Rapid Return To Sport After Lumbar Epidural Steroid Injection

Abstract

HISTORY: A 66-year-old healthy active adult male with acute onset lumbosacral pain with referral into left leg while putting weights down after exercising. Initial primary care evaluation was unremarkable and patient was given Naprosyn, Percocet and an XRay was ordered, showing grade 1 spondylolithesis L2-3. Pain continued and he presented one week later with continued severe pain and new left lateral leg numbness. Oral steroids and physical therapy were initiated and pain continued. Gabapentin was tried with no response. He was seen at 9 weeks and complained of pain with all activities, including sitting. MRI was ordered and he was referred to physiatrist. He was seen one week later with 6/10 severe pain in left low back radiating down the left leg into lateral foot and ankle. Activity remains limited with pain even in the seated position and ADLs affected PHYSICAL EXAMINATION: Positive straight leg raise, decreased sensation left lower limb in the entire foot and lateral calf, 4/5 strength left ADF. DIFFERENTIAL DIAGNOSIS: Lumbar disc herniation, lumbar radiculopathy, spondylolithesis, lumbar stenosis. TESTS AND RESULTS: MRI Lumbar Spine without Contrast:L4-L5 broad-based left-sided disc herniation extruding inferiorly left paracentral measuring 16 x 14 x 15 mm effacing the thecal sac and displacing the left L5 nerve root. FINAL WORKING DIAGNOSIS:L5-S1 disc herniation with left L5 radiculopathy. TREATMENTS AND OUTCOMES: Symptoms persisted despite oral steroids, NSAIDs, and physical therapy, and lumbar epidural steroid injection was performed. Patient had 98% pain relief with resolution of numbness. Left ankle dorsiflexion strength that improved (5-/5), pain was only 1/10 in left lumbosacral junction. Physical therapy was restarted for 4 weeks to improve core strengthening. At 6 wks, numbness had resolved, strength had normalized, and he was back to normal activities of biking 21 miles and lifting regularly.