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[
musculoskeletal imaging
]
FIGURE 1. (LEFT) Lateral radiographic view of the lumbar spine demonstrating a spondylolisthesis at L4-5 with significant disc space narrowing at L4-5 and L5-S1. FIGURE 2. (ABOVE) Sagittal T2-weighted magnetic resonance image of the lumbar spine. At L4-5, there is severe central canal stenosis produced by a posterior disc protrusion, a degenerative forward listhesis, and a left-sided synovial cyst (arrow). At L5-S1, there is posterior disc bulging and decreased disc height. There is also posterior disc bulging at T12-L1, L1-2, L2-3, and L3-4.
Chronic Low Back and Left Lower Extremity Pain in an Elderly Woman ANN M. HAYES, PT, DPT, OCS, Department of Physical Therapy and Athletic Training, Saint Louis University, Saint Louis, MO. HOWARD M. PLACE, MD, Department of Orthopaedic Surgery, Saint Louis University, Saint Louis, MO.
T
he patient was a 79-year-old woman who presented to her primary care physician with complaints of constant low back and left lower extremity pain that had progressively worsened over the previous 6 months. The patient reported that her symptoms were insidious in onset and currently limited her ability to walk greater than 27 m, stand longer than 10 minutes, and sit longer than 5 minutes. Physical examination revealed an antalgic gait, limited lumbar flexion and extension range of motion that both exacerbated the patient’s symptoms, and weakness of the left L5 myotome as assessed with manual resistance to great-toe extension. Given the patient’s age, progressive-
ly worsening symptoms, and positive neurologic findings, radiographs were ordered, which demonstrated a spondylolisthesis at L4-5 with significant disc space narrowing at L4-5 and L5-S1 (FIGURE 1). Further evaluation through magnetic resonance imaging demonstrated severe central canal, lateral recess, and foraminal stenosis, as well as a posterior disc protrusion, a degenerative forward listhesis, and a left-sided synovial cyst at L4-5 (FIGURE 2). The patient was referred to an orthopaedic surgeon, who recommended a trial of conservative management that included oral pain medication, 3 epidural steroid injections, and 3 months of physical therapist management. However, de-
spite these interventions, the patient did not improve and continued to have significant functional limitations, as noted by her Oswestry Disability Index score of 78% at her last visit with the physical therapist. The patient subsequently underwent an L3-4 laminectomy, an L4-5 fusion, and removal of the synovial cyst. The patient was also managed by a physical therapist following her surgery. At 1 year following surgery, the patient’s Oswestry Disability Index score was 8%, and she reported that she was able to fully perform all of her required activities of daily living independently. t J Orthop Sports Phys Ther 2013;43(9):674. doi:10.2519/ jospt.2013.0417
674 | september 2013 | volume 43 | number 9 | journal of orthopaedic & sports physical therapy
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[
musculoskeletal imaging
]
FIGURE 1. (LEFT) Lateral radiographic view of the lumbar spine demonstrating a spondylolisthesis at L4-5 with significant disc space narrowing at L4-5 and L5-S1. FIGURE 2. (ABOVE) Sagittal T2-weighted magnetic resonance image of the lumbar spine. At L4-5, there is severe central canal stenosis produced by a posterior disc protrusion, a degenerative forward listhesis, and a left-sided synovial cyst (arrow). At L5-S1, there is posterior disc bulging and decreased disc height. There is also posterior disc bulging at T12-L1, L1-2, L2-3, and L3-4.
Chronic Low Back and Left Lower Extremity Pain in an Elderly Woman ANN M. HAYES, PT, DPT, OCS, Department of Physical Therapy and Athletic Training, Saint Louis University, Saint Louis, MO. HOWARD M. PLACE, MD, Department of Orthopaedic Surgery, Saint Louis University, Saint Louis, MO.
T
he patient was a 79-year-old woman who presented to her primary care physician with complaints of constant low back and left lower extremity pain that had progressively worsened over the previous 6 months. The patient reported that her symptoms were insidious in onset and currently limited her ability to walk greater than 27 m, stand longer than 10 minutes, and sit longer than 5 minutes. Physical examination revealed an antalgic gait, limited lumbar flexion and extension range of motion that both exacerbated the patient’s symptoms, and weakness of the left L5 myotome as assessed with manual resistance to great-toe extension. Given the patient’s age, progressive-
ly worsening symptoms, and positive neurologic findings, radiographs were ordered, which demonstrated a spondylolisthesis at L4-5 with significant disc space narrowing at L4-5 and L5-S1 (FIGURE 1). Further evaluation through magnetic resonance imaging demonstrated severe central canal, lateral recess, and foraminal stenosis, as well as a posterior disc protrusion, a degenerative forward listhesis, and a left-sided synovial cyst at L4-5 (FIGURE 2). The patient was referred to an orthopaedic surgeon, who recommended a trial of conservative management that included oral pain medication, 3 epidural steroid injections, and 3 months of physical therapist management. However, de-
spite these interventions, the patient did not improve and continued to have significant functional limitations, as noted by her Oswestry Disability Index score of 78% at her last visit with the physical therapist. The patient subsequently underwent an L3-4 laminectomy, an L4-5 fusion, and removal of the synovial cyst. The patient was also managed by a physical therapist following her surgery. At 1 year following surgery, the patient’s Oswestry Disability Index score was 8%, and she reported that she was able to fully perform all of her required activities of daily living independently. t J Orthop Sports Phys Ther 2013;43(9):674. doi:10.2519/ jospt.2013.0417
674 | september 2013 | volume 43 | number 9 | journal of orthopaedic & sports physical therapy
43-09 Imaging-Hayes.indd 1
8/20/2013 3:48:25 PM
