L5-S1 disc

Case #254: MRI L-S spine,4/7/94: L5-S1 disk herniation with S1 radiculopathy.

CC: buttock pain.

Hx: This 24 y/o RHF began experiencing left buttock pain in 8/93. She denied any trauma to the back or body around that time. She described the pain as dull and constant with sharper pain radiating intermittently down her left posterior thigh. The pain progressively worsened and she developed numbness on the left posterior thigh and tingling in that thigh down to her foot. She had difficulty ambulating due to LLE pain. She required increasing doses of Tylenol #3 to control the pain. The pain worsened upon coughing.

MEDS: Tylenol #3

PMH: as above.

FHx: noncontributory.

SHx: unremarkable.

EXAM: Vitals signs were unremarkable.

MS: unremarkable.

CN: unremarkable.

Motor: 5/5 strength throughout with exception of limited effort secondary to pain in the LLE

SENSORY: decreased PP in the posterior lateral region of the left thigh.

Coord: unremarkable.

Station: unremarkable.

Gait: antalgic.

Reflexes: 2+/2+ in BUE. 2+/2+ patellae. 1+ right ankle. Absent in left ankle. Plantar responses were flexor, bilaterally.

A left straight leg raise of 30 degrees elicited low back pain which radiated down the LLE.

Right straight leg raise was unremarkable. Hoover's sign was absent.

COURSE: MRI of the L-S spine showed an L5-S1 leftward disc herniation impinging on the left nerve root and neural foramina. There was decreased T2 signal within the L3-4, L4-5 and L5-S1 discs. The findings are consistent with degenerative disc disease and disc herniation.

She was treated with epidural steroid injections. This temporarily improved her pain. She eventually underwent L5-S1 discectomy on 6/27/94 and had subsequent resolution of her pain and numbness.