Case Studies

Case Studies in Orthopedic Care: Spine (nonsurgical)

Patient history

Ski instructors aren’t supposed to take spills, so good are they at the sport. At least that’s what their admiring students assume. Nevertheless, this 33-year-old trainer did indeed fall one day and landed with sufficient impact to leave his lower back in acute pain and symptoms of sciatica radiating down his left leg.

The pain led to curtailment of many of his routine activities of daily living and caused problems on the job (in addition to a ski instructor, the man held a position as a hotel bellhop, with its requirement for strenuous lifting and carrying). Compounding matters, he no longer could rest comfortably in bed – fitful sleep resulted, which in turn produced mood-darkening sleep deficits.

Case description

The patient was treated initially by his primary-care physician, who prescribed activity restrictions in concert with multiple courses of oral analgesics, anti-inflammatory steroids and muscle relaxants.

After 10 weeks, the patient showed no sign of improvement (and had in fact worsened), so he was referred to us at Tahoe Fracture & Orthopedic Medical Clinic.

Upon first encounter, we performed a comprehensive medical workup that included a detailed history and physical examination. An MRI study confirmed our suspicion of a left-sided L4-L5 herniated disc with impingement on the left L5 nerve root.

Treatment plan

We sought to alleviate the patient’s pain through conservative treatments and so facilitate a return to his pre-injury level of functioning.

Recommendations included changing to more appropriate oral anti-inflammatory medications and having the patient wear a brace to help stabilize his lower back during different activities. Also, physical therapy was prescribed: First, modalities such as heat and ice plus soft-tissue mobilization techniques were used to reduce the patient’s inflammatory response; later, as his tolerance for physical therapy increased, strengthening and conditioning exercises were added. An EMG/NCS of the left lower limb was conducted to aid with injection-site approach planning and targeting. (Results of the EMG test: no peripheral nerve damage detected.)

Further, the patient was scheduled for an image-guided epidural steroid injection in the lumbar spine. The effects lasted only a short time, making a second injection necessary.

Outcome

After four visits (each spaced approximately four weeks apart), the patient was discharged back to his primary-care physician at a normal level of functioning and with use of minimal amounts of medications.

Discussion

Our goal above all was to help the patient’s body resolve this problem without invasive surgery. Conservative treatment is usually preferable to surgery in a case like this because, among other considerations, it is lower in risk and less costly.

All of the elements of this treatment plan contributed to a successful outcome. The single most effective was the epidural injections (in many practices, three injections is considered the standard of care, but in this instance the second injection worked so well that it negated the need for a third). However, without the EMG testing (which we can provide in-office), the effectiveness of the injections would have been reduced – EMG gives us a clear sense of which nerve roots might be involved or if other types of neurological and muscular conditions are involved.

Also very effective was physical therapy. Our approach is having the physician closely coordinate with the physical therapy team to ensure appropriate exercises for the best possible results. In this case, the initial goal was to reduce inflammatory response; later, the goal shifted to preventing recurrence of the patient’s problem.

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