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Welcome to today's session, where we aim to delve deep into a lumbar spine MRI case study and hands-on demonstration of C arm-guided interventional procedure accordingly. Our focus will be pinpointing the pain generator amidst multiple pathological levels in the lumbar spine and discussing reasonable interventional procedures.
Key Areas of Focus:
We are specifically focusing on two key areas of pathology: L4-5 and L5-S1. We aim to identify which levels are the primary generator of the patient's pain and discuss appropriate intervention strategies.
Meet My Patient:
We have a 52-year-old female patient experiencing bilateral gluteal pain, anterior thigh discomfort, and nocturnal calf pain. Although she has had lower back pain for around four years, the pain recently worsened two weeks ago. Importantly, she didn't feel the need to consult a pain doctor for her back pain during those four years, suggesting it was not severe. Also, it's worth noting that the areas of pain she's currently experiencing seem to differ from what she experienced in the past.
So, we have to think about the underlying cause of chronic mild pain and the cause of a new episode of pain generator.
But before we proceed further with the patient's profile and pain map, please be aware that the initial pain drawing was completed by my assistant, who may need to be fully trained to capture the medical nuances. Keep this in mind as we proceed. But it is also a good way to train and interpreting skills.
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The Patient's Journey:
The pain our patient experiences started worsening two weeks ago. Initially, she felt swelling in both knees, extending to the anterior thigh, gluteal, and calf areas. Interestingly, she started taking aerobic dance classes around this time. However, unexplained soreness in both calves is particularly noticeable during nighttime, not intermittent claudication.
In her quest for relief, she visited a hybrid hospital combining Oriental and Western medical practices. An X-ray indicated spinal stenosis at the L4-5 level. She underwent acupuncture treatment, which was supposed to widen the narrowed spinal canal.
Anyway, she felt the pain of VAS of 5 to 6 when she visited me, better than the first attack, whether the acupuncture worked or time worked.
Rest and time are critical factors in relieving the pain.
As a pain doctor, understanding the pain generators, progression, and mechanism of relieving the pain are more important subjects than just relieving the pain.
Let's start with the simple x-ray.
Preliminary assessments from a simple X-ray reveal isthmic spondylolisthesis at the L4-5 level and mild disc space narrowing with a spur at L5-S1. Dynamic flexion and extension view show mild instability and vacuum phenomenon in the L4-5 disc space.
Second, anterior thigh pain.
Furthermore, her anterior thigh discomfort may very well be exercise-related, owing to her recent involvement in aerobic dance.
Notably, she reported a reduction in her symptoms when she took a break from her aerobic dance classes for two weeks.
Thus, we could consider excluding this from being lumbar-origin pain. To exclude the anterior thigh pain from the lumbar origin, I am particularly interested in looking for disc herniation at the L3-4 or L4-5 levels that could be compressing the L3 or L4 segmental nerve roots. Typically, patients with isthmic spondylolisthesis rarely complain of radicular pain unless associated with acute disc herniation or severe anterior spondylolisthesis affecting nerve roots.
Third, Gluteal Pain:
I aim to isolate the cause of her gluteal pain from the lumbar spinal origin.
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Fourth, Underlying Low-Grade Chronic Back Pain:
The pain may be attributed to the ongoing transition from instability to the stabilization phase in her L4-5 isthmic spondylolisthesis.
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16 июл 2024
