Dear Colleagues,
I wonder if you can help me with a current clinical dilemma. A
32 year old female patient. She was an elite hockey player since her
teens and has been having problems with LBP / sciatica since 1990. By
1993 - her 3rd season out of the game - and with poor results with
conservative management - she had a microdiscectomy in June 1993
which gave relief from pain. She continued to suffer from stiffness
and eventually thoracic pain. She has been seen for management of
this by physiotherapists and osteopaths since. She admits that she
did not have time for thorough rehabilitation post-operatively and
feel that this may have bee partly responsible for the limited
outcome. Needless to say she has never returned to hockey, but
managed occasional running / golf. She had a recurrence of acute
right-sided LBP with sciatica in November 1998. This did not calm
down with conservative measures (osteopathy). She had an MRI in
December 1998 which apparently showed some scar tissue around the
operation site. She had an epidural on 14.01.99 and then came to see
me.There was minimal improvement post-epidural and although we have
improved posture, spinal stability and baseline fitness levels with
pool work, things improved but remain very irritable. The orthopaedic
surgeon then suggested a possible posterior fusion to relieve the
increase in pressure due to disc space narrowing ( not prolapsed
tissue) - and that scar tissue would be removed at the same time. This week she saw a
neurosurgeon for a second opinion at my suggestion. His impression is
that she had additional prolapsed tissue which is tethering the nerve
root, but which if she could work through with exercise may well
resolve. He suggested trying this for a month and then reviewing the
situation.
He also suggested additional microdiscectomy should this fail, but
advised that the risks of success may be less following the second
procedure. He felt that a fusion was inappropriate at this time due
to the high risk of permanent damage.
The patient is a very intelligent young lady who works as a project
manager. Her workplace has been extremely supportive and she could
feasibly go with either recommendation timewise. Ultimately her aim is to achieve
a good level of fitness and get back to work ASAP.
Her current symptoms of LBP, calf pain and fott numbness are constant
but vary in intensity greatly. Her SLR also varies from 30-45
degrees. She has no cross-over symptoms.
My dilemma is that the baseline diagnoses of impingement due to disc
tissue / mechanical pressure from vertebrae are inherently different.
The two experts apparently have different approaches.
Does anyone have any experience of this type of situation ? Should she
give the less aggressive option a try first ? Get another opinion ?
I would be grateful for some inspired suggestions.
Many thanks,
Lesley Haig
St. Mary's College,
Twickenham
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