Dr. El-Hewie Forum

[Mohamed F. El-Hewie]

case 47
Case Studies in Clinical Examination
1997

By Epstein et al

HISTORY

A 30-year-old male weight-lifter, had been in excellent health in the past. He was single. He had always refused to use illicit drugs in aiding his career (they had frequently been available) and despite this had represented his country at the Olympic Games. Like many of his fellow athletes, his back could trouble him from time to time and he always wore a support when lifting, even though he appreciated that its value was limited. He was competing in his national championships and had already won his title but decided to attempt a national record with his last lift. He expected to retire from the sport and concentrate on his other love, sheep farming. He realized that the weight was at the limit of his capacity. As he lifted the final phase, he developed an intense low back pain. Somehow he sustained the lift for the statutory period but then had to immediately drop the weight, narrowly escaping injury. The pain persisted and appeared to extend to his buttocks bilaterally. He insisted on returning to his hotel room to rest rather than seeking immediate medical attention. Already he was aware of an ill defined numbness in the posterior thighs. He took several aspirins and went to bed. On waking the pain was still present and the numbness, if anything, more intense. He struggled out of bed but realized that his feet were weak and he had difficulty getting to the toilet. His bladder felt somewhat full and he decided to sit on the toilet to micturate. He realized that his buttocks were numb and, to his horror, found he could not pass urine. He rang for an ambulance and was admitted to hospital. He had no other neurological complaints and, apart from an occasional tendency to wheeze (for which he tried to avoid taking medication because of his concerns about drug testing), he was well.

Consider:
• Where is the pathological process likely to be situated?
• What neurological structure has been disturbed?

EXAMINATION
On neurological examination his cranial nerves and upper limbs were normal. He was tender over the lumbosacral junction. Straight leg raising was limited to 20° bilaterally, evoking posterior thigh pain on either side. Femoral stretch was negative. He had weakness of planter flexion, knee flexion and hip extension bilaterally. The knee jerks were brisk and the ankle jerks absent. The plantars were weakly flexor. Tone was normal and co-ordination intact. He had blunting of cutaneous sensation over the posterior thighs extending to the perianal region bilaterally. His anal sphincter tone was reduced. His bladder was palpable to the umbilicus. A general systems examination was satisfactory.

Consider:
• What segments are affected on the basis of the motor assessment?
• What segments are affected on the basis of the sensory assessment?
• What investigation would be most helpful?
• How would you manage this problem?



The distribution of the cutaneous sensory loss.

DIFFERENTIAL DIAGNOSIS
1. Central disc prolapse in the lumbosacral spine

DISCUSSION
The history is strongly suggestive of an acute disc prolapse. The bilateral distribution of the symptoms and signs and the evidence of sphincter disturbance suggests that this is a central rather than posterolateral prolapse. Plantar flexion (gastrocnemius and soleus) is supplied by L5 and S1 (mainly 51), knee flexion _— - (hamstrings) by S1 and hip extension (gluteus maximus and medius) by S1. The posterior aspect of --- the thigh is supplied by 52 as is the inferior border of the buttock. The perianal area is supplied by sacral segments 3-5. The sensory deficit suggests, therefore, involvement of the sacral dermatomes from 52-55. This problem should be investigated as an emergency. Plain radiographs of the spine will not provide any useful data. The main alternatives are computerized tomography myelography or magnetic resonance imaging. The former is invasive but is generally more rapidly and widely available. The latter is the investigation of choice. It will allow assessment of all the lumbar spine rather than just the affected segment. A potential disadvantage occurs with computerized tomography myelography if the central disc prolapse (probably at L5/51) is complete. Insufficient contrast may go past the obstruction to show the higher lumbar levels. The only appropriate treatment here is surgical. The patient should be catheterized and taken to theatre immediately. Providing a satisfactory decompression of the cauda equina is achieved, the outlook should be good but further delay may well jeopardise this patient's recovery, particularly with regard to bladder function.

Reference

_________________
Dr. Mohamed F. El-Hewie.
Author of
"Essentials of Weightlifting and Strength Training"
http://www.lift-4-life.com

[sjaak smorenburg]

Thanks.

This is very interesting.

[Mohamed F. El-Hewie]

SOAP format

S: Subjective (what the patient tells?)

“I could not pass urine since yesterday,
after trying to lift record weight in a weightlifting contest,
I had low back pain and took aspirin for it,
I also feel numb in rear end area”

O: Objective (what the observer finds?)

A 30-year-old male weight-lifter
had been in excellent health in the past
single
no history of illicit drugs
low back pain is common among his peers
competed nationally in weightlifting
no other neurological complaints
occasional tendency to wheeze
cranial nerves and upper limbs were normal
tender over the lumbosacral junction
Straight leg raising was limited to 20° bilaterally
evoking posterior thigh pain on either side
Femoral stretch was negative
He had weakness of planter flexion
knee flexion and hip extension bilaterally
The knee jerks were brisk and the ankle jerks absent
The plantars were weakly flexor
Tone was normal and co-ordination intact
He had blunting of cutaneous sensation over the posterior thighs extending to the perianal region bilaterally
His anal sphincter tone was reduced
His bladder was palpable to the umbilicus
A general systems examination was satisfactory

A: Assessment (how the cause and effect fit biological integrity?)

Central disc prolapse in the lumbosacral spine
The history is strongly suggestive of an acute disc prolapse.
The bilateral distribution of the symptoms and signs and the evidence of sphincter disturbance suggests that this is a central rather than posterolateral prolapse.
Plantar flexion (gastrocnemius and soleus) is supplied by L5 and S1 (mainly 51),
knee flexion _— - (hamstrings) by S1 and hip extension (gluteus maximus and medius) by S1.
The posterior aspect of --- the thigh is supplied by 52 as is the inferior border of the buttock.
The perianal area is supplied by sacral segments 3-5. The sensory deficit suggests,
therefore, involvement of the sacral dermatomes from 52-55.



P: Plan of management (What to do?)

This problem should be investigated as an emergency.
Plain radiographs of the spine will not provide any useful data. The main alternatives are computerized tomography myelography or magnetic resonance imaging.
The former is invasive but is generally more rapidly and widely available.
The latter is the investigation of choice.
It will allow assessment of all the lumbar spine rather than just the affected segment.
A potential disadvantage occurs with computerized tomography myelography if the central disc prolapse (probably at L5/51) is complete.
Insufficient contrast may go past the obstruction to show the higher lumbar levels.
The only appropriate treatment here is surgical.
The patient should be catheterized and taken to theatre immediately.
Providing a satisfactory decompression of the cauda equina is achieved,
the outlook should be good but further delay may well jeopardise this patient's recovery, particularly with regard to bladder function.
_________________
Dr. Mohamed F. El-Hewie.
Author of
"Essentials of Weightlifting and Strength Training"
http://www.lift-4-life.com

[sjaak smorenburg]

Great stuff, thank you.

Sjaak