interesting cases

Patient AY is a 36 year old man, who has had a 5 year history of significant low back pain.  He has no lower extremity pain.  His weight is 360 pounds, and height is 5'5".  His physical exam was significant for tenderness to palpation over the lower lumbar area.  There was no weakness in the lower extremities.  MRI scan of the lumbar spine, seen here, is notable for degeneration of the three lower disk spaces (the disk spaces which are normally white on this MRI sequence, are instead dark).

Treatment strategy:   Although there is degeneration of the disk spaces in the lumbar spine, this patient was handled in a conservative manner.  Initially a weight loss and exercise program were implemented.  The patient still has pain, although it is improving.  If, after substantial weight loss, the pain persists, then we will have the patient undergo a discogram, and if indicated, consider an anterior lumbar interbody fusion (ALIF).

Patient TK is a 28 year old man who has had 5 weeks of severe low back pain an spasm.  There is no pain in the lower extremities. Neurological examination is intact.  The lumbar spine x rays are normal.  This patient responded very well to conservative care, which included conservative care, stretches, and massage.  Pain resolved completely.

Patient RT is a 56 year old man, who had a four year history of significant pain radiating to the lower extremities, along with low back pain.  MRI scans of the lumbar spine showed significant spinal stenosis at L4/5.  He underwent a decompressive laminectomy at L4/5, and a fusion with pedicle screws and rods, and a bone growth stimulator.  Postoperatively, he did very well, with significant improvement in low back and lower extremity pain.  On the x-rays, the pedicle screws and rods can be easily seen in the lateral lumbar x-ray (left) as well as the AP x-ray (right).

Patient CM is a 19 year old woman, who has had a 6 month history of worsening thoracic and lumbar pain.  She has no pain radiating to the lower extremities, and there is no difficulty with bowel or bladder control.  Neurological exam was completely normal.  

On MRI she was found to have a tumor adjacent to the thoracic spine.  It is seen on the axial cuts (above left) as a bright ovoid mass adjacent to the spine, and on the coronal images (above, right) again as a sausage shaped mass adherent to the spine.   She underwent a transthoracic gross total removal, and has had a good recovery.  She suffers no lower extremity pain, mild low back pain, and her returned to work.

TJ is a 65 year old man, who has had 5 years of low back pain, and two years of lower extremity pain.  The pain radiates to both legs when walking and standing, but improved with sitting.  We can see from the plain x rays that there is a degree of scoliosis.  On the sagittal MRI we see that there is significant stenosis of the lumbar spine. There is also a grade I spondylolysthesis (slip) of L3 on L4.  This patient underwent a lumbar decompression, but at surgery, the bone was too weak and osteoporotic  to adequately hold pedicle screws.  The patient did well, and had significantly improved lower extremity function, although a mild amount of low back pain persisted.