Teenager with Acute Back Pain After Falling on Trampoline

Abstract

INITIAL CONSULTATION cc: low back pain HPI: This is a13 yo female acute onset of low pack pain that has persisted for 6 weeks prior to evaluation. Patient states that she was jumping on the trampoline with her brother when they both landed on their backs stretching the trampoline and resulting in her back hitting the ground. Later in the day her back began to hurt and this back pain has been persistent over the past 6 weeks. She reports intermittent pain in the right lower limb with numbness in the right foot. Initial evaluation by primary care physician included lumbar radiographs and lumbar CT, which were normal. She has been taking ibuprofen 600 mgs twice a day with little benefit. She is a typical physically active 8th grader with no past medical or surgical history. Her family history is noncontributory in this case. PHYSICAL EXAM: Lumbar range of motion is limited specifically with flexion. There is 15 degrees of flexion with significant guarding of the right side of the lumbar spine secondary to pain and normal extension and side bending range of motion. There is no significant lumbar paraspinal or SI joint tenderness. Straight leg raise results in back pain with no radicular symptoms. She has normal muscle strength in both lower limbs except 4+/5 right ankle dorsiflexion and 4-/5 right great toe extension. Sensation to light touch is diminished in the right L5 distribution. Muscle stretch reflexes are 1 + and symmetrical throughout DIFFERENTIAL DIAGNOSIS: Herniated lumbar disc Paraspinal muscle strain/sprain Spondylolysis Plan: Lumbar MRI to evaluate disc pathology. Advised to continue current dosing of ibuprofen 600 mgs twice a day. Trial of lidoderm patches to affected lumbar area. Lumbar MRI Results Central and rightward L4-5 subligamentous disc herniation Shallow leftward L5-S1 disc protrusion Revised Plan: Prednisone taper Physical therapy regimen with emphasis on an extension-based lumbar stabilization exercise program with the use of passive modalities as needed. Consider epidural steroid injections if there is no improvement with the oral prednisone taper. FINAL WORKING DIAGNOSIS Herniated disc L4-5 and L5-S1 disc Right L5 radiculopathy TREATMENT AND OUTCOMES 3 weeks after initial assessment the patient is reported by physical therapy to have decreased low back pain by utilizing the extension based physical therapy program with a focus on avoiding bending/twisting during activities of daily living.