Neurosurgery Case Presentation

Uyen Phan Musculoskeletal Physiotherapy Stream Leader Melbourne Health

43M presents to Neurosurgery clinic• Referred from ED 4 months ago.

“Low back pain, shooting, L4/5 compression, CT done in the community report summary in the notes.”

Timeframe: Urgent 1-8 weeks.

ED Discharge Summary• LBP 3-4 months ago, treated in community with analgesia• CT showing:

- Degenerative disc changes L3/4, L4/5, L5/S1.- L3/4 disc bulge causing moderately severe spinal canal stenosis- L4/5 right foraminal disc bulge likely compressing right emerging nerve root.

• No red flags• Examination unremarkable• SLR 40-50° on the right side• Normal sensation, power, gait• Advised weight reduction• Analgesia• OP neurosurgery follow up

S/EHOPC• 12 months gradual onset of LBP, right groin and right anterolateral

thigh pain to knee.• Past 6 months bilateral anterolateral thigh pain, rarely past knee,

not into feet. • No P&N, N, B & B, saddle paraesthesia, ataxia

Agg• Walking (10’), standing (<60’), bending, stairs

24/24• No significant night pain. Both legs stiff in morning 60’

S/EGeneral Health• NIDDM• Hypertension• Hyperlipidaemia• High BMI (47)• No red flags

Medications• Metformin Hydrochloride• Telmisartan and Amlodipine• Proxen• Endep• Lipitor

Management to date• Seen private Neurologist• Lx MRI

L3/4 posterior disc bulgeL4/5 posterior disc bulgeL5/S1 posterior disc bulge containing annular tear centrally

• Dx: L3/4 right discogenic sciatica

• MedicationsPrednisolone 5mg 2/52ProxenEndep

Differential Diagnosis• LBP and right L3/4 radiculopathy• LBP and L3/4 central canal stenosis• LBP and L3/4 bilateral foraminal stenosis• LBP and peripheral neuropathy • LBP and bilateral meralgia paraesthetica• Hip referral • Inflammatory arthropathy?• Infective?• Vascular?• Metabolic?

O/E• Obs: Obese• Gait: Antalgic • Lx AROM: Mild stiffness reproducing LBP• Sensation: NAD• Strength: NAD• Reflexes: NAD• Tone, clonus, plantar reflex: NAD• SLR R = 50° groin pain, L = 60°• Palpation: Nil significant tenderness lumbar, groin• Vascular Ax: Good pulses in lower limb

Differential Diagnosis• LBP and right L3/4 radiculopathy• LBP and L3/4 central canal stenosis• LBP and L3/4 bilateral foraminal stenosis• LBP and peripheral neuropathy • LBP and bilateral meralgia paraesthetica• Hip referral • Inflammatory arthropathy?• Infective?• Vascular?• Metabolic?

Indications for Imaging (ACP)• Immediate imaging in patients with acute LBP who have high risk

factors for cancer, spinal infection, cauda equina syndrome, severe/progressive neurological deficits

• Imaging after a trial of therapy in patients with minor risk factors for cancer, inflammatory back disease, vertebral compression fracture, S & S of radiculopathy, symptoms of symptomatic spinal stenosis

• Repeated imaging only recommended in patients with new or changed low back symptoms

Imaging OptionsX-rays• Cheap, quick, accessible• Radiation• Poor sensitivity

CT• Cheapish, quick, accessible• Radiation• Poor evaluation of disc, cord, nerve roots, soft tissue tumours

MRI• Expensive, long, less accessible, contraindications• No radiation• Evaluates all elements – marrow, joints, disc, cord, nerve roots

Disc Definitions• Bulge: >50% circumference• Protrusion: Focal <25% circumference

Broad based 25-50%• Extrusion: Herniated disc material

diameter > annulus defect• Migration: Movement of extruded disc

away from disc level• Sequestration: Migrated fragment is

separated from main disc• Annular tear: Focal defect in annulus

containing nucleus pulposis

Disc Lesions

Disc Extrusion

Jensen et al 1994• 98 asymptomatic subjects (50M, 48F, 20-80 yrs, mean 42 yrs)• 2 independent blinded neuroradiologists• MRI defined as normal, bulge, protrusion, extrusion• 36% had normal disc at all levels• 52% had bulge at at least 1 level• 27% had a protrusion• 1% had extrusion• 38% had abnormality of more than 1 disc• 14% had annular tear• 8% had facet arthropathy• Prevalence of bulges (but not protrusions) increased with age• Findings similar in women and men.

Boos et al 1995• 46 symptomatic subjects with moderate LBP/sciatica vs. 46

asymptomatic matched controls (age, sex, occupational risk factors)• 2 independent blinded neuroradiologist• MRI defined as disc herniation (normal, bulge, protrusion, extrusion,

sequestration), disc degeneration, neural compromise• Disc herniation had a substantially high prevalence (76%) in

asymptomatic subjects (96% symptomatic)• Individuals with minor disc herniations are at a very high risk that

their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable morphologic findings

• The only highly significant difference between the study group and the control group regarding morphologic findings was the criteria of a nerve root compromise.

Cheung et al 2009• 1043 Chinese volunteer subjects aged 18-55 • Reason for volunteering not made clear. • Questionnaire on back pain (>2/52), questionnaire on lifestyle, MRI• MRI features of disc degeneration, disc herniation, annular tears,

Schmorl’s nodes

Cheung et al 2009

Cheung et al 2009• LDD was common occurring in 40% of subjects under 30 years of

age, with prevalence increasing up to 90% at the age of 50-55 years.

• Age is related but not the only factor• Disc degeneration is relevant to LBP. A significant association

between LDD and symptoms was observed.• The more severe the degeneration and the more levels involved

increased likelihood of pain

O/E continued• Hip Flexion = 80° bilaterally, pain• Hip Abduction = 10° bilaterally• Hip ER = 20° bilaterally• Hip IR = 0° bilaterally, pain

• Knee ROM full pain free range bilaterally

• No history of hip injury, trauma, pain• Oxford Hip Score 15/48 (severe)• Already tried weight loss (dietician x 3)• Difficulty with exercise/walking• Greatly impacting on QOL• Referred to Orthopaedic surgeon• On wait list of THR

Reflection• Beware of confirmation bias• Match radiology findings to clinical findings• Importance of thorough, systematic assessment• Used case to advocate AMP role