Herniated Disc of the Lumbosacral Rachis
Short summary
72-year old male experiencing lower limb pain with exacerbation after physical exercise. Radiological findings suggest chronic lateral recess stenosis. The recommended treatment is root block injections and surgical decompression.
Patient's questions
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What therapy would you recommend?
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Would you advise any further diagnostic tests?
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What is the prognosis?
Medical Background
72-year old male experiencing lower limb pain with exacerbation after physical exercise.
Arterial hypertension, under therapy with Sequacor, 2.5 mg;
Migraine;
Relapsing prepatellar bursitis of the kneecap diagnosed in April 2006 and for which the patient underwent bursectomy in June 2006;
Bilateral gonarthrosis;
Recent heavy epigastric pain (November 2007) radiating into the back and responding to therapy with pump inhibitors for suspected gastropathy.
Current medical status:
Examined by a neurologist on September 21, 2007 for pain in the lower right limb exacerbated after physical rehab cycle (probably TENS), after a walk on the shore-line and an attempt of psammatotherapy (autochthonous).
The exam showed negative Laseguè’s sign, hyporeflectivity of the right Achilles deep tendon reflex and TTD hypoesthesia of the dermatomerically corresponding region. A vertebral-medullary lumbrosacral CAT scan is recommended, placing temporarily the patient under injective therapy with Dicloreum 75 mg and Muscoril.
The rachis and vertebral canal CAT scan, between L2 and S1, taken on October 13, 2007 shows:
“Disc L2-L3 normal. Minimum protrusion of the posterior edge of the L3-L4 disc. The L4-L5 disc shows a reduction in height with a modest protrusion of its posterior edge and minimum engagement of intervertebral foramen. The L5-S1 disc shows an even greater reduction in height. Protrusion of its posterior central edge in calcification areas. Interapophyseal arthrosis more accentuated at L4-L5 and L5-S1, diameters of the vertebral canal are normal”.
Medical opinion
A 72 year old man complaining of Rt. Lower limb pain with exacerbation after physical exercise (I am not sure that the assumption of TENS is correct) and walking. On physical examination there were signs of Rt. S1 root impairment (reduced RT Achilles tendon reflex and corresponding sensory findings). Radiological findings suggest chronic lateral recess stenosis, finding consistent with the clinical data of the patient. Although the L5-S1 seems to me as the most probable site, I would be glad to see the CT scan and perform a M.R.I. scan to validate this idea.
Assuming L5-S1 lateral recess stenosis is the cause of the patient's complaints, I would suggest acting gradually: recalling that physiotherapy and medication didn't help the patient, the next logical step is to perform aroot block at the RT. L5-S1 level. Clinical improvement may support the diagnosis and serve as a treatment modality (it can be repeated several times). If root block injections give beneficial but temporary results, surgical decompression should be considered (laminectomy and foraminotomy). Prognosis of lateral recess stenosis is good. In some patients spontaneous improvement may appear, with or without conservative treatment. The outcome of surgical decompression is favorable but the possibility of surgical complications should be kept in mind. The patient should also realize that his walking ability may be limiter by other problems, such as gonarthrosis.
