Dr. MZ Ebrahim
As the saying goes, “common things occur commonly”. That being said, not all clinical features suggestive of a lumbar radiculopathy are a result of a herniated lumbar disc.
My practice received the following referrals in the last few months, these cases clearly illustrate the value of further investigation when conservative management has failed.
A 75 year old female was referred for my opinion with a 2 month history of progressively worsening right sided leg pain. There was no clear dermatomal distribution to her pain and she presented with no back pain or sphincter dysfunction. She had difficulty walking and was bed bound for a week due to her pain, which had a poor response to analgesics. She had no medical co-morbidities.
Her neurological examination revealed a positive straight leg raise on the right with no other clinical findings. X-rays of her lumbar spine showed mild degenerative changes.
However, an MRI of her lumbar spine revealed a right L4/5 facet cyst causing compression of the thecal sac and lateral recess stenosis.
A lumbar laminectomy and decompression was then performed with excision of the cyst.
Her pain has since completely resolved following surgery and she has remained symptom free with return to full independent mobility.
An 80 year old male was referred with lower back pain and severe right leg pain in the distribution of the L3 nerve root.
He had a normal neurological exam, and his back pain had settled with analgesics and physiotherapy. His right leg pain, however, persisted and got progressively worse.
An MRI of the lumbar spine revealed multi-level degenerative changes of the lumbar spine without significant compression of any neural structures or any features to explain the patient’s symptoms.
The X-ray examination of the pelvis, hips, right femur and knee were all normal and an ultrasound of the leg revealed no venous thrombosis.
In this case, an additional MRI of the right proximal leg, was indicated. This revealed a tumour in the region of the mid-shaft of the femur with features of malignancy.
He was referred to an orthopaedic surgeon for excisional biopsy and further management.
Taking into consideration cases as described, we should have a low threshold to investigate patients with back and leg pain, who fail conservative management. It is important to identify “red flags” and to be cautious with patients presenting with pain that is out of keeping with clinical findings.
It is important to note, that in these situations, even in the absence major neurological deficit, further opinion and investigation should be sought. Surgery may not always be indicated, but conservative management can only be safely continued once other diagnoses have been excluded with the relevant investigations.