Case Presentation

History

A 22 year old male with a two year history of low back pain and intermittent right leg pain sustained an acute worsening of his right leg pain 12 days prior to evaluation. He proportionalized his pain to 5% back and 95% leg pain. He complained of a new onset of weakness, tingling, and constant numbness. The pain and numbness radiated down the posterolateral leg to the dorsum of the right foot. He was unable to bear weight on the right leg and was using a walking pole for support. He was unable to sleep supine and had to sleep in a recliner to minimize the pain. Sitting provided some relief. He denied bowel or bladder incontinence, but had constipation for the last 12 days.

Physical Exam

Physical exam revealed an antalgic gait, limited lumbar extension to 10 degrees, tenderness in the right sciatic notch, positive straight leg raising (SLR) and Lasegue’s tests, positive contralateral SLR, 2+ bilateral patella and Achilles deep tendon reflexes, decreased sensation to light touch over the dorsum of the right foot and to a lesser extent the lateral border of the foot, and weakness. The right sided weakness was graded as 4/5 anterior tibialis, 2/5 EHL, 3/5 hip abductor, 4/5 gastroc-soleus. (5/5 is full strength). This was consistent with severe radiculopathy at L5 > L4 and S1.

Imaging

MRI revealed a large right paracentral/foraminal extruded herniated nucleus pulposus with slight caudal (inferior) migration causing compression of both the exiting and traversing nerve roots. (fig. 1)

Treatment

Surgery was recommended due to the acute onset and progressive neurologic deficits. After a full discussion of his risks, benefits, and alternatives the patient elected to undergo outpatient selective endoscopic posterolateral discectomy. The patient experienced over 80% pain relief immediately post-op. He had some mild dysesthetic burning over the L4 distribution that started a few days post-op. This completely resolved by 4 weeks with the aid of neurontin 300mg three times per day. A post operative MRI revealed excellent herniation removal without any retained fragments. (fig 2) The patient’s acute pain resolved within 24 hours and he had no pain at all by 4 weeks. His weakness improved to full 5/5 strength.

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