELBOW 5/5 5/5
FLEXORS
C7 – ELBOW 5/5 5/5
EXTENSORS
C7 – WRIST 5/5 5/5
EXTENSORS
C8 – FINGER 5/5 5/5
FLEXORS
T1 – FINGER 5/5 5/5
ABDUCTORS
PARAMETER REGIONS RIGHT LEFT

POWER – LOWER LIMB L2 – HIP FLEXORS 5/5 5/5

S1 – HIP EXTENSORS 5/5 5/5
L3 – HIP ADDUCTORS 5/5 5/5
L5 – HIP ABDUCTORS 5/5 5/5
L3 – KNEE EXTENSORS 5/5 5/5
S1 – KNEE FLEXORS 5/5 5/5
L4 – ANKLE DORSIFLEXORS 5/5 5/5
S1- ANKLE PLANTAR FLEXORS 5/5 5/5
L5 – GREAT TOE EXTENSOR(EHL) 5/5 4/5
S1 – GREAT TOE FLEXOR(FHL) 5/5 5/5

• No involuntary movements.
• Normal co-ordination
• Superficial reflexes
• Abdominal reflexes T7-T12 - intact
• Plantar reflexes L5-S1– normal both sides
• Cremastric reflexes L1-L2 – normal
• Anal reflex S3-S4 – normal
• Bulbocavernal reflex S3-S4– normal
DEEP REFLEXES RIGHT LEFT

BICEPS REFLEX – (C5) NORMAL NORMAL

SUPINATOR REFLEX – (C6) NORMAL NORMAL

TRICEPS REFLEX – (C7) NORMAL NORMAL

KNEE REFLEX – (L3, L4) NORMAL NORMAL

ANKLE REFLEX – (L5, S1) NORMAL NORMAL

CLONUS:
PATELLAR CLONUS ABSENT ABSENT
ANKLE CLONUS ABSENT ABSENT
SENSATION RIGHT AT L5 dermatome LEFT AT L5 dermatome

• TOUCH FINE TOUCH INTACT Sensation decreased by

25% compared to normal
dermatome
DEEP TOUCH INTACT Decreased by 50%
• PAIN SUPERFICIAL INTACT Decreased by 50%
DEEP INTACT Decreased by 50%
• TEMPERATURE HOT INTACT Decreased by 50%
COLD INTACT Decreased by 50%
• VIBRATION INTACT Decreased by 50%
• PROPRIOCEPTION INTACT NORMAL
 PERIPHERAL PULSES:
• Dorsalis Pedis: Felt bilateral, with equal volume.
• Posterior Tibial: Felt bilateral, with equal volume.

OTHERS:
• Examination of B/L hip and knee joint – Normal.
• Lymph nodes examination – Normal.
• Per Rectal examination - Normal
 Summary
• 38 year old male with low backache with left radicular pain
since 1 year
• Forward stooping gait and weakness on walking on heel
with lumbar paraspinal muscle spasm
• Painful restriction of lumbar movements & muscle wasting
left lower limb
• Positive special tests & altered sensation at L5 dermatome
• Weakness of EHL(L5) with no bowel / bladder deficits
Diagnosis

• Left sided L5 nerve root radiculopathy most probably due to

SPINAL CANAL STENOSIS secondary to
• Disc disease
• Ligament or facet arthritis
• What are the investigations u do ?
X rays
• Points
• AP View
• Psoas soft tissue shadow
• Spinous process alignment
• Pedicle; check presence bilaterally
• Vertebral body and disc
• Facet joints
• Sacrum, sacral ala, sacroiliac joints
• Lateral View
• Vertebral body contour and alignment
• Intervertebral disc space height
• Pedicles, spinous processes, superior and inferior articular processes, intervertebral foramina
X rays
MRI
MRI
MRI
MRI
Final diagnosis
• Lumbar Canal Stenosis at L4-L5 with L5 nerve root involvement
secondary to Degenerative Disc disease.
Thank you