43 yr old female, lower back pain with proximal right leg pain, for two years. Onset was due to repetitive torsional lifting over one 8 hour shift when a conveyor belt became dysfunctional. Pain onset was progressive. The patient saw a physiotherapist and was encouraged to induce lumbar flexion even though it was painful. Two years later, difficult to get to sleep because of pain and cannot sleep on the left side because of pain onset within minutes. Very stiff upon the first rise out of bed. Sitting causes lower back pain. Walking helps but only if not longer than 45 minutes.
“Technique: Sagittal T1 and T2 with axial T2. 5 lumbar type vertebrae have been assigned. FINDINGS: The conus is unremarkable. Incidental note is made of a vertebral hemangioma posteriorly within the T12 vertebral body. This is not believed to be significant. No significant abnormalities are seen within the upper lumbar spine. At L3-4 disc height is preserved. There are mild degenerative facet joint changes. The central canal and foramina are widely patent. At L4-5 there are mild degenerative facet joint changes. Disc height is preserved. There is a tiny disc bulge with a small right posterior annular tear. This is not resulting in nerve root impingement. At L5-S1 there are mild degenerative facet joint changes. Central canal and foramina are widely patent. IMPRESSION: No evidence of significant spinal stenosis or nerve root impingement. There is a tiny disc bulge or protrusion with annular tear at the L4-5 level. This could be resulting in minor irritation of the traversing right L5 nerve root. ”
Interestingly, an annular fissure was identified in the report but the emphasis, according to the patient, was on the ‘tiny disc bulge‘ by the insurance carrier.
The patient’s pain continued, and further tests were conducted:
Pelvic X-ray – negative for findings
Sacroiliac X-ray – negative for findings
MRI Lumbar Plexus without contrast:
“Technique: Axial T1, T2 and STIR of the pelvis. Coronal oblique T1 and STIR with axial oblique T1, T2 and PD fat sat of the lumbar plexus. FINDINGS: No intrapelvic mass is identified. The uterus is retroverted. The bony pelvis is unremarkable. The pubic symphysis and SI joints are normal. The gluteal muscles are normal in size and signal intensity with no evidence of edema or significant fatty muscular atrophy. There is only very mild fatty atrophy of the anterior aspects of the gluteus medius minimus muscles. The adductor aponeurosis is unremarkable. No bursal fluid collections are identified. There is no evidence of significant gluteal tendinosis. The common hamstrings origins are unremarkable. There is no abnormality identified within the inguinal or femoral canal. The piriformis muscles are symmetrical in size and signal intensity. No abnormalities are identified along the course of the lumbar plexus. IMPRESSION: No abnormalities are identified to account for the patient’s symptoms.”
Presented to a Chiropractor
This patient, after two years, presented to a chiropractor. Upon careful observation of the general act of flexion, even though she could achieve full flexion, there was a painful onset of axial lower back pain at 25 degrees from neutral. The patient did not hesitate in her motion as her lumbar spine became painful during this movement and did not show any behavioural cues like grimacing. A physiotherapist encouraged her to move through the pain two years ago. Lumbar standing extension did not exacerbate her lower back pain.
The attending chiropractor identified the suspected annular fissure on MRI and shared this imaging finding, along with the use of a ddd model, to explain why symptoms were worse when bending forward.
How would you manage this case from here on out?