Author: Calvin Luu, DO
Co Author #1: Christopher Bruti, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Michael Moreland, DO

Patient Presentation:
A 52-year-old woman with a history of hypothyroidism, hypertension, and R-sided low back pain presented for the third time in a week to the ED for persistent back pain, right lower extremity weakness and numbness.

History:
The patient initially presented to the ED with sharp right-sided low back pain associated with weakness and numbness to right foot and areas of her right leg. She denied any known trauma or injuries. Her symptoms had not improved with Tylenol or NSAIDs. She was discharged from the ED without imaging completed after being diagnosed with sciatica and nerve impingement by piriformis syndrome. She was given a prescription for Flexeril with instructions to follow up with her with plans for outpatient MRI. The following day the patient returned to the ED with continued back pain and right leg weakness and numbness. At that time, a lumbar spine XR and lumbar MRI were obtained without acute pathology so she was again diagnosed with sciatica. She was given morphine for pain relief and prescription for Medrol dose pack as an outpatient. An outpatient orthopedic spine follow up was also arranged, The patient again returned to the ED with continued complaints. She noted her symptoms were progressively getting worse. She had worsening ambulation over the past week, intermittent radicular pain radiating from right lower back and buttocks down her right leg, and constant numbness and weakness on the right side. She denied saddle anesthesia, bowel or bladder incontinence and urinary retention.

Physical Exam:
General: non-antalgic gait with right foot drop
Neuro: Decreased sensation to light touch along dorsum of right foot and lateral aspect of right leg. Achilles and patellar reflexes 2+ bilaterally
Extremities: trace pitting edema bilaterally, R greater than L
MSK:
RLE –1/5 TA, 1/5 EHL, 1/5 foot eversion. Muscle strength otherwise 5/5 RLE.
LLE – 5/5 strength throughout

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