CLINICAL VIGNETTE:

A 36-year-old male suffered from  severe low back pain. His pain diagram indicated a localized region of  pain around his left lower lumbar region, sacroiliac joint and buttock.  He states that he occasionally feels a slight tingling sensation in his  left posterior thigh, but not distal to the knee. This tingling  sensation only occurs for a few moments once or twice a week. The lower  back pain is daily, and worse in the mornings upon rising from bed.  After he gets to work the pain subsides; but then worsens again by  mid-afternoon. The patient is employed as a car mechanic and must  frequently work bent over the hoods of cars in a flexed position, which  aggravates his pain. He says that occasionally he will get “stuck” in a  position where he is leaning forward and to the right, and that he must  slowly work out his back to be able to straighten up again. He does not  recall any specific low back injury that set off this particular episode  of acute pain, which began insidiously about 3 wks before his first  visit. How- ever, he has had such episodes about once or twice a year  for over 10 yr, and has previously seen chiropractors with fairly good  results.

Physical examination began with lumbar ranges of motion, which  were restricted into flexion at 25 degree, left lateral bending at 15  degree, and left rotation at 10 degree. He exhibited a mild antalgic  lean to the right. He does not walk with an obvious limp, but is  observed to avoid full weight-bearing on his left leg. Kemp’s maneuver  elicited sharp but localized left low back pain over the left L5/SI  facet and sacroiliac joint, with only mild left buttock pain. There was  no reproduction of any left thigh symptoms. Static palpation of the L5  and Sl spinous processes elicited sharp local pain, and motion palpation  P-A over- pressure on the left L5/Sl facet joint also caused sharp  local pain. Muscle palpation revealed some hyper tonicity of the left  erector spinae, quadratus lumborum, and gluteus medius / minimus muscle;  however, no true spasm was detected. Repeated extension in the standing  position elicited some increased pain over the left lumbar facets, but  repeated extension in the prone position afforded the patient some  relief of his low back pain.

Plain film radiographs of the lumbar spine demonstrates about  50% narrowing of the L5/Sl disc space, and a mild right lateral lean of  the lumbar spine. There is no apparent loss or accentuation of the  lumbar lordosis. There is slight rotation of the 15 spinous toward the  left, but no other gross malalignments were noted. He was scheduled for  an MRI by his primary care physician, but the insurance company denied  authorization for the test, citing “lack of compelling medical  necessity” to perform advanced diagnostic imaging tests. Tentative  diagnosis by his primary care physician was lumbar sprain, and he was  given a prescription for Ibuprofen 800 mg t.i.d.


Chiropr Technique Vol. 11, No. 1, February 1999

Author information: Michael J. Schnelder, D.C., James M. Cox,  D.C., Bradley S. Polkinghorn, D.C., Charles Blum, D.C., Harvey Getzoff,  D.C., and Stephan J. Troyanovich, D.C.

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