Peer Reviewed by the American Chiropractic Rehabilitation Board
This case study will provide information regarding the assessment, diagnosis, multi-disciplinary co- management, and successful treatment of a significant lumbar intervertebral disc herniation leading to radiculopathy accompanied by foot drop and secondary Chronic Regional Pain Syndrome (CRPS) involving the lower extremity.
The subject is a 44 year old caucasian female, who is married with two teenage children. She is fully employed performing childcare duties.
The patient reports that she awoke on April 1, 2015 with severe buttock and left lower extremity pain with no prior history. She was evaluated at a local emergency department and provided pain relieving medications. She had to return to an urgent care facility the following day for ongoing, unrelenting pain. She then followed up with her Primary Care Provider (PCP) soon thereafter for further management. After initial onset, she quickly developed a foot drop, and paresthesia and anesthesia over the left lateral leg, lateral and dorsal foot. Deviation from a neutral posture would cause severe pain in the lower extremity. She was referred to physical therapy where she obtained approximately 6 visits of care with little improvement. She reported that she gradually developed generalized swelling, redness, and discoloration of the left foot, when her PCP then obtained a left lower extremity vascular study where no abnormalities were found. She was last evaluated by her PCP on May 12. At that point, the treating physical therapist advised she obtain further assessment and care in the author’s office.
At the time of her initial visit on May 22 she was taking 100 mg of Neurontin, 3 times daily to no avail. This was the only medication she was taking at that time. Pain relieving medications and oral steroids all provided no relief of any significance during prior trials. Prior to the visit, the patient had prior pelvic and lower extremity vascular studies performed. The subject was complaining of pain, muscle cramps, and weakness in the left buttocks, thigh, lower leg, and foot without complaint of lower back pain. The pain in the buttocks, calf, and foot was rated 5 to 6 out of 10 on average. The quality of the complaint was described as burning, loss of sensation, stabbing, tension, and tingling. The location was solely as described previously. The prior symptoms were present 50 to 75% of the day, worsening and more specific to the afternoon and evening. The symptoms were reported to wake the subject at night, only providing some interference to Activities of Daily Living (ADL). Exercise, hobbies, household chores, and sleep are most affected, with intensity and interference varying from day to day. The only noted interventions and activities that provide relief were physical therapy, and only temporarily. Coughing, sneezing, forward bending, household chores, and reaching all worsened pain immediately.
No significant or related personal, social, or family history of trauma, disease, or disorders. Review of systems was unremarkable except for symptoms associated with presenting complaint. The patient did not drink alcohol or use tobacco and exercised at least 3 times per week.
The patient had the following general appearance and characteristics: cooperative, maintained eye contact, mentally alert, no deformities, oriented x 3, and walked with a limp and obvious loss of left ankle dorsiflexion. The patient appeared to be in no apparent distress.
|Height: 63”||BMI: 23.7||BP: 135/89||SpO2: 98%|
|Weight: 133.4 lbs||Aural Temp: 98.8 F||Pulse: 93 BPM|
The patient was unable to perform active dorsiflexion of the foot and ankle with gravity eliminated. Any deviation from neutral standing or sitting caused severe pain to radiate to left lower extremity. Patient unable to adopt any other postures. The seated and supine straight leg raise on the left was grossly positive for acute buttock and left lower extremity pain, with crossed straight leg raise overtly positive as well in both sitting and lying. Ankle jerk absent on the left, 2+ on the right. Patellar response 2+ bilaterally. Loss of sensation to both light and sharp touch over left lateral leg and dorsal foot, present on the right. Left foot and toes grossly and generally swollen, red, and considerably cool and moist to touch. Lower extremity pulses were full and palpable.
- Venous Duplex Ultrasound
- A left lower extremity venous duplex ultrasound was performed. No abnormal findings present.
- Computed Tomography
- A CT of of the abdomen and pelvis without contrast was performed. No abnormal findings present.
- Computed Tomography Angiogram
- A CT angiogram of the bilateral lower extremities was performed. No abnormal findings present.
- Magnetic Resonance Imaging
- An emergent MRI of the lumbar spine without contrast was performed on May 22 after initial assessment in the author’s office. The most significant finding was a 1.1 cm AP x 3 cm TR x 1.6 cm CC lobulated left posterior paracentral/foraminal/extraforaminal disc extrusion resulting in moderate central spinal stenosis, severe narrowing of the left lateral recess and neural foramen with impingement upon the left S1 descending, and foraminal and extraforaminal portion of the left L5 nerve root. In addition, a hematoma was also appreciated as a space occupying lesion. (Figures 1-3).
Figure 1. Sagittal T2 weighted lumbar MRI with disc herniation at L5/S1.
Figure 2. Close up of Sagittal T2 weighted lumbar MRI with disc herniation at L5/S1.
Figure 3. Axial T2 weighted lumbar MRI with disc herniation centrally and laterally.
- Laboratory Studies
- WBC – 7.4 K/uL
- CRP – 5.7 mg/l
- Sed Rate – 13 mm
- All labs performed and found to be within normal limits, with no indication of systemic infectious or inflammatory process.
Given the availability of prior imaging and testing at the time of the initial visit, the patient subjective history and objective physical examination findings, a lumbar intervertebral disc herniation leading to lumbar radiculopathy was strongly suspected, and this was confirmed via emergent MRI. Secondarily, the presence of pain, foot discoloration, swelling, diaphoresis, and coolness was uniquely indicative of CRPS given that no vascular claudication was present. Given the degree of symptom severity and loss of reflex activity and strength deficits in the left lower extremity, immediate surgical consultation was warranted.
When presenting with sudden onset of lower extremity pain without trauma, in a radicular pattern, including pain in the buttock with or without lower back pain, the most common suspicion is lumbar radiculopathy. The most common cause of lumbar radiculopathy is a herniated disc, though the differential may include non-neural lumbopelvic referred pain, lumbar spinal stenosis, lumbosacral plexopathy, and mononeuropathies of the of the leg of varying etiologies. Developing lower extremity weakness, loss of sensation, and paresthesia further confirms and supports neural involvement. When presenting with singular lower extremity pain, discoloration, cold skin, and swelling, the initial diagnostic reaction and differential is typically one of a vascular cause, most commonly a venous thrombosis, or secondarily an infection.
There was no presence of spinal or lumbar pain, nor was there any prior history of lower back pain leading up to April 1, and I believe this initially prevented more direct assessment of the lumbar spine as a cause of complaints. There was no family or personal history of cardiovascular or hematologic risk factors, history of chronic disease, nor any recent illness or surgical procedures, and no use of medications. This did not typically support the most common associated factors of a venous thrombosis. When all symptoms taken into context, with and without prior or current knowledge of advance imaging or laboratory testing, the constellation of symptoms supported the presence of a lumbar radiculopathy with secondary development of CRPS due to severity of neural compromise. This was further proven and supported via the testing as stated, both in the negative and positive examination findings. However, the presentation of both of these conditions at the same time is also unique and perplexing, as they share common and interrelated causation, as well as symptomatology.
After presenting on May 22, with severe radiculopathy, loss of strength, and signs strongly suggestive of CRPS, an immediate MRI of the lumbar spine was obtained on the same day. Following the discovery of a considerable lumbar intervertebral disc herniation, immediate contact with an orthopedic spinal surgeon was made, and subsequent patient follow up was scheduled for the same day. After orthopedic evaluation, surgery was scheduled for June 2. Upon the day of the operation, the patient’s status had not changed for better or worse. The surgical procedure consisted of a far lateral left L5/S1 microdiscectomy and a central L5/S1 left sided microdiscectomy. Two different surgical approaches were required given the nature of the disc herniation. A laminoforaminotomy was carried out and a complete hemilaminectomy was performed on the left side of L5. A large hematoma as well as a large disc extrusion were retrieved. During the procedure, a small dural rent was made, found, and repaired inter- operatively. Following the procedure, the patient was discharged on the same day.
Outcome of Care
On June 5, three days following the surgery, the patient presented to the operating orthopedist’s office complaining of positional, severe frontal headache, worse with standing and being upright, relief being obtained lying supine. The patient also noted on this visit that her left foot was dramatically improved in both strength, coloration, and comfort. Objective examination revealed that extensor hallucis longs (EHL) and ankle dorsiflexion strength were 4/5, whereas they were 0/5 pre-operatively. The patient was instructed to lie supine for 48 hours with only bathroom privileges to alleviate and address dural headache secondary to dural puncture. Upon further follow up on June 8, the patient reported that her headache had resolved and was not sensitive to postural position any longer. Was again evaluated on June 18 by the operating orthopedist, who noted continued patient improvement both objectively and subjectively. The final orthopedic follow up occurred on July 30, where the patient continued to report improved function and strength. Objective examination revealed 4+/5 strength of EHL and ankle dorsiflexion, with mild, ongoing discoloration and coolness over the left foot. She was released to full activity as of that date with instruction to consider further therapies or interventions to address ongoing CRPS symptoms.
The patient sought treatment, complaining of constant (75%-100%) dull, aching, sharp and shooting discomfort in the back of the left hip. She rated the intensity of discomfort, using a VAS, as a level 7 on a scale of 1 to 10 with 10 being the most severe. The discomfort was reported to increase with prolonged sitting.
The patient presented today to discuss ongoing pain across lower back, pain in left buttock, loss of function, left leg giving away. Stated that she had discectomy performed due to disc herniation earlier this summer after evaluation here for same. Stated that since that time, CRPS had improved in left lower extremity. Stated that sensation was dull, and that foot felt “asleep” mildly at all times. Stated that ankle strength had improved quite a bit, however, leg would give away at times without warning. Stated that she could no longer sit on the floor and play with children, nor care for them as needed due to pain in lower back and buttock. During discussion, she was in tears, as she was distraught, and concerned that she would never regain full function or her “life” back.
Seated SLR and supine SLR on the left were acutely painful down posterior thigh to knee and in the left buttock. Patient could not extend lumbar spine without discomfort, and was severely limited from what she called a “block”. Forward bend was limited fingers to mid shin. Acute pain noted with palpation of left buttock and posterior hip. Left lower foot was very cool with mild perspiration and no noted color changes. Right lumbar paraspinal muscle spasm noted. Acute pain noted over L4 and L5. Heel and toe raise revealed normal strength bilaterally. Great toe dorsiflexion 4/5 on the left. Reflexes a little sluggish on the left as compared to right at S1. Sensation intact but decreased on the left across the foot as compared to right.
Subsequent examinations during further follow ups revealed the following findings, in no particular order or importance, each contributing to the entire presentation, with each finding being addressed specifically: hypertonic and/or overactive musculature, myofascial tissue dysfunction, inhibited and/or weak musculature, altered motor control upon movement pattern examination, pain in left buttock sitting cross legged, active, pain producing surgical scar; limited straight leg raise and active straight leg raise on the left with buttock pain, loss of passive spinal and extremity joint mobility, limited ability to forward bend or extend due to restriction and pain in lumbar spine, poor single leg balance and loss of intrinsic foot muscular activity on the left.
I advised the patient, at length, that I felt she stood a great chance to return to all of her normal activities without pain or dysfunction. I advised her that she suffered from a rare disc herniation and sequelae. Additionally, she was not given and/or did not take the opportunity to have therapy immediately after surgery. Given those facts, warning was issued that progress may be slow, and the reason why she was still struggling with after effects of radiculopathy and CRPS. With much work and effort, I advised she could return to life fully.
The patient was tentatively scheduled 2 times per week for 5 weeks beginning September 14, with frequency depending upon her compliance with follow up visits and self-care strategies, and improvement and/or exacerbation of current condition. At that time, further care, discontinuation of care, or referral would be considered according to evaluation of condition. Re-evaluations were to be performed as needed according to changes in condition. Over the course of care and subsequent re-evaluation, additional treatment was prescribed, with episodes of care not exceeding 2 times per week, and then moving to 1 visit per week, with occasional weeks without care due to scheduling conflicts.
The goals of care were to improve the patient’s objective findings related to her subjective complaints and allow for the performance of caring for family, bending, most movements, sitting, and walking.
Additional short and long term goals included: decreased muscle spasm, decreased paresthesia, return of sensation, decreased pain, decreased restrictions on social life due to pain, improved ability to engage in personal care, improved tolerance to work duties, increased active range of motion, increased spinal stability and muscular endurance, increased ability to perform ADL, and increased function. Objective improvement would be monitored through the use of a pain scale, improved functional/orthopedic testing, and the ability to attain previously mentioned goals.
The goals were pursued through the use of education, chiropractic manipulation and mobilization, manual therapies, neuromuscular techniques, and rehabilitative exercise as indicated and deemed necessary by objective examination and clinical judgement at each visit to address the patient’s presenting complaints. The patient would be progressed as tolerated.
Chiropractic manipulative treatment and joint mobilizations were used to restore joint mobility, reduce pain, and reduce muscular tone. Manual therapies such as Active Release Technique (ART) and Graston Instrument Assisted Soft Tissue Mobilization were used to reduce myofascial restrictions and adhesions to restore related joint and/or soft tissue mobility and to reduce pain. Neuromuscular techniques were used to address re-education of movement, balance, coordination, posture, and proprioception accordingly. Rehabilitative and corrective exercises were used to develop appropriate strength, endurance, stability, and mobility where indicated.
At each visit, the timing, intensity, and location of symptoms were recorded, as were the aggravating and relieving factors. These were monitored using a scale of time of 1 to 100% of the day and the intensity on a Visual Analog Scale of 1 to 10.
Over the course of 18 visits from September 22 to January 4, the following strategies and techniques were performed as indicated and deemed necessary, varying in implementation and performance on given days of treatment.
Post-isometric relaxation was used to lengthen and reduce hypertonicity in the following muscle groups: left external hip rotators, left hamstring.
Graston Instrument Assisted Soft Tissue Mobilization was used to reduce myofascial adhesions and/or fibrosis in the following areas to improve mobility: left hamstring, left external hip rotators, lumbar spine surgical scar, left lumbar paraspinals, left lateral thigh.
Active Release Technique protocols were used to release myofascial restrictions/adhesions and improve mobility in the following areas: left external hip rotators, left gluteus maximus, left hamstring, left hip adductors, left plantar foot, left gluteus medius, left iliopsoas, and left tensor fasciae latae.
Chiropractic manipulative therapy was applied to reduce joint restriction and improve articular mobility in the following areas: left ankle mortise joint, left mid-tarsal shear, L3/L4 side posture extension, right sacroiliac joint prone drop, T10 prone extension, thoracolumbar junction supine extension, right sacroiliac joint side posture, T4 extension supine, thoracolumbar junction extension side posture, L5 side posture extension.
Dynamic Neuromuscular Stabilization was performed in varying developmental positions to facilitate agonist and antagonist muscular co-activation to achieve joint centration and stability, in addition to facilitation of inhibited musculature and a proper breathing pattern to reduce global muscular hypertonicity, resulting in coordinated and balanced movement patterns.
The following self-care strategies were demonstrated and assigned to Carol and were to be performed at home to tolerance as instructed to address objective examination findings and achieve stated goals:
- Single Leg Standing in Bucket of Pea Gravel, 5 minutes, 2 sets, 1 to 2 times daily
- Active Ankle ROM with Yellow Theraband, 10 reps each plane, 2 sets, 2 times daily
- Seated Sciatic Nerve Mobilization, 10 reps, 2 sets, 2 times daily
- Cat Camel, 10 reps, 2 sets, 2 times daily
Additional exercises were added to ongoing home exercise program:
- Wall Bug, 10 reps, 2 sets, 2 times daily
- Standing Forward Bend Progression, Hip Hinge Focus, 3 Variations, per Gray Cook, 10 reps each variation, 2 sets, 2 times daily
The following changes and additions were made to the home exercise program:
- Eyes Closed, Single Leg Standing in Bucket of Pea Gravel, 5 minutes, 2 sets, 1 to 2 times daily
- STOP – Seated Sciatic Nerve Mobilization, 10 reps, 2 sets, 2 times daily
- STOP – Cat Camel, 10 reps, 2 sets, 2 times daily
- Seated Left Piriformis Tri-Planar Stretch, 10 reps, 2 sets, 2 times daily
The following addition was made to the home exercise program:
- Foam Roller Left Posterior Hip, 3 to 5 minutes per day, to tolerance
The following changes and additions were made to the home exercise program:
- STOP – Active Ankle ROM with Yellow Theraband, 10 reps each plane, 2 sets, 2 times daily
- STOP – Wall Bug, 10 reps, 2 sets, 2 times daily
- STOP – Seated Left Piriformis Tri-Planar Stretch, 10 reps each plane, 2 sets, 2 times daily
- Wall Slide Squat, 10 reps, 2 sets, 2 times daily
- Supine, 3 Way Hamstring Mobilization with Band, 10 reps each plane, 2 sets, 2 times daily
The following changes and additions were made to the home exercise program:
- STOP – Wall Slide Squat, 10 reps, 2 sets, 2 times daily
- STOP – Supine, 3 Way Hamstring Mobilization with Band, 10 reps, 2 sets, each plane, 2 times daily
- Long Sitting Reach with Adductor Activation, 10 reps, 2 sets, 2 times daily
Outcome of Care
Over the course of 18 treatment visits and strong adherence to the home exercise program, the patient was able to attain nearly all goals of care. The following improvements were reported by the patient and/ or objectively observed on given days of treatment. No episodes of significant regression were noted, with consistently trending positive progress, with intermittent days of decreasing return of symptoms. The following improvement progression was noted, in no particular order: foot was no longer cold, discolored; area of paresthesia consistently grew smaller and less frequent, was able to walk a 5K without symptoms or difficulty, able to jog upstairs, no longer had episodes of leg “giving away”, could sit cross legged in any orientation freely, fully, and pain free; straight leg raise was equal bilaterally to 90 degrees, as was active straight leg raise, each without pain; regained all ankle dorsiflexion and EHL strength, regained full forward bending ROM, able to reach toes easily with good movement patterning; able to perform lumbar extension without restriction, full long sitting reach without discomfort, overall considerable reduction in pain intensity levels. This was in addition to improvement of movement pattern quality, balance, strength, soft tissue quality, as well as joint mobility. On January 4, upon discussion, review of progress, and goal review, it was mutually decided to release the patient from further care, with instructions to continue home exercise program for the next several weeks. On the final visit, the patient reported occasional (1 to 25%) dull discomfort in the back of the left hip, rating the intensity of discomfort as a level 1 on a scale of 1 to 10, with 10 being the most severe. The discomfort was reported to increase with prolonged sitting on hard surfaces. The discomfort was reported to improve with movement. The patient also reported mild, recurrent episodes of paresthesia over the left lateral foot, but the frequency continued to reduce. This was a symptom that she was more than willing to live with. I advised that this had the potential to improve further, or may be a permanent issue given the severity of neural compromise in the past.
Review of Anatomy and Physiology
Per the patient presentation and imaging findings, dominant L5 radiculopathy, with lesser involvement of the S1 nerve root were present as a result of considerable compression by both an intervertebral disc herniation and an epidural hematoma, which developed as a result of the trauma sustained by the epidural venous plexus system due to discal compression. The patient suffered from loss of EHL strength with subsequent foot drop associated with L5 radiculopathy and typical dermatomal and dynatomal distributions of L5 and S1 patterns. A dynatome is the area of symptoms produced by an injured nerve root. This is in contrast to a dermatome, which is the peripheral distribution of symptoms as a function of conduction loss along the nerve root due to trauma and/or compression. Each can result in pain, paresthesias, and loss of sensation.
In 1995, the International Association for the Study of Pain, defined the term Complex Regional Pain Syndrome, better known as CRPS. CRPS is an orthopedic, neurological, and traumatological disease following trauma, surgery, fractures, and peripheral nerve damage. Typical symptoms include circulatory disorders, edema, skin changes, disproportionate pain, sudomotor changes, and loss of function in the extremities. CRPS seldom occurs in the absence of an identifiable trigger, and is much more common in women than in men. The exact etiology is unclear, where neuronal inflammation and maladaptive changes in the central nervous system are believed to be involved, leading to continuous sympathetic neural reaction as a result of continuous pain provocation by tissue damage. CRPS is primarily a clinical diagnosis. Early diagnosis and management of this disorder is key to prevent long term damage and suffering. Interventions typically include physical therapy and sympathetic nerve blocks, the latter of which was not utilized in this case. This was due to the fact that the acuity of the pain and symptoms improved significantly following surgical intervention, resulting in decompression if the involved nerve roots, and therefore alleviating the perpetuating factors.
Wolter T, Knoller SM, Rommel O. Complex Regional Pain Syndrome following Spine Surgery: Clinical and Prognostic Implications. Eur Neurol 2012;68:52-58.
Abdi S. Complex Regional Pain Syndrome in Adults: Pathogenesis, Clinical Manifestations, and Diagnosis. UpToDate. Retrieved from http://www.uptodate.com/home
Overall, the patient was seen during the time period of September 14, 2015 through January 4, 2016 over the course of 19 visits after the initial evaluation on May 22 and subsequent recovery period post- operatively. From the time of onset, the patient had undergone approximately 9 months of care and recovery from an acute, unprovoked lumbar disc herniation leading to an epidural hematoma and resultant radiculopathy and secondary CRPS.
Ideally, the patient would have begun rehabilitative therapy immediately following surgical intervention, but was lost to further follow up until prompted to seek additional care for ongoing symptoms. Post- operative therapy was likely not pursued due to perception and belief that surgical intervention had and/or would resolve complaints. Potentially, an additional intervention to consider would have been mirror box therapy, as this is a novel approach to address the central nervous system component of CRPS and has shown promise for this condition. In addition, procedural sympathetic nerve blockage could have also been considered if progress was not being made, had stalled, or patient pain levels were too great.
Never the less, the patient still obtained an outstanding outcome given the degree and severity of presenting complaints. The successful outcome was due to several factors, of which included the presence and recognition of pathological “red flags” upon patient presentation, diagnostic triage, interdisciplinary communication and cooperation, appropriate and timely surgical intervention, and post- operative rehabilitation that included a variety of patient and condition specific interventions. Most importantly, an active, engaged, and motivated patient allowed for the plan of care to be carried through and completed.
As of February 29, 2016, per oral communication, the patient reported that she was doing very well, walking, playing with children on the floor, taking stairs, and performing all activities as she had before. She stated that she occasionally has very mild paresthesias over her left lateral foot and toes, and has an aching in left buttock if she sits for too long, but could be resolved with self-care strategies as assigned.