Low Back Pain - Recreational Soccer Player

Abstract

HISTORY: A 21-year-old female recreational soccer player presented with intermittent right-sided low back pain for two years. She denied any trauma or inciting event. Pain was localized to the right lumbosacral region without radiating leg pain and was described as dull and aching. It was rated on average 5/10 on a numerical rating scale and associated with nausea when pain worsened. Symptoms were worse with prolonged sitting, and several times in the last month she reported worsening of typical pain with alcohol intake. She denied leg weakness, numbness, or bowel/bladder dysfunction. She participated in six weeks of physical therapy, which helped with nausea and pain with sitting, but she continued to have pain with alcohol consumption. PHYSICAL EXAM: Full and symmetric strength, sensation, and reflexes. Mild lumbar dextroscoliosis. No palpable step-offs. Tenderness over right lumbar paraspinals and above right iliac crest. No tenderness over PSIS. Full, non-painful range of motion with lumbar flexion and extension. No pain with facet loading. Full, non-painful hip range of motion. Negative FABER, FADIR, and straight leg raise test bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Discogenic pain 2. Facet-mediated pain 3. Disc herniation 4. Muscular strain 5. Sacroiliac joint dysfunction 6. Intrabdominal/ intrapelvic etiology 7. Neoplasm TESTS AND RESULTS: 1. Lumbar spine X-rays: -Normal alignment, normal vertebral body and disc space height -Partial lumbarization of S1 vertebral body -Five degrees of lumbar dextroscoliosis 2. MRI lumbar spine: -Lumbarization of S1 vertebral body -Normal disc heights and signal -Normal central canal and neural foramen size throughout lumbar spine -T1/T2 hyperintensity within S2 vertebral body, likely lipoma -Increased T2 signal medial to right kidney suggestive of hydronephrosis 3. Renal ultrasound: -Moderate right hydronephrosis with extrarenal pelvis. No nephrolithiasis. 4. Renogram with furosemide: - Right kidney with blunted flow and delayed clearance improved slightly with furosemide, consistent with partial obstruction at right ureteropelvic junction FINAL/WORKING DIAGNOSIS: Ureteropelvic junction obstruction causing Dietl’s crisis TREATMENT AND OUTCOMES: 1. Referral to urology 2. Resolution of pain and improvement in renal function after pyeloplasty