Spine and Pain Case Studies 1

Case 1

  • 57 year old female

  • Referred by Dr. Rios Chiropractor

  • Chief Complaint “Right Low Back and leg Pain”

  • Seen in consultation initially on 09/06/2017

  • Vitals: W 199lbs, H 65in, BMI 33.1, BP 151/89
    Pulse 68, Pain 9/10 VAS

  • Past Medical History:
    - DM
    - Migraine/ Headaches
    - High Cholesterol
    - HTN

  • Non-smoker, occasional drinker

  • Employment: Texas Dept of Health and Human Services eligibility worker

  • Patient complaining of back pain for 15 years. 

  • Significantly worsened and is shooting down the right leg since 2 weeks prior. 

  • History of MVA in 1999 and 2004

  • Pain is constant, burning, sharp, stabbing and tingling in the right leg

  • Previous treatment modalities tried:
    - Adujustments
    - Massage
    - NSAIDs (Meloxicam), OTC meds
    - Low dose narcotics (Norco and Tramadol) by PCP
    - Muscle relaxant (Flexeril) by PCP

  • Positive findings on the exam:
    - Positive SLR 10 degrees on the right, negative on the left side
    - Decreased sensory to light touch and cold - temperature right L5 and S1 dermatomes
    - Weakness 4+/5 right EHL, pain contributing
    Reflexes 2+ bilateral knee, ankles

     

  • Decided to proceed with Right sided L5 and S1 Transforaminal Epidural Steroid Injections

    • ​1st on 09/15/2017 > 70% relief of symptom

    • 2nd on 10/20/2017 > 80% relief of symptom

    • 3rd on 11/21/2017 > 90% relief of symptom

  • ​Along with injections patient continued to have adjustments, therapy and massage under care of Dr. Rios

  • Upon follow up, patient no longer had any weakness or numbness in her right leg, SLR became negative

Are all “Epidural Steroid Injections” equally effective?

NO!

Interlaminar Epidural Steroid Injection

Transforaminal Epidural Steroid Injection

  • Patient was happy, no follow up with us needed, continued care under her chiropractor; however, patient experienced return of same symptoms; but much more severe on 04/20/17 suddenly without any trigger event.

  • Exam on 04/25/17 Revealed a very miserable female unable to sit comfortable

  • Positive SLR on the right side at 5 degrees

  • Decreased sensory right L5 and S1 to light touch and cold temperature

  • 4/5 Right ankle flexion, pain contributing

  • Achilles reflex 2+ on the left, 1+ on the right

  • Again recommended continuation of medical management and chiropractic care as well as 
    proceed with another epidural steroid injection

  • Obtain a new MRI of the lumbar spine
     

  • This time minimal relief from her first epidural steroid injection, patient extremely miserable

  • Referred to Dr. Benae, seen in consultation yesterday

Case 2

  • 28 year Supervisor Auto body repair shop

  • Initial consultation 10/27/16

  • Found us by “Google search”

  • Chief Complaint “Low Back Pain”

  • Upon Exam he was unable to sit comfortably.

  • Rated the pain as 9/10.

  • Pain upon percussion of the low lumbar region.

  • Normal neurological exam.
     

  • Reported pain being there on and off for about a year

  • Started without any known trigger event

  • Worsened since 3-4 months prior

  • Saw Dr. K in Allen for three months to get Airrosti treatments

  • Pain was reported as Sharp in the low back, constant, occasionally radiating to both legs

  • Worse with sitting, driving, standing up holding his daughter.

  • Had tried Ibuprofen and Massage in addition to Airrosti treatments.
     

  • Prescribed muscle relaxant (Flexeril) 10 mg po qhs and hydrocodone 7.5-325 mg po tid prn.

  • First Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/01/2016 > 30% Relief

  • Second Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/29/2016 > 50% Relief

  • Third Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 12/27/2016 > 70% Relie

  • Pain is now “Tolerable”

  • Patient referred to Dr. Mills Chiropractor to start chiropractic therapy with adjustments and physical therapy

  • Emphasized importance of ongoing adjustments and physical therapy

  • No follow up with Pain needed

  • Happy camper

  • No PCP > Spine Surgeon > Surgery > More problems down the road

  • No High Dose Narcotics > Dependence > Addiction > Impact of life/ Job

    However,

  • Return of symptoms in from of back pain 4 month later

  • Exam revealed positive facet loading maneuvers

  • Lumbar Facet blocks (Diagnostic)

  • After positive (more than 80% relief) short term response to facet injections and confirmatory medial branch blocks, patient underwent Rhizotomy resulting in 60% to 70% relief of symptoms

  • Pain is now again “Tolerable”

  • So, if someone had lumbar facet rhizotomy, likely remaining pain is from the?

    • Discs

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Dr. Ghalambor is a Harvard Fellowship Trained and Board Certified Specialist. 

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