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  • AvatarColoradoPT
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    Post count: 3

    The patient is a 37 yo male who was injured on 1/23/20. He was moving a refrigerator down a flight of stairs, he was below the fridge, when he lost his footing–he “bounced” down each step on his feet and ended up in a hyper-flexed position at the bottom of the stairs. He felt a pop in his back. He reports that the pain was so severe he almost passed out.

    He had an MRI 2/11/20: Per report ” shallow broad-based bulging disc with superimposed right paracentral disc extrusion at L5-sS1. No neurologic compression or displacement was identified but the bulge was felt to contract the S1 nerve roots and slightly indent the ventral sac.

    3/20/20: left sided L5S1 and S1 transforaminal epidural steroid injections under fluoroscopy–pt. reported only several days of relief from this intervention.

    6/9/20: left SI joint injection–pt. reported no relief at all

    Repeat MRI 6/26/20: T12 -L1, L12, L23, L34. L45 all No significant disc bulge. No evidence of neural foraminal stenosis. No central canal stenosis; L5S1–Broad-based disc bulge with small right paracentral disc protrusion. Mild bilateral facet arthropathy. No evidence of nerve root compression.

    NCS &EMG 6/24/20
    Nerve Conduction Study:
    Left peroneal motor nerve: no measureable nerve conduction at the ankle (report)
    Left peroneal motor nerve: some response from testing at fibula (reading graph)
    Right peroneal motor nerve: prolonged distal latency onset and reduced amplitude (report)
    Left tibial motor nerve: no comment on report so WNL
    Right tibial motor nerve: decreased conduction velocity (report)
    Left sural sensory nerve: prolonged distal peak latency and decreased conduction velocity (report)
    Right sural sensory nerve: prolonged distal peak latency and decreased conduction velocity (report)

    H-Reflex: assessment of alpha-motor neuron activation in spinal cord
    Left tibial (Gastroc): no response (report)
    Right tibial: no comment (report)

    EMG showed diminished recruitment:
    L VastusMed Peroneal n. L2-4
    L BicepsFem Sciatic n. L5-S1
    L Ant Tib DpPeroneal L4-5
    L medGast Tibial S1-2
    L VastusLat Femoral L2-4
    L TFL SupGlut L4-5, S1

    R TFL SupGLut L4-5, S1
    R MedGast Tibial S1-2
    R Ant Tib DpPeroneal L4-5
    R BicepsFem Sciatic n. L5-S1
    R VastusLat Femoral L2-4

    EMG Normal:
    R & L Ext Dig Brev DpPeroneal L5, S1

    In Physical Therapy, he has had no relief from interventions that have included dry needling L/S with intramuscular electrical stimulation, lumbar traction, muscle activation, soft tissue mob, and ROM.
    He continues to have debilitating bilateral leg pain, which at times “burns” and this pain limits his ability to sleep. His pain increases with sitting; standing in a forward flexed position gives him the most relief.

    Any ideas about what could be the etiology? Do you have any test / assessment recommendations?

    Thank you,
    Sharon DPT, CHT, OCS

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 7626

    We should start with his symptoms; “He continues to have debilitating bilateral leg pain, which at times “burns” and this pain limits his ability to sleep. His pain increases with sitting; standing in a forward flexed position gives him the most relief”. Can I assume he has no lower back pain, only leg pain? Does he have buttocks pain or does the pain skip to the lower legs? Is his pain greater in one leg than the other (i.e. LLE 70% RLE 30%).

    MRI 2/11/20: Per report “shallow broad-based bulging disc with superimposed right paracentral disc extrusion at L5-sS1. No neurologic compression or displacement was identified but the bulge was felt to contract the S1 nerve roots and slightly indent the ventral sac”. Slight root effacement but nothing on the left side and right side is “minor”.

    /20/20: left sided L5S1 and S1 transforaminal epidural steroid injections under fluoroscopy–pt. reported only several days of relief from this intervention. Was this diagnostic?? That is, did the patient keep a pain diary for the first three hours after surgery, especially after he aggravated the pain prior to injection?

    MRI 6/26/20: “T12 -L1, L12, L23, L34. L45 all No significant disc bulge. No evidence of neural foraminal stenosis. No central canal stenosis; L5S1–Broad-based disc bulge with small right paracentral disc protrusion. Mild bilateral facet arthropathy. No evidence of nerve root compression”. Degeneration of the L5-S1 level which could be consistent with disc/facet injury.

    NCS &EMG 6/24/20
    Nerve Conduction Study:
    Left peroneal motor nerve: no measureable nerve conduction at the ankle (report)
    Left peroneal motor nerve: some response from testing at fibula (reading graph)
    Right peroneal motor nerve: prolonged distal latency onset and reduced amplitude (report)
    Left tibial motor nerve: no comment on report so WNL
    Right tibial motor nerve: decreased conduction velocity (report)
    Left sural sensory nerve: prolonged distal peak latency and decreased conduction velocity (report)
    Right sural sensory nerve: prolonged distal peak latency and decreased conduction velocity (report)

    NCV looks to identify peroneal nerve injury at the lateral knee, tarsal tunnel syndrome or even peripheral neuropathy.

    H-Reflex: assessment of alpha-motor neuron activation in spinal cord
    Left tibial (Gastroc): no response (report)
    Right tibial: no comment (report)

    Not too important. H reflex is inconsistent.

    EMG Normal: This means no evidence of motor nerve involvement so I would assume the patient has peroneal nerve injury at the lateral knee, tarsal tunnel syndrome or peripheral neuropathy. Firmly tap at the lateral knee at the fibular head or at the tarsal tunnel. If there is an electrical sensation like a “zap” that radiates down, this is a positive Tinel’s sign and is more evidence of an entrapment syndrome.

    See: https://www.neckandback.com/conditions/peroneal-nerve-entrapment-at-fibular-head-knee/
    https://www.neckandback.com/conditions/tarsal-tunnel-syndrome/

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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