Peter Farrell Sameer Sinha Andrew Palmisano Mark Upton Lower Limb Case #2 Peter Farrell Sameer Sinha Andrew Palmisano Mark Upton

Chief Compaint 28 year-old African American male Walks in examination room with an abnormal gait in which he: Leans his body toward the right side during the single stance interval of the right lower limb’s stance period Shortens the stride to minimize the duration of the right lower limb’s stance period Feels uncomfortable when he sits down

Physical Exam Vital Signs: Normal Musculoskeletal Examination: Inspection, movement, and palpation of the lower back and the upper and lower limbs are normal except for the following findings: Inspection of the lower back shows a flattening of the normal lumbar lordosis and a listing of the lumbar spine to the right. Pain restricts active flexion of the lumbosacral spine. Extension of the lumbosacral spine is relatively painless. The straight leg raising test exacerbates right lower limb pain; lowering the leg to the highest level at which pain is relieved and then dorsiflexing the foot reintensifies the pain. Palpation of the lower back reveals bilateral paraspinal muscle spasm in the lumbar region.

Neurologic Exam The patient reports diminished pin and cotton touch sensation on the medial aspect of the dorsum of the right foot and the contiguous areas of the big and second toes. Extension of the big toe in the right foot has a strength of grade 1. Pertinent normal findings include bilaterally symmetrical knee jerk and Achilles tendon reflex tests

Differential Diagnosis What could be causing this patient’s symptoms? Nerve Cyst Cancer of the spinal cord Sciatica Herniated Disc

Paraspinal Muscle Spasms Paraspinal Muscles are muscles which are adjacent to the vertebral column (i.e. Multifidus, Rotatores, etc.) Spasms (contractions that can’t be controlled) of these muscles can occur when a part of the spine around the area near them has been injured Injuries can include a problem with: Intervertebral Discs, ligaments, or the muscles themselves

Straight Leg Raising Test Test used to identify compression of the Sciatic Nerve Most commonly due to a herniated intervertebral disc The patient lays in the supine position while the examiner raises his/her leg while it is fully extended The level at which pain is experienced is noted Dorsiflexing the ankle may increase the strain on the Sciatic nerve – further increasing the pain The area of pain can be indicative of the type of spinal cord injury Back pain  Central Disc Protrusion Leg pain  Lateral Disc Protrusion

Reflex Tests These tests can help clinicians determine where a potential herniation has occurred In our case two reflex tests were conducted: 1.) Knee Jerk Reflex – What muscle(s) does this reflex involve? Quadriceps Femoris What is the innervation of the Quadriceps? Femoral nerve Spinal Cord Segments? L2-L4

Achilles Tendon Reflex Test Reflex Tests Achilles Tendon Reflex Test What muscles does this test involve? Gastrocnemius Soleus What nerve innervates these muscles? Tibial Nerve This test specifically tests the S1 spinal nerve

Herniated Discs Herniated discs most commonly occur at either the L4-L5 IV disc or the L5-S1 IV disc Based on the reflex test results where do you think the herniation has occurred in our patient? Most likely in the L4-L5 IV disc There is no definitive reflex test for this level

What is a Herniated Disc? What are the two parts of an intervertebral disc? Annulus Fibrosis and Nucleus Pulposis What happens when a disc is herniated? Nucleus Pulposis protrudes out and impinges a spinal nerve Which nerve root tends to be impinged in an IV disc? The lower nerve root i.e. L5 in an L4-L5 herniation

Symptoms

Symptoms Why did our patient experience pain during active flexion of the lumbosacral spine and no pain when the back was extended?

Nerves of the Leg and Foot What are the Major Nerves of the Leg and Foot? Sciatic Nerve (L4-S3) Tibial Nerve (L4-S3) Common Fibular (L4,L5,S1) Superficial Fibular Deep Fibular

Dermatome Pattern of the Lower Limb

Extensor Hallicus Longus Origin Insertion Action Innervation

Abnormal Gait L5 nerve  superior gluteal nerve  gluteus medius?

Treatment Many times herniated discs will heal on their own over time To help decrease the recovery time Bed rest is advised to reduce pain and the load on the spinal cord Pain medication is given if needed In severe cases surgery may be necessary