Back and leg pain in a middle-aged man

Published on 10/04/2015 by admin

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Problem 52 Back and leg pain in a middle-aged man

A 50-year-old man experiences a sudden onset of back and leg pain while walking. The pain radiates from the left buttock to his knee and as far as his ankle. There is no recent history of trauma. He has no significant past medical or surgical history. He has been bedbound for 3 days.

Q.1

What key features need to be sought from the history?

On specific questioning, there is a similar pain which radiates down his right leg although this is of a lesser intensity. The patient has noticed that the pain is aggravated when he coughs or strains. He has noticed some numbness over his buttocks. This is associated with some difficulty in voiding. Prior to the onset of this pain, the patient had not experienced any urinary symptoms. There has been no alteration in bowel function. His general health is good and he has not lost any weight recently. He is not on any medications.

Q.2

What specific features should be sought on physical examination?

A general physical examination is unremarkable. His blood pressure is 130/90 mmHg and his heart rate is 90 bpm. The rest of the cardiovascular system is normal, and in particular all his peripheral pulses are present and of good volume. Abdominal examination is unremarkable except for some dullness to percussion in the suprapubic region. Digital examination of the rectum suggests a rather lax anal sphincter. Examination of his back reveals no significant spinal tenderness. Straight leg raising is restricted to 30° in both legs, with reproduction of leg pain. The power and tone of both legs are normal to testing in the bed but he is unable to stand on his toes, indicating plantar flexion weakness. The ankle jerks are bilaterally absent and his plantar responses are flexor. Hypoaesthesia is present in the lateral and plantar aspects of both feet. In addition, sensory testing to pin-prick reveals some numbness over the buttocks and reduced sensation in the perineum.

Q.3

What is the diagnosis?

The clinical picture fits for an acute neurological problem.

Q.4

How should the patient be investigated?

An investigation is performed as shown in Figures 52.1–52.3.

Figure 52.1

Figure 52.2

Figure 52.3

Q.5

What is the investigation and what do the three images show?

The patient underwent a microdiscectomy as an emergency procedure. This gave him relief of his pain and his symptoms of cauda equina compression resolved over the next week.

Answers

A.1 The first aim of the history is to try to distinguish between the major causes of limb pain. These include:

– intermittent claudication

– chronic venous insufficiency.

• Musculoskeletal:

– joint disease

– muscle/ligament injury

– stress fracture.

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