Degenerative disc disease
Imaging study
Sagittal MRI scan of the lumbosacral spine
showing disc dehydration and bulging at L4-L5.
There is a large spinal canal and no nerve root
pinching. The disc space is otherwise well preserved
with no loss of height and no Modic changes.
The cartilaginous endplates are otherwise intact.
The other disc spaces all appear normal. (See Figure
1.)
History
This is a 42-year-old female homemaker who
lifted a box and felt a pull in her back. Initially,
she had a couple days of stiffness, but then
the pain started to progress. She has referred
burning pain down the back of both legs. She
was previously healthy and active, but has since
had to give up all sporting activities including
golf and tennis. Her pain is activity related,
although she still has discomfort at rest. Sitting
will make the pain worse, and although she has
trouble standing for prolonged periods of time
she actually feels better when she is walking.
The pain ranges from 3 to 7 on a pain scale of
1 to 10. So far she has tried ibuprofen and Tylenol
for her pain which helps some. She saw her family
practice doctor who placed her on a muscle relaxant
(Soma) but this made her too sleepy. She is frustrated
with her activity limitations, and is afraid
that her pain is getting worse.
Physical Exam
Healthy appearing 42 year old female who
stands throughout much of the interview. She
is tender to palpation throughout the paraspinal
muscles on both sides. She has limited forward
flexion with her fingertips only reaching as
far as her knees. Her reflexes at the ankle and
knee are intact and symmetrical and there is
no muscle weakness.
Diagnosis
Acute low back pain probably from degenerative
disc disease. |
