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Right cervical brachialgia from cervical arthritis with low back pain with slight left sciatica from L4-L5 and L5-S1 discopathyThe patient is 36 years of age with no significant previous medical conditions. From around 2 years prior to this report, she has reported right cervical brachialgia from cervical arthritis. Low back pain with slight left sciatica from L4-L5 and L5-S1 discopathy. At the specialist visit the patient’s spinal column appeared mobile and free of pain in the lumbosacral region. Lasègue’s sign slightly positive on left. No neurological deficits in upper and lower limbs. The orthopedic specialist ordered the following: ESR (ErythroSedimentation Rate =7), AST (AntiStreptolysin Titre =70), CRP (C-Reactive Protein =0.10), Alpha-1-Glycoprotein = 48 (the only abnormal value, range 51-117), Reuma Test (Reumatoid Factor =10), Waaler-Rose Reaction (negative) and x-rays. The result of the lumbosacral spinal column x-ray of just over 11/2 years prior was as follows: “metamers largely in axis and normally aligned. Reduction in physiological lumbar lordosis. Reduction in amplitude of intersomatic space between L5-S1. Left L5 hemisacralization. No focus-like structural bone lesion”. A CAT scan of L3-S1 carried out 2 days after x-ray showed the following: “Signs of widespread spondyloarthritis. Significant reduction in the space L5-S1 with stenosis of the spinal channel and median posterior osteophyte formation, resulting in compression of corresponding endochannel structures. No clear morphodensitometric abnormalities were observed in the remaining spaces that were examined.” The full spinal column x-ray carried out 5 month prior showed the following: “Reduction in physiological cervical lordosis. Slight right convex scoliosis of lumbar tract. Left hemisacralization of L5. Misalignment of iliac crests and femoral heads towards left side by 1.2 cm”. Another specialist visit 1 month prior confirmed: “Lumbalgia with slight left sciatica from L5-S1 vertebral stenosis. The spinal column appeared mobile and free of pain in the lumbosacral region. Lasègue’s sign slightly positive on left. Postural physio-kinetic therapy, swimming and massage therapy are advised.”
Questions:
Medical Report:
Diagnosis: Spinal Stenosis L5-S1 Slipped Ring apophysis L5 Disc herniation (bulge) L4-5 Transitional vertebrae L5 The patient is 36 years of age with no significant previous medical conditions. For about 2 years, she has reported right cervical brachialgia from cervical arthritis. Low back pain with slight left sciatia from L4-L5 and L5-S1discopathy. At the specialists visit the patient´s spinal column appeared mobile and free from pain in the lumbosacral region. Lasegue´s sign slightly positive on left. No neurological deficits in the upper or lower limbs.
Labratory tests: ESR (Erythmosendimentation Rate=7), AST (Antistreptolysin Titre=70), CRP (C reactive protein=0.10), Alpha-1-Glycoprotein=48 (the only abnormal value, range 51-117), Reuma Test (Reumatoid factor=10), Waaler-Rose reaction, negative. A second physical exam by another specialist over 1 1/2 years before this report confirmed, "Lumbatia with slight left sciatia from L5-S1disc vertebral stenosis. The spinal column appeared mobile and free of pain in the lumbosacral region. Lasegue´s sign slightly positive on Left. Postural physio-kinetic therapy, swimming and massage therapy are advised."
The result of the lumbosacral spinal column x-ray of just over a year and half prior was as follows: slightly reduced lumbar lordosis, narrowing of the L5-S1 disc space and transitional L5 vertebrae (partial sacrilization of L5 vertebrae). Obligue revealed no sign of spondylolysis.
A CAT scan of L3-S1carried out 2 days after x-ray showed the following: Mild facet arthropathy and bulge of the intervertebral disc (central and to the left) in the L4-L5 level. On the L5-S1 level there is central bony rim narrowing the spinal canal with central compression of the dural sac and some Lt. Foraminal stenosis.
Discussion: a young patient , unknown history of occupation, sport activities and smoking with back pain slightly radiating to the left lower limb. Physical examination revealed sparse positive findings. On radiological examination mild disc bulge, central and to the left on the L4-L5 level and L5-S1 stenosis due to what appear to be slipped ring apophysis. There is mild facet arthropathy that in such young patients suggests premature degeneration (smoking?). I believe that the radicular symptoms are mainly due to the L4-5 disc but some lateral recess stenosis on the left L5-S1 level may also have some contribution. The spinal stenosis on L5-S1 level may also pose some difficulty in the future due to additional degeneration and further narrowing of the canal.
The proper treatment, according to my opinion, is conservative; reduce predisposing factors for accelerated degeneration (such as obesity, smoking) and carry back and abdominal strengthening exercises. At the time of exacerbating pain, short bed rest, NSAID and analgesics are recommended. In case these measures are not enough, epidural steroid injection should be considered and only if this treatment fails, the patient should be offered nucleotomy (a minimally invasive procedure) at the L4-5 level.
Sincerely,
Dr----
Orthopedic and Spinal Surgeon
------ Hospital |
