Left Lower Extremity Pain Research Articles

Cancer as a Cause of Low Back Pain in a Patient Seen in a Direct Access Physical Therapy Setting

Resident's case problem. This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient's low back and hip pain. A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient's most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient's condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient's physician is warranted.

Metastatic Melanoma Presenting as a Massive Abdominal Mass with Lower Extremity Radiculopathy

Purpose: The purpose of this case report is to highlight the unusual and often vague presentations of melanoma metastatic to the abdomen. Case: A 63 year old male with past history of prostrate cancer and surgically resected left arm melanoma, presents with left lower extremity pain and weakness, one month after finishing brachytherapy for prostrate cancer. In the following months patient was evaluated for sciatica, claudication and DVT with normal doppler studies and x-rays of the lumbar spine and pelvis. The lower extremity parasthesias and paresis progressively worsened in this 8 month period requiring the patient to use a cane for ambulation. Patient also had 40-lb weight loss with anorexia but no other gastrointestinal complaints. At admission the abdominal exam revealed a large palpable mass extending from the midline to the left flank. Catscan of abdomen/ pelvis revealed a massive 11×14 left abdominal mass with multiple nodular masses in the mesentery. FNA biopsy showed a poorly differentiated non-small cell carcinoma with following immunochemistry: HMB-45: positive Vimentin: strongly positive S-100: focal weak positive PSA: negative CK7: negative Cytokeratin: negative The above findings were consistent with metastatic melanoma. An MRI of the spine done for worsening paraparesis showed cauda equina compression requiring radiation therapy. However the patient was unable to undergo further treatment due to his deteriorating clinical status and succumbed to complications of the malignancy. Discussion: Malignant melanoma metastastic to the abdomen has a clinical diagnostic rate of just 2%, in contrast to 60% of autopsies that are found to have gastrointestinal involvement in patients that died with disseminated disease. Most cases of metastatic melanoma to the gastrointestinal tract present with vague symptoms of weakness, fatigue, abdominal pain and anemia. Our case report is very unusual in that it presented as a huge abdominal mass with mesenteric invovlement and lower limb radiculopathy. It also highlights the need for early imaging which is effective in ascertaining the extent of disease and the potential benefit of surgery as complete resection of metastasis is associated with prolonged survival. Conclusion: The presentation of melanoma metastatic to the gastrointestinal tract is vague and requires early investigation of symptoms as curative surgery can prolong survival.

Atypical Color Doppler Findings Related to Remote Lower-Extremity Traumatic Injury

Introduction Ultrasound artifacts can be misleading. This case demonstrates an unusual color Doppler artifact encountered while performing a lower-extremity venous evaluation. This color Doppler artifact was so unique that initially it was thought to be an incidental vascular finding. Case Study A 46-yr-old military veteran was seen in our noninvasive vascular laboratory for a lower-extremity venous evaluation because of left lower-extremity edema. He gave a history of chronic left lower-extremity pain from a war injury to his anterior left calf. An abscess developed 1.5 yr ago after he received whirlpool therapy. When the transducer was placed on the injury site, a large portion of the abscess filled with mosaic color that appeared to originate from the anterior portion. This color occurred without transducer movement. The appearance was similar to an arteriovenous fistula, which was suspected because of varicosities in the vicinity. However, pulsed Doppler revealed artifactual noise. Conclusion It was suspected that this was an impressive, atypical color Doppler reverberation artifact. The patient's tibiofibula radiographs showed pieces of shrapnel throughout the abscess. We hypothesize that the artifact was created by acceleration of the sound waves through the fluid in the large abscess with resonation between fragments of shrapnel. This is an example of a color Doppler artifact making it appear that there is flow in a location where there is none.

A Retroperitoneal Mass in an Elderly Woman

71-year-old nun living in a convent was seen by her primary physician because of persistent left abdominal flank discomfort during the previous 6 months. This was accompanied by a 15-lb weight loss and left lower extremity weakness, numbness, and pain on ambulation. Except for systemic hypertension, her past medical history was unremarkable. On physical examination, a tender mass was palpated in her left lower abdomen. The pain elicited by palpation radiated to the left hip and groin areas. There was also contracture of the left hip that was painful on straightening. Results of laboratory examinations were within normal limits. Computed tomographic scanning revealed a large enhancing left retroperitoneal soft tissue mass juxtaposed to the left iliac bone that involved the left iliopsoas and the inferior extent of the left psoas muscle (Figure 1). A subsequent computed tomography‐guided fine-needle aspiration biopsy of the retroperitoneal mass was consistent with a malignant neoplasm. The patient was referred to Loyola University Medical Center for surgical management, and the radiologic survey for metastatic lesion was negative. Preoperative embolization of 2 lumbar vessels and a branch of the iliac artery that supplied the tumor was performed. During the surgical resection, the retroperitoneal mass was noted to be closely associated with the left iliacus and left psoas muscles and to be encasing a segment of the left femoral nerve. Except for extrinsic compression, the adjacent visceral organs, including the lumbosacral vertebrae, were not involved by the tumor.

Acute Thrombosis of Inferior Vena Cava in a Pregnant Woman Presenting with Sciatica: A Case Report

A 20-year-old pregnant woman was admitted to our department with symptoms of deep venous thrombosis in the left lower extremity and excessive lumbar pain. Low-molecular-weight heparin was administered. She recovered with this treatment, however, severe lumbar pain continued. A lumbar magnetic resonance image showed dilated epidural veins compressing the roots and acute thrombosis of the inferior vena cava extending to renal veins. During the same period she had acute deep venous thrombosis in her right leg. An urgent venous thrombectomy was performed. Sciatica and deep venous thrombosis resolved after the operation. Low-molecular-weight heparin was administered until the end of her pregnancy.

Femoral Artery Pseudoaneurysm Caused by an Osteochondroma of the Femur: A Case Report

Introduction The osteochondroma is the most common benign tumor of bone. Typically asymptomatic bony protuberances are discovered in childhood or adolescence. Although vascular complications are rare, these bony spikes can course along an artery and cause severe arterial complications. Reported here is a case involving the use of color duplex ultrasonography (CDU) to identify a superficial femoral artery (SFA) pseudoaneurysm as a result of an osteochondroma. Case Report A 12-year-old girl had been experiencing left lower extremity pain for approximately 2 months. The pain became progressively severe, and her parents noticed that she was limping. Magnetic resonance imaging (MRI) demonstrated a mass in the left thigh, suggesting the possibility of a femoral aneurysm. A bony spicule was noted on x-ray at the distal femur, projecting posteriorly. Clinical evaluation revealed an impressive pulsatile mass in the left distal medial thigh. The left thigh was noticeably larger than the right with poor pedal pulses compared with the asymptomatic limb. CDU was performed and identified an aneurysm of the SFA at the adductor canal. There was unusual oscillatory flow in the SFA proximal to the aneurysm with monophasic signals distally. The large aneurysm size displaced the normal anatomic course of the SFA and vein. Ankle-brachial indices (ABI) were 0.72 and monophasic in the affected limb and >1.0 and triphasic in the contralateral limb. Angiography confirmed the CDU and MRA findings, demonstrating a large pseudoaneurysm at the adductor canal caused by an osteochondroma of the femur. At time of surgical repair, the bony spicule was noted to have eroded into the femoral artery. Conclusion Vascular complications as a result of an osteochondroma are rare. Rapid diagnosis is necessary to prevent serious arterial compromise in these young patients. CDU can quickly and accurately confirm the presence of a pseudoaneurysm when an osteochondroma is suspected.

Diabetic Myonecrosis in a Previously Healthy Woman and Review of a 25-Year Mayo Clinic Experience

To describe a case of diabetic myonecrosis, an unusual complication of diabetes mellitus, and to provide an overview of an institutional experience with this condition. We report the clinical, laboratory, and imaging findings in a 50-year-old woman with no history of diabetes, who was hospitalized because of weakness in her left lower extremity and an infection in her right hand. A morbidly obese woman had sustained several falls attributable to left leg weakness, which had resulted in repetitive trauma to, and subsequent infection of, her right hand. Laboratory studies showed a fasting blood glucose level of 204 mg/dL, a glycated hemoglobin of 12.8%, and a calculated hemoglobin Alc of 10.6%. Results of evaluations for retinopathy and nephropathy were negative. Electromyography of the left leg suggested the presence of a diabetic plexopathy. Two weeks after admission of the patient, severe left lower extremity pain and swelling developed abruptly. Ultrasound evaluation of the leg was negative for deep venous thrombosis. Laboratory data revealed a leukocyte count of 7.1 x 10(3)/mL and a creatine kinase level of 26 U/L. Magnetic resonance imaging of the left leg demonstrated extensive muscle edema and collections of fluid surrounding the femur and posterior compartment of the thigh and extending into the left calf. Gram stain and cultures of aspirated fluid were negative. The patient was managed with supportive care, including strict glycemic control, periodic analgesia, and physical therapy. A review of medical records for a 25-year period at the Mayo Clinic disclosed only five patients with the diagnosis of diabetic myonecrosis. All five patients had insulin-treated diabetes and severe end-organ disease. The current case is the first report of myonecrosis as the initial manifestation of diabetes. This case also demonstrates that myonecrosis, although typically involving the thigh, can extend abruptly to the calf. Diabetic myonecrosis should be included in the differential diagnosis of an acutely painful lower extremity mass in patients with diabetes.

Diagnosis and endovascular treatment of iliocaval compression syndrome

Purpose: The purpose of this study was to evaluate the clinical presentation, diagnosis, and endovascular treatment of iliocaval compression syndrome (ICS). Patients and Methods: During a 3-year period, 18 patients (17 women, 1 man; mean age, 42 years) presented with clinical and imaging findings consistent with ICS. All patients were evaluated with venography and Doppler ultrasound (DUS), 13 of 18 with intravascular pressure measurements, 12 of 18 with intravascular ultrasound, 9 of 18 with air plethysmography (APG), and 4 of 18 with magnetic resonance venography. Seventeen patients were treated with endovascular stenting, one was treated with angioplasty alone, and six received adjunct thrombolysis. Results: Despite the presence of stenosis or occlusion in all cases, APG indicated no iliac vein obstruction (outflow fraction ≥ 40%) in nine patients. DUS revealed acute (6) or chronic (7) unilateral iliofemoral deep venous thrombosis in 13 of 18 patients, whereas the results of five of 18 DUS studies were normal. Recanalization and stent placement (n = 17) or angioplasty (n = 1) was achieved in all patients. The average pressure gradient was 5.6 mm Hg preprocedure and 0.6 mm Hg postprocedure. The primary patency rate demonstrated with DUS (n = 17) and venography (n = 7) at 6 months was 89%. The primary patency rate at 12 months was 79%. Conclusions: ICS often presents as sudden unilateral left lower extremity pain and swelling in young to middle-aged female patients after pregnancy, surgery, or a period of inactivity. Venography, intravascular ultrasound, and magnetic resonance venography demonstrate high sensitivity, whereas APG–outflow fraction demonstrates low sensitivity in the diagnosis of ICS. Endovascular stenting and angioplasty provide safe and effective early and intermediate-term treatment of symptomatic ICS. (J Vasc Surg 2001;34:106-13.)

胸腰椎移行部前方固定術後に下肢循環が悪化したＬｅｒｉｃｈｅ’ｓ ｓｙｎｄｒｏｍｅの一例

A 72-year-old woman experienced severe left lower extremity pain associated with muscle weakness and sensory disturbance. Rentgenograms of the thoracolumber spine showed old compression fracture of L1. MRI studies showed spinal canal stenosis at L1 upper vertebral level. The patient's symptoms was thought most likely caused by the spinal canal stenosis, we performed anterior spinal instrumentation surgery on the thoracolumbar spine Th12-L2. No problems were encountered during the operation, but her left lower extremity showed cyanosis one day after the operation. Emergency angiography showed chronic occulusion of the terminal abdominal aorta, and she was diagnosed with Leriche's syndrome.The deterioration was thought to have been segmental arteries approaching to the vertebral body. Since consevative therapy was not effective so axiller-femoral bypass grafting operation was done.

Revision of a spinal column stimulator lead without lead replacement

Objective: The objective of this case report is to describe a technique for percutaneous spinal column stimulator (SCS) revision without lead replacement. Case Report: A 35-year-old woman with a single-lead SCS implanted for control for left lower extremity pain underwent revision of her SCS lead because of loss of stimulation paresthesia in the area of pain. Using the method described, the lead was revised without lead replacement. Conclusion: SCS leads can be revised without placement of a new lead. Reg Anesth Pain Med 2000;25:201-203.

Percutaneous Aspiration of Lumbar Facet Synovial Cyst

Percutaneous Aspiration of Lumbar Facet Synovial Cyst

Adenomyosis as Seen on Blood Flow and Blood Pool Imaging During Bone Scintigraphy

A 42-year-old woman presented with intermittent low back and left lower extremity pain. The blood flow and blood pool images of bone scintigraphy showed a large focus of increased activity in the right lower abdomen. Computed tomography showed an enlarged uterus displaced to the right side of the pelvis. At surgery, the uterus was found to be involved with adenomyosis. Three-phase bone scintigraphy consisting of blood flow and blood pool images over the anterior pelvis may be a valuable diagnostic aid in the evaluation of lower back or pelvic pain of a woman.

Ln-111 Labeled Leukocyte Imaging in a Case of Pseudogout

In-111 labeled leukocyte scintigraphy was performed on a 90-year-old woman who had a fever and left lower extremity pain for 3 days. Leukocyte images demonstrated abnormal activity in the left knee and ankle. Aspiration of the left knee joint yielded cloudy yellow fluid with a leukocyte count of 30,000 per mm3 (75% polymorphonuclear leukocytes, 1% lymphocytes, and 24% monocytes). Cultures of the aspirate were reported as no growth. Microscopic examination of the aspirate revealed the presence of rod-shaped crystals of calcium pyrophosphate dihydrate, confirming the diagnosis of calcium pyrophosphate deposition disease, also known as pseudogout. The acute arthritis of pseudogout stimulates an intense leukocyte response; therefore, labeled leukocyte images performed on patients suspected of having this condition must be interpreted cautiously because scintigraphically it may not be possible to distinguish pseudogout from septic arthritis.

Breast cancer with osseous metastasis and herniated lumbar disc A cautionary tale

A 39-year-old white woman with breast cancer, metastatic to her skeleton, developed low back and left lower extremity pain and lower extremity weakness. A bone scan evidenced increased radioisotope activity in her lumbar spine and a computed tomography (CT) scan showed a lesion of the L4 vertebra. Because of myelographic findings of a extradural defect at the L4-5 disc space and the possibility of a herniated disc causing the patient's pain and neurologic deficit in her lower extremities, the patient underwent surgery and a large herniated L4-5 disc was removed. As a consequence, the patient experienced relief of the lower extremity pain and return of strength in her lower extremities. She died a considerable time later from refractory hypercalcemia.

Dissecting thoracic aortic aneurysm in a 16-year-old

A 16-year-old boy presented with a one-hour history of left lower extremity pain and weakness, and was found to have a dissecting aortic aneurysm. The patient underwent emergency aortic angiography and immediate reparative aortic aneurysm surgery. He died on the fifth postoperative day. Because the majority of cases occur in the fifth to sixth decade of life, dissecting aortic aneurysm is a rare and usually fatal condition in adolescents. Potentially favorable outcome in this age group depends on prompt diagnosis and immediate medical and surgical intervention.

Resident's Page

<h3>PATHOLOGIC QUIZ CASE 1</h3><h3>Jaime A. Tschen, MD, Houston</h3> A 2-year-old boy had a 2-cm midline swelling in the floor of his mouth. This was asymptomatic and had been present for three months before admission for surgery. At the time of operation, a well-circumscribed cyst was readily removed by blunt dissection. The wall of the cyst is shown in Fig 1 and 2. What is your diagnosis? <h3>PATHOLOGIC QUIZ CASE 2</h3><h3>Victor L. Roggli, MD, Houston</h3> A 47-year-old man was admitted to the hematology service for left lower extremity pain and erythema. Two and a half years prior to admission, he was noted to be pancytopenic, and one year prior to admission, a diagnosis of acute myelogenous leukemia was made. Antileukemic chemotherapy had not been instituted because of pancytopenia and recurrent infections, including<i>Serratia</i>pneumonia, atypical mycobacterial infection of skin, and<i>Pseudomonas</i>osteomyelitis of the left foot. The patient