Quadriceps weakness due to disc protrusion causing nerve root compression. A case report and literature review

Abstract

Most common presentation of spinal disc herniation is pain. Next common presentation is pain associated with neurological symptoms [1] . It is relatively unusual to present muscular weakness purely due to disc herniation in the absence of lower back or neuropathic pain and can be a diagnostic challenge. A male patient of 45 presented to his family physician with five days history of weakness in the left quadriceps. There was no pain in the back or leg or any sensory symptoms at this stage. There was no other significant past medical history apart of history of spontaneous disc prolapse when he was 26. (radiating pain to the left leg but no neurological symptoms at that time). Clinical examination revealed motor deficit of 4/5 in the left quadriceps and diminished knee reflex. There was no sensory deficit elicited at this stage. Patient was referred to neurologist (by this time patient had developed sensory deficit at medial lower leg) who arranged nerve conduction studies which revealed L4 radiculopathy. Patient was referred to spinal surgeon who after consultation arranged MRI of the lumbosacral spine which showed disc extrusion at L3-4 level causing root compression of L4 nerve root. Since the patient was active sportsman, it was decided to do discectomy. However, after case discussion in spinal team meeting, (and patient started to feel slight improvement in sensory symptoms after couple of weeks) it was decided to manage conservatively. Patient started physiotherapy for three months and gradually noticed complete resolution of sensory loss after a month and gradual improvement in motor weakness. Patient started light sporting activities after three months of orthopaedic consultation. Patient continued to recover and had complete resolution of motor symptoms within a year. Patient had a follow up MRI after about a year which showed subtle improvement of compression at the same level. Patient was discharged from outpatient follow up. This case illustrates diagnostic dilemma when symptoms are not typical. However, it is proven the ‘common things are common’ again. Conservative management seems to be way forward when neurological symptoms are mild especially in the absence of neuropathic pain, However, it needs to be decided on case-by-case basis