A 45-Year-Old Man With Low Back Pain and a Numb Left Foot

DR DALEY: Mr S is a healthy, active 45-year-old attorney and father of 5 children who has low back pain and a numb left foot. He lives in a suburb of Boston and his medical insurance is through a managed care plan in Massachusetts. Mr S has experienced intermittent episodes of low back pain after exertion or physical activity for 17 years. He remembers first having an episode of low back pain after playing basketball. During ensuing years, he had occasional episodes of low back pain that responded to treatment with 1 or 2 days of bed rest and nonsteroidal anti-inflammatory agents. He has never had a trauma resulting in a back injury. Mr S is very physically active. He runs several miles 4 to 5 times per week, logging 700 to 1000 miles annually. He has competed in 6 marathons and expects to run another marathon in 1999. He jogs to ease work stress and to stay fit. He also enjoys skiing in the winter and fly fishing in the summer. He is physically active with his 5 young children. In the summer of 1997, Mr S moved some furniture and had an excruciating episode of back pain that radiated down his left buttock and leg. He was unable to stand up straight and sought medical attention at a local hospital. He was given a mild narcotic analgesic and a nonsteroidal anti-inflammatory agent and was prescribed bed rest for several days with gradual improvement. Since then, he has experienced numbness in his left calf and left foot without apparent weakness. People who have jogged with him have told him that he limps when he runs, but he notes no pain or weakness while running. In November 1997, Mr S saw his primary care physician because he was concerned about continuing to jog with a numb left leg and foot. On physical examination, he was noted to have normal lordosis of the lower back without tenderness. He had full muscle strength in all muscle groups and no sensory deficits. Straight-leg raising was negative on both left and right sides. All deep tendon reflexes were intact with the exception of an absent ankle jerk on the left. His medical history is unremarkable. Two years ago, Mr S had a borderline elevated blood pressure and total cholesterol level and weighed 9 kg more than he currently does. He resumed his running regimen, and his blood pressure, cholesterol level, and weight have returned to normal. Dr P referred Mr S to an orthopedic surgeon, who obtained lumbosacral spine films and magnetic resonance imaging (MRI). Lumbosacral spine films showed disk narrowing at L5-S1 with small anterior osteophytes and facet arthrosis. Magnetic resonance imaging of the lumbosacral spine showed moderate spinal stenosis at L4-L5 with focal disk protrusion superimposed on a diffusely bulging annulus. Moderate neural foraminal narrowing was present, greater on the left than on the right. There was an L5-S1 disk protrusion resulting in a moderatetomarked leftneural foraminalnarrowingandprobable impingement of the left L5 nerve root (Figure 1). The consulting orthopedic surgeon has recommended lumbar laminectomy with spinal fusion to include instrumentation of the lumbar spine. Mr S asked for neurosurgical consultation as a second opinion. The neurosurgeon advised against surgery butrecommendedthatMrSstopjoggingaltogether.MrSwould like to know what might happen to him if he elects not to have surgery at this time. Will he jeopardize his ability to run and jog? If he elects to have surgery, what is the best operation for him, lumbar laminectomy alone or lumbar laminectomy with spinal fusion? What are the advantages and disadvantages of spinal instrumentation in his situation? The dominant priority in Mr S’s life is his ability to continue running.