Andreen 2004

Journal/Andreen - August 2, 2004

Simone Burton 19. 07. 1976 Phone +34 952661221, 678205783.

Social
Lives with her husband partly on the coast, partly in their house in London. IT business.

Earlier
Healthy and no major complaints

Actual problem
Operated for idiopathic scoliosis at 12 years age. Harrington distraction Th4-L1 with contra lateral compression rod. Has been functioning very well during the years.

Since a couple of years though, more and lower back pain. The pain is now very debilitating and her function much reduced. Walking ability down to 100 m. Pain also down the left leg. Numb in the thigh with allodynia. Hard to sit in a car, going to restaurants. Difficult to sleep. Try not to take any pills. Has been to an orthopaedic surgeon ho tried to give her a sacroiliac block; it was very difficult to reach and she suffered a lot pain.

Most of the pain is now situated centrally low back over the L5S1 region. She also suffers some shoulder pain but can control that by physiotherapy. Also has been helped by reflexology. Constantly under pressure due to the pain, although the pain is also load depending.

Clinical Examination
Walks slowly and with a slight limp on her left side. Fairly well balanced with only a very low gibbus on her right side. The lumbar lordosis is reduced and also the thoracic kyphosis. There is some pain over the upper hook, but it is well fixed. No real problems in the local aspects of the lower hook. Further down in the area of L5S1 however she is very painful on palpation. In forced extension she is feeling much worse. but we cannot find any nerve root symptoms. She stands on heels and toes all right. She is bending down to the floor. SLR negative bilaterally. Patellar tendon reflexes are normal, as is the left Achilles, while the right is not possible to release. No paresis of the foot extensors. Allodynia on the lateral aspect of her left thigh.

X-ray pictures from July 2004 shows the Harrington rod and good fusion down to L1. The height of disk L3L4 is somewhat reduced and there is a fragmentation in the upper anterior end plate of L4, which reminds of MB Scheuermann. The process is however very localised. I am also looking for a sign of spondylolysis in the L5 vertebra but the films are not appropriate for that. The sacroiliac joints look normal.

Evaluation
We decide that she will try to wear a tight brace daily during a period. I also want her to try Voltaren 50mgx2 daily for a few weeks, but she is reluctant about that. Injection therapy is not very desirable. We eventually decide that we want a new MRI, the last one was done in 1998. It can be difficult to interpret, but since we are interested mostly by the lowest lumbar region it should not be a great problem. I suspect that she has a fairly localized degenerative process in the L5S1 segment, but we cannot exclude the L3L4 one, the symptoms in the left leg could fit well to that. She is calling me for a new appointment in the end of the month and by then she might have the feeling about the effects of the brace.

Hospital Clinica Santa Elena
Dr Olof Andreen
MD, PhD
Consultant orthopaedic spinal surgeon