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From: [log in to unmask] <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: Thursday, March 04, 1999 9:29 AM
Subject: LBP Patient
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
Lesley,
If this patient was a relative of mine, I would want to make sure that her
pelvis (in general) and SIJs in particular had been assessed by someone (a
physical therapist) who is used to regularly treating this part of the body.
I assume this is the case but .... no, to tell the truth I can't assume that
this is the case... seeing that until recently the vast majority of all
medics and physiotherapists seemed to think that you'd taken leave of your
senses if you even suggested that SIJs could perhaps move!
The fact that she's got scar tissue on scan isn't surprising after the first
op. but doesn't NECESSARILY mean that her symptoms are coming from it. Her
report of initial improvement from the first op. may have been:
1) Genuine - it may have relieved pressure at one point of the nerve but she
might still have a restriction at the SIJ (UNLIKELY ?)
2) Wishful thinking - After such an op. she may have convinced herself that
she was better (UNLIKELY)
3) Genuine - But then she may have developed a second (?secondary) problem
which may have stemmed from her SIJ (UNLIKELY ?)
As you can see, I don't really think the above 3 are likely, but (as I said
before) If this were one of my relatives/friends then I'd want to check out
all possibilities (especially such an obvious one ... obvious, that is, to
one working on SIJs a lot) before subjecting her to the probably
unsuccessful handiwork of the knife-weilding surgeons.
Of course, as you mention, neural mobilisations is another (LIKELY) problem
that should be sorted out.
All the best,
Mark Poulter MSc MCSP
(as fibres from nerves L2-S2 pass through the SIJ capsules any old leg
symptoms can result)
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