Case Study 1: Lumbar Disc Herniation

Patient Name: Rudy  

Age: 46 year old Male

Rudy presented in our office complaining of chronic low back and left leg sciatic pain. He stated that he has struggled with low back pain off and on for the last 6 years. This most recent bought caused him to spend a night in the emergency room because he was having troubles walking due to the intense pain and muscle spasm. He stated that his pain levels were a 9 out of 10 for his low back pain and his leg pain. He also stated that he’s had to take off work for the last 6 days, and that he was concerned that he would lose this job if this continued.

Previous Medical Treatment:

2 Lumbar Facet Nerve Blocks (Epidurals)

Physical Therapy (3 months done during the last bought 1 year prior)

OTC Pain Relievers (Motrin / Tylenol)

Prescription Pain Relievers : Vicodin, and Oxycodone

Examination Findings:

Rudy had a severe decrease in his lumbar spine flexibility with an overall 60% loss in Lumbar ROM. Upon palpation of this lumbar spine, pelvis and hips, he had severe pain (9 out of 10) in the L3-L5 region, left paraspinal musculature. In addition, Left Piriformis, Quadratus Lumborum, and Gluteal Trigger points were noted with severe sensitivity to pain. Lumbar orthopedic tests for nerve impingement were all positive indicating compression of the sciatic nerve. (Left Side)

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