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Man with lower extremity pain

There are rarely emergencies in the field of pain management. The following case is an exception that could have been permanently detrimental to the patient.

 

A patient came to Advanced Spine and Pain worried that for the past 4-5 days his right lower extremity pain had become significantly worse. He mentioned having new-onset bladder incontinence for 4-5 days. Upon further questioning, he additionally had constipation for the same amount of time. During physical examination, it was determined that the extensor hallicus longus (EHL) muscle was significantly weaker on the right side compared to the left, which was a new finding from previous examination. Also new was a decreased right patellar reflex. The patient was lucky enough to present to the office for the purpose of reviewing a new MRI of the lumbar spine, which demonstrated severe central canal stenosis at the L4/L5 level.

The stenosis at this level corresponds to impingement upon the L4 & L5 nerve roots, which provides the motor signal to the patellar tendon, and the motor signal to the EHL muscle, respectively. Below these levels are the sacral nerve roots, which primarily controls the bladder and bowels, and were also subject to damage. The patient’s subjective complaints, physical examination, and imaging studies synergistically highlighted a neurosurgical emergency. If missed, the patient would be left with permanent nerve damage, manifesting in paralysis to the lower extremity and bowel/bladder incontinence/retention.

The patient was promptly diagnosed with Cauda Equina Syndrome and sent to the emergency room for a spine surgeon evaluation and lumbar spine decompression. This syndrome is highlighted by progressive lower extremity weakness, new onset bowel/bladder weakness, and saddle anesthesia from compression of the lumbosacral nerve roots.

The patient was able to express his concerns in a non-judgmental environment. We were then able to perform an in-person physical examination and link this with an imaging review, allowing us to see that all things were congruent in confirming the beginning of a disaster that would be minimized if caught and acted upon early. At Advanced Spine and Pain, we pride ourselves on being a practice that listens to our patients and recognizes when prompt emergency interventions need to occur.

Hatgis J., Hall A.J. (2017) Cauda Equina Syndrome. In: Kahn S., Xu R. (eds) Musculoskeletal Sports and Spine Disorders. Springer, Cham. https://doi.org/10.1007/978-3-319-50512-1_99  https://link.springer.com/chapter/10.1007/978-3-319-50512-1_99

 


 

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Advanced Spine and Pain is a leading pain management group based in Phoenix, AZ, and quickly expanding throughout the state. Offering minimally-invasive pain care services, the ASAP group consists of Arizona's top pain management specialists, including Drs. Abram Burgher, Todd Turley, and Jarrett Leathem.

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