Complete Resolution Of Subjective And Objective Findings With Chiropractic Care And IDD Therapy In A Patient With Disc Extrusion And Radiculuar Symptoms

History

A 37-year-old female presented to the clinic two weeks after she had injured her back. The patient was lifting a door and felt a pain in her lower back and then Immediately felt sharp pain down her left leg from her lower mid back to the bottom outside of her left foot. The patient reported that she felt numbness under the ball of her left foot and outside pinky toe. The patient denied any bladder or bowel problems and stated that she felt no pain, numbness, or tingling down her right leg. The patient stated that the pain was so bad that they were taking 6-8 Ibuprofen every hour to help with the pain and that she had not slept for any length of time in the last 2 weeks. The patient stated they had never experienced pain like this in the past.

SYSTEMS REVIEW

The patient reports a complaint with the following musculoskeletal system, the presenting complaints, the patient denies any other challenges. The patient reports no other no complaints with the following systems, neurological, head, nose and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, and dermatological.

PAST HEALTH HITSTORY

The patient reports an allergy sensitivity to sulfa based medications, and a breast augmentation 4/2011. The patient reports to taking the following medications: pain meds, none other reported. The patient reports the suffering from frequent neck pain, frequent lower back pain, and frequent headaches. The patient reports no accidents.

FAMILY AND SOCIAL HISTORY

The patient reports nothing in her family history, working in an RV factory lifting, bending, twisting and doing laborious work. The patient denies smoking, drinking, or recreational drug use. The patient reports to walking several times per week, and to eating 3 meals per day.
History

Exam

A 37-year-old female presented with a height of 64 inches, a weight of 110 lbs. She had a pulse of 68bpm, blood pressure of128/80 mm/Hg measured using her right arm. The patient’s gait was poor as the patient could only walk a few steps the needed to sit because of pain. The patient’s postural analysis revealed forward head posture present, with the patient being antalgic to the right.
Palpatory Evaluation

Severe muscle spasms in the patient’s erector spinae from lumbar spine to the thoracic spine bilateral were palpated and recorded. The patient’s left piriformis and semitendinosus were in severe spasm. There was hypomobility noted from L1-Sacral base.

Orthopedic Evaluation

The following orthopedic tests were performed: Straight leg raise was positive with the patient indicating an 8 out of 10 (10 being the most severe) pain down her left leg on a verbal pain scale when the left leg was raised to 45 degrees. Raising the left leg also increased the patient’s numbness to the outside of her foot at 45 degrees. Braggards Sign was positive as it increased the patient’s pain down her left leg to an 8 out of 10 (10 being the most severe) on a verbal pain scale.

NEUROLOGICAL EXAM

The following reflexes were tested patellar and ankle and were noted to be normal. Babinski was negative. The following muscle testing of the lower extremity was performed: Hip flexion(L2), Knee extension(L3), Ankle dorsiflexion(L4), Big toe extension(L5) was equal and within normal limits 5/5. Left foot plantarflexion resistance was graded a 3/5 compared to the right and the patient could not stand on her toes as her left plantarflexion muscles were too weak to hold her left heel off the ground. The following sensory test of the lower extremity revealed loss of sensation on her outside left calf S1 dermatome compared to her right. All other L1-L5 dermatomes were within normal limits. Radiographs of the lumbar spine revealed a loss of disc height between L4-L5 on the lateral view and a left leaning lumbar spine on the A to P view. Otherwise, normal alignment. No signs of fractures or tumors. The plan was to order a lumbar MRI due to the loss of muscle function and dermatomal abnormality at the left S1 nerve. The patient was told to ice at home in the lower back for 15-20 minutes every hour until the MRI was performed and further results were received. The MRI was to be obtained the same day, and patient was scheduled to return the following day for her results.

Findings

MRI of the Lumbar Spine (1Day post Initial Exam)
MRI of the lumbar spine shows evidence of a left paracentral disc extrusion type herniation with a caudal migration at the L5-S1 disc level [1]. The disc material appears to efface the left ventral aspect of the thecal sac and causes displacement of the left S1 nerve root. There is no osteophyte formation present which would be consistent within the patient’s injury time frame explained via Wolff’s law [2]. A high signal is noted coming from the central nucleus pulposus out into the outer layers of the posterior annulus fibrosis or herniation, which indicates a newer injury [3].

Differential Diagnosis

Initial Diagnosis
Lumbar radiculitis, Lumbar Sprain Strain.

Updated Diagnosis: