Author: Charlene Jones, MD, MPH
Senior Editor: Christian Fulmer, DO, FAMSSM
Editor: Caitlin Lewis, MD

Patient Presentation:
A 54-year-old female with no significant past medical history presents to sports medicine clinic with a 2-month history of low back pain.

History:
She was initially seen in the Emergency Department for the back pain which started after a sudden twisting motion while doing laundry. The pain started in the right lower back and radiated down the right leg. Her neurologic exam was non-focal, and she was diagnosed with lumbar radiculopathy, prescribed prednisone and methocarbamol, and discharged to follow up outpatient. She saw her primary care physician who gave a dose of intramuscular Toradol in office, prescribed gabapentin, ordered x-rays of the lumbar spine and hip, and referred her to physical therapy. Her symptoms improved somewhat but did not fully resolve. She returned to the Emergency Department approximately 3 weeks after her first visit, now complaining of pain localized to the left buttock with radiation down the left leg into the foot with associated numbness and tingling. She was given intramuscular Toradol in the Emergency Department, prescribed prednisone and a short course of Percocet, and referred to orthopedics/sports medicine outpatient.

She presented to sports medicine clinic 2 weeks following her second Emergency Department visit. She continued to have left-sided low back pain with radiation down the left leg to the foot and associated numbness and tingling. The prior prescribed medications helped while she was taking them, but symptoms returned once she completed her course. She had done physical therapy three times a week for several weeks with no significant improvement. She was currently taking prednisone 20mg nightly to keep the pain manageable. She denied bowel or bladder dysfunction, saddle anesthesia, leg swelling, and weakness. She had no prior history of lumbar spine surgery or spine injections.

Physical Exam:
Physical exam showed a well appearing female in no acute distress with a normal tandem gait. Targeted lumbar spine exam showed intact skin with no signs of infection, bruising, or swelling. There was no tenderness to palpation along the midline spine or paraspinal muscles. She had tenderness over the left sacroiliac joint and left gluteal muscles. She had full active range of motion of the lumbar spine and pain with active lumbar extension, lateral bend to the left, and truncal rotation to the left. There were mild strength deficits of the hip flexors, abductors, quadriceps, and hamstring muscles bilaterally. Stork and Slump tests were both positive on the left. Straight leg raise was negative bilaterally. Sensation was intact in the L1-S5 distribution bilaterally.

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