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.