Back Pain - Cycling

Abstract

HISTORY: 17 year-old competitive road cyclist presents with a complaint of left-sided lower back pain for the past 6 months that has worsened over the last 2 months. He denies any specific injury. Initially, his pain was intermittent, moderate, and associated with a feeling of "tightness" in the left hamstring area, but no radiating pain, numbness, or tingling. Pain is now described as constant, more severe, and radiating down the posterior aspect of his left thigh and into his calf. He reports an intermittent numbness in that distribution as well, but the more prominent symptom is pain. Alleviating factors are rest, lying down, and pain medicine. Aggravating factors are vigorous exercise, stretching, bending forward, and sitting for a prolonged period of time. He denies right-sided symptoms, weakness, bowel or bladder dysfunction, fever, or recent weight changes. PHYSICAL EXAMINATION: Alert, well-appearing, athletic young man. Exam of his back reveals no ecchymosis, swelling, or deformity. Pelvis is level and leg lengths are clinically equal. No obvious scoliosis or rotation is noted in the lumbar spine. Range of motion is limited secondary to pain, particularly flexion. Positive straight leg raise on the left, both sitting and supine. FABER test is equivocal. Tenderness is localized over L4 and L5, both midline as well as left-sided in the lumbosacral area. He has 5/5 strength and normal sensation bilaterally. Lower extremity deep tendon reflexes are 2+ and symmetric. Antalgic gait with discomfort on his left side. DIFFERENTIAL DIAGNOSIS: Mechanical low back pain Discogenic back pain Sacroiliac dysfunction Lumbar spinal stenosis Fracture Metastatic disease TEST AND RESULTS: Lumbar spine series - Negative. No fracture, subluxation, or mass. No evidence of spondylolysis or spondylolisthesis. Lumbar Spine MRI - Severe central and left lateral spinal canal stenosis (central canal AP diameter measures 3 mm) at the L4-5 level with disc protrusion FINAL WORKING DIAGNOSIS: L4-5 disc herniation with severe lumbar spinal stenosis TREATMENT AND OUTCOMES: Conservative management initiated including activity modification and over the counter pain medicine PHYSICAL THERAPY: Pain management consultation and epidural steroid injection Surgical consultation regarding possible surgical intervention