An Emergency Condition: Can You Spot It in Time?

The following putative case report discusses a lower motor neuron lesion that is an emergent condition. The patient presents with a chief complaint / chief concern of lower back pain: "My back is really hurting."

This patient presentation requires you to perform a differential diagnosis, which indicates the need for an immediate MRI and referral for neurosurgical intervention. Spinal manipulation or other modalities are contraindicated. This case should challenge your evaluation and management.

History / Presentation

A 55-year-old male patient returns to your office for the treatment of chronic low back pain. You have been treating him over the past 20 years for several episodes of lower back pain. Your diagnoses have progressed from the initial lumbar facet syndrome to degenerative joint and disc disease. Several of the episodes included lifting injuries at work, and one episode was due to a slip and fall on an icy sidewalk.

Subjective Findings

The patient reports a dull, deep, aching pain in his lower back, which started about two weeks ago. He thinks he tweaked his back while lifting heavy bags of potting soil and large pots of plants at home.

The pain has interfered with his sleep, and the pain and stiffness of the lower back are worse in the morning. It seems to feel better after a hot shower, some ibuprofen and performing normal activities of daily living. Later in the day, his back feels tired and the deep, dull ache in the lower back returns.

He denies any pain in his legs. Pain severity is rated at 4-6/10. He believes chiropractic care will help him, as it has over the past 20 years.

Objective Findings

• Postural evaluation reveals pelvic obliquity with an inferior posterior left ilium.
• Gillet's test demonstrates a fixation of the left sacroiliac joint.
• The long-sit test demonstrates a functional short left leg.
• Palpation of the supraspinous ligaments at L4-5 and L5-S1 produces pain, as does palpation of the multifidi muscles bilaterally at the same levels. An active trigger point in the left iliopsoas muscle is revealed with palpation of a taut band and a painful nodule.
• Active range of motion is full and without pain in all ranges, except for reduced extension and right lateral flexion with pain at the L4-5-S1 spine.
• Kemp's maneuver is reduced and painful to the right, with the pain located at the L4-5-S1 spine.
• The straight-leg-raise test of the right lower extremity produces pain at the levels of L4-5-S1 at 85 degrees. The left lower extremity does not produce pain at 90 degrees of straight-leg raise.
• Slump test reproduces the pain in the L4-5-S1 spine.
• Dejerine's triad is absent.

Three-part neurological examination:

• Deep tendon reflex  2+ bilaterally and brisk for the patellar and Achilles tendons.
• Sensory evaluation of the lower extremities reveals the L4-5-S1 dermatomes to be intact for sharp and dull sensations.
• Motor testing of the lower extremities demonstrates 5/5 strength bilaterally for the L4-5-S1 myotomes.
• Babinski sign absent bilaterally.
• Anterior and posterior joint dysfunctions revealed at the levels of L4-5 and L5-S1 with pain, reduced range of motion and hypertonicity of the paravertebral muscles.

Assessment / Initial Diagnosis

Acute sprain / strain of the lumbar spine complicated by degenerative joint and disc disease.

Treatment Plan

Conservative chiropractic care includes six spinal manipulation and soft-tissue treatments to reduce pain, joint dysfunction and active trigger points over a period of two weeks.

Your patient seems to respond well to the initial three treatments, but the following week he complains of increasing lower back pain, and some pain and numbness in the legs. He thinks additional lifting of furniture at home over the weekend might have aggravated his lower back. Hence, you re-evaluate your patient.

Re-Exam / Re-Assessment

Objective findings: Kemp's maneuvers produce pain down both of his lower extremities with radiating pain to the feet. Slump test increases the lower back pain with radiating pain down both legs to the feet.

Sensory evaluation reveals hypesthesia in the L5-S1 dermatomes bilaterally. Motor testing is 5/5 bilaterally of the lower extremities. Deep-tendon reflexes of the lower extremities reveal 2+ and sluggish Achilles reflexes. Babinski sign is absent.

Assessment / Plan: Lumbar sprain / strain with lumbar discopathy and radiculopathy. Ordered a lumbar MRI to evaluate lumbar disc herniation. The imaging center is able to evaluate the patient in two weeks.

What's Happening? Quiz Time

You suggest he return for a follow-up treatment the next day, but he does not return for the appointment. You call the patient to check on his status. He mentions that the pain in the lower back and legs is severe. He does not believe that he can safely drive to the office. The patient then mentions that he is having some difficulty urinating.

Now, what is your differential diagnosis? Should you change the plan for this patient? I offer two multiple-choice questions:

1.    The working diagnosis should be one of the following:

a.    Spinal subluxation syndrome
b.    Lumbago and sciatica
c.    Degenerative disc disease with lumbar radiculopathy
d.    Cauda equina syndrome

2.    The treatment plan should be one of the following:

a.    Prescribe daily chiropractic spinal manipulation to reduce subluxations
b.    Prescribe acupuncture to reduce the pain
c.    Prescribe spinal traction to decompress the lumbar nerve roots
d.    Prescribe emergent MRI and neurosurgical consultation

Clinical Pearls

I hope your answer is "d" for both questions. This patient is presenting with the signs and symptoms of an incomplete cauda equina syndrome. Emergency surgery might prevent this patient from experiencing complete cauda equina syndrome with permanent loss of bowel and bladder function, chronic weakness in the legs and permanent loss of sexual function.

Any intervention offered in your office is an absolute counterindication. Emergency neurosurgical consultation is the only indicated recommendation you should make for this patient.

This case is an example of a rare spinal degenerative joint and disc disease condition that progresses to cauda equina syndrome. As a chiropractic clinician, you must always perform appropriate evaluation procedures, including history taking and physical examination. Each follow-up visit should include both subjective and objective evaluation, which permits you to determine your patient's status.

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Author's Note: If you have experienced a cauda equina syndrome case in your office, I would appreciate hearing from you: jlehman@bridgeport.edu.