Degenerative Disc Disease - Multi-specialty case review

Degenerative Disc Disease Imaging study

Sagittal MRI scan of the lumbosacral spine showing disc dehydration and bulging at L4-L5. There is a large spinal canal and no nerve root pinching. The disc space is otherwise well preserved with no loss of height and no Modic changes. The cartilaginous endplates are otherwise intact. The other disc spaces all appear normal. (See Figure 1.)

History

This is a 42-year-old female homemaker who lifted a box and felt a pull in her back. Initially, she had a couple days of stiffness, but then the pain started to progress. She has referred burning pain down the back of both legs. She was previously healthy and active, but has since had to give up all sporting activities including golf and tennis. Her pain is activity related, although she still has discomfort at rest. Sitting will make the pain worse, and although she has trouble standing for prolonged periods of time she actually feels better when she is walking. The pain ranges from 3 to 7 on a pain scale of 1 to 10. So far she has tried ibuprofen and Tylenol for her pain which helps some. She saw her family practice doctor who placed her on a muscle relaxant (Soma) but this made her too sleepy. She is frustrated with her activity limitations, and is afraid that her pain is getting worse.

Physical Exam

Healthy appearing 42 year old female who stands throughout much of the interview. She is tender to palpation throughout the paraspinal muscles on both sides. She has limited forward flexion with her fingertips only reaching as far as her knees. Her reflexes at the ankle and knee are intact and symmetrical and there is no muscle weakness.

Diagnosis

Acute low back pain probably from degenerative disc disease.