Denne et al. Journal of Medical Case Reports 2011, 5:440 http://www.jmedicalcasereports.com/content/5/1/440 Page 3 of 4 Figure 2 The corresponding axial T2-weighted MRI image at L4/L5 demonstrates the centrally herniated disk material narrowing the spinal canal. feet and toe extensor muscles as well as paresthesia of the dorsum pedis and toes corresponding to dermatome L5 for one week. A lumbar NMR scan showed a para- median LDH at L4/5 with compression of nerve root L5 and a paramedian LDH at L5/S1 touching nerve root S1. A decompression operation was not performed despite the neurosurgeons’ recommendations as our patient refused because of the fear of prolonged ventila- tion and respirator dependency after operation in the light of her severely impaired lung function. In spite of intensive physiotherapy, full mobilization took several weeks and inspiration was impaired by the pain, so that it was not possible to perform respiratory physiotherapy to its full extent. The paresis disappeared under phy- siotherapy but the pain did not fully disappear, needing NSAIDs and opioids. A course of intravenous antibiotic therapy was necessary at one, four and five months later. Her lung function parameters declined further and home oxygen therapy was started three months after LDH diagnosis, with 3 to 6L of O2 per minute. From six months after LDH diagnosis onwards she was hospita- lized in an intensive care unit. A sternal fracture occurred seven months after LDH due to coughing and osteoporosis. Finally, our patient died eight months after LDH diagnosis while on the high urgency waiting list for lung transplantation because of an unmanageable pulmonary infection with massive pulmonary bleeding. She had spent three weeks on extracorporeal membrane oxygenation (ECMO) before she died. The fact that she temporarily fell from the high urgency list a month before her death because of improving partial CO2 values on blood gas analysis may have also played a role in the disease process, as it tremendously destabilized her mood and raised fears she may not get a transplant organ. Discussion Though the observation of LDH in CF has so far not been the clinical focus of the literature, and though the increased rate of LDH might also be coincidental, this special association seems clinically plausible. In a popu- lation-based epidemiological study of persons older than 30 years of age, the prevalence of radiologically-proven LDH with typical clinical symptoms was found to be 1.9% in men and 1.3% in women, with lower percen- tages in the age cohort of 30 to 44 years of age (men 1.0%, women 1.0%) [8]. At the age of about 20 years (the approximate age of our three patients at diagnosis) and in adolescence in general, LDH is extremely rare. This age distribution was also observed in people pre- senting to hospital for LDH surgery [9]. Pediatric cases only represent a marginal proportion (0.5% to 6.8%) of all LDH [10]. We hypothesize that the prevalence of 6.5% in our clinic population is due to CF-specific char- acteristics. Back pain in patients with CF is primarily of a musculoskeletal origin [11]. Frequent coughing can cause muscle splinting and musculoskeletal pain syn- dromes. The more the disease progresses, the more patients suffer from chronic coughing, often in spite of still-sufficient lung function parameters. Epidemiological studies clearly hint at the association of chronic cough and herniated lumbar inter-vertebral disc or sciatica due to widespread spondylotic changes of the lumbar spine [12]. Due to malnutrition and malabsorption syndromes compression fractures can occur in patients with osteo- porosis as a result of the mechanical power of coughing, with peak cough expiratory flow rates ranging up to 700L per minute [13]. Patient 3 had a LDH with neuro- logical deficits (paralytic symptoms) about six months before her death as a result of respiratory failure. A neu- rosurgical decompression operation was not performed as a result of the bad lung function. The accelerated process of lung deterioration was thought to be influ- enced by the limited ability to perform adequate respira- tory therapy following the LDH. For example, it was not possible to perform reflectory respiratory treatment to its full extent, as well as some mucus mobilization man- euvers involving intensified compression techniques dur- ing assisted autogenous drainage and jumping on a trampoline or a pezzi ball. Opioids may also interfere with mucus drainage by a reduction of respiratory power, especially in higher doses. In addition to the phy- sical aspect, the psychological burden on the patients with CF is extremely complex [14]. Patients with CF suf- fer from a chronic disease, inevitably leading to prema- ture death respective to a high degree of morbidity. A reduced quality of life, ineffective coping strategies [15] and physical impairments increase the risk for anxiety and chronic depression in patients with CF [16].