Miller, Tricia wrote:
> I have an interesting and challenging case I could use some suggestions for.
> An otherwise healthy 24 year old female came to the clinic 1 1/2 years after
> a motor vehicle accident resulting in an L5-S1 transverse process fracture,
Transverse process fx should not be contributing to her present sxs.
>
> and sacral fracturing x 3.
Did the sacrum heal? Any malalignment? Any intraarticular fxs?
If the answers are yes, no, no. Then the sacrum should not be contributing to
her sxs.
> She has a history of spondylolisthesis of the
> lumbar spine.
How much slippage? Has it recently progressed? If there is less than 25%
slippage then surgery is usually not indicated. Particularly as there is not any
neuro sxs.
> 7 months ago she had her coccyx removed.
Why? Did she have a fx?
> She presents to the
> clinic with complaints of constant pain in the sacral region and low back,
> and little/no tolerance for sitting or static standing. Examination reveals
> nearly full trunk ROM with pain on extension. Strength findings are
> minimal, with minimal decrease in hip rotation and flexion muscle power.
> Flexibility of the hamstrings is good, hip flexors good. Special testing
> reveals pain with SLR, Fabers, long sit and prone knee bend. Neuro signs
> are negative. Palpation reveals significant severe pain with mild-moderate
> pressure over the central lumbar spine, paraspinals, and entire sacral
> region.
Any abnormal SI mechanics?
>
> This patient is facing spinal fusion surgery if conservative physical
> therapy is not successful.
> Please email any suggestions for effective techniques to decrease pain,
> increase stability, etc. to allow this patient to meet her goals for
> recovery.
> Thank you,
> Amy Corazzari, MPT and Tricia Miller, PT at MacNeal Hospital, Berwyn, IL
Results of imaging studies would be very helpful. Based on the information
presented, most of her sxs are likely soft tissue. However, any secondary gain
issues associated with accident liability and chronic pain should be recognized
and appropriately addressed. Given the reproduction of her pain with the tissue
tension tests I would work on restoring the soft tissue mobility throughout the
area. She needs to be on an aerobic conditioning program. Pool if she can't
tolerate land exercise but transition to land ASAP. She should also by
prescribed a lumbar stabilization program. Correct any abnormal SI mechanics as
well. Don't expect improvement for 6-8 weeks. She'll need a lot of psychological
support. She needs to buy into the program and agree to be compliant for a
minimum of two months. A interesting and challenging case, good luck. I'd be
interested in follow up postings.
Douglas M. White, PT, OCS
Milton, MA USA
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