Lumbosacral Disorder Acquired During Military Training - Report Example

Introduction Competitive athletic sports training dictates a certain degree of fitness and readiness from the athlete. In sports the different body parts especially the musculoskeletal system, is exposed to a lot of stress. Scar from old injury or disease may have weakened the musculo-skeletal system rendering the athlete unfit for training. Military training puts a trainee at risk for injuries of the musculo-skeletal system especially of the spine. The intensity the training exposes the body to load stress. As such, fractures of the spine are quite common. Unfortunately, fractures of the spine may compress the spinal cord, affecting stimulation and function of other body structures. One common type is stress fracture. This may occur in as much a twenty percent of military trainees (Jansson, et.al., 2004) This type of fracture may leave a scar which can still be evident in the future. The next paragraphs will be a narration of the author’s personal experience regarding a lumbosaccral injury incurred nine years ago during military training. This is a hindrance to the author’s willingness to participate in sports at present. Patient Presentation In 1998, thirty minutes after carrying a pile of ammunition on my forearms, I felt sudden onset of sharp, deep, and severe pain on the lumbosaccral area . The pain is worse when I tried to lean back while standing and gets a little better when stooping or during recumbency. At first. I did not mind the pain. I thought that I just got tired like the previous days of training. During the night, however, I did not feel comfortable. The pain was bothering me and I could not last fifteen minutes in one position. It was as if something heavy was on my back. Initially, I would grade the pain as 3/10 in the pain scale. However, during the night, the pain progressed to 6/10. I then took Mefenamic Acid, 500 mg capsule to relieve the pain. The medicine was able to relieve the pain for a while. However, the relief only lasted for an hour. It came back after an hour. When the pain came back, it ws 8/10 on the pain scale. Although I just took the Mefenamic Acid an hour before, I decided to take another capsule of Mefenamic Acid, 500 mg. The pain was again relieved. At that time, the pain became 5/10 on the pain scale. I then decided to seek consult from the physician in our infirmary. Note: To aid in the quantifications of my pain, the Visual Analogue Scale or the Pain Scale was used. This is based on a visual chart developed by Wewers (1990). Below is a copy of the Visual Analogue Scale. A V.A.S. card was printed by on a piece of cardboard in the infirmary. I have included the VAS score of the pain I felt during that time. I did not feel tingling sensation nor numbness on my legs. I did not have fever. I did not feel any sense of my back giving in. My bowel movement was fine and I did not have problems when urinating neither. No wound is evident on my back. There is also no hematoma nor palpable deformity on my back. Decided to consult the infirmary where a general practitioner was. A review of my state of health at that time was done. I have not incurred any major illness except for flu from time to time especially during winter. I haven’t had tuberculosis nor primary complex. No one in our community was sick either. At that time, I haven’t had any accident. I do not have hypertension nor did I have diabetes. I do not have any mass in my body. I haven’t had any surgery nor blood transfusion. In the family, the only disease I know was cancer of the breast which was the cause of death of one of my aunts. My parents told me that my grandparents had hypertension but they died of old age anyway. There was no heart disease nor diabetes in the family. No one suffered from tuberculosis. There is no cancer in the family. Old relatives had arthritis. At that time, I did not smoke and I just drank alcoholic beverage on occasion. I did not use illicit drugs. I haven’t had sexual contact at that time also. When I went to the infirmary, I was in distress and I had to ask a classmate to accompany me. The nurse took my vital signs. I did know the exact value but she assured me that it was within the normal range. The examination of the spine showed that there were no deformities. The physician also palpated by back. There was no localized tenderness. The hyperextension of the back caused the pain to worsen while it felt better on flexion. A special test called straight leg test was done and the doctor said that the result was negative. Digital rectal examination with tests on the anal sphincter was normal. Stimulation of the perianal skin revealed that the area was normal. Deep tendon reflexes were normal and no pathologic reflexes were elicited. The abdominal and pelvic examinations were unremarkable. The physician prescribed analgesics and suggested bed rest for a couple of days. I was very compliant to the orders of the physician and took two days off to rest. However, the pain still remained. The analgesics would just partially relieve the pain only to come back after a few hours. I then decided to consult an orthopaedic surgeon. Hypotheses/ Differential Diagnosis Given the history, it is clear that the main problem is Mechanical Low back Pain. The sudden onset, and the previous injury or strain are very important parameters. The severe and incapacitating pain is also typical of Mechanical Low Back Pain. The type of pain is usually aggravated by movement of the back and attempts to perform such movements are associated with sharp, catching pain. The pain is localized on the lumbosaccral area and radiates to the posterior thighs. The radiation is a deep aching type of pain. The usual mechanism of injury to the lower back is trauma as in my case . Because of the amount of weight carried by the spine, load stress fracture occurred. The lumbosacral area is a critical level between movable and immovable portions of the spine. It is very liable to injury from forces applied in an obliquely antero-posterior direction, as in violent flexion or hyperextension of the spine. In the case, it is important to see if the problem is mainly muscle strain or if the patient has disc herniation already. In the latter, there may are commonly associated manifestations such as numbness and changes in bladder and bowel habits. During the initial stages after the injury, I did not feel numbness nor had bowel and bladder problems. Initially, higher doses of pain relievers were effective for the pain. However, the pain progressed each day until the oral pain relievers could no longer afford relief. I then went to an orthopaedic surgeon who did more comprehensive physical examination as well as diagnostic tests. Physical Examination Findings and Diagnostic Test Results Five days after the injury, the pain was intractable. I went to an orthopedic surgeon. Physical examination was performed. I was conscious and not in distress. My blood pressure was 130/80, slightly higher than my usual blood pressure of 110/80 because I was in pain. Heart rate was 89 beats per minute. Respiratory rate was 19. I did not have fever. There back was stiff and lumbar lordosis was flattened. There was a slight curvature of the lumbar spine to the left. On palpation, there was tightness of the lumbar muscles. There was a little weakness of muscles of the thighs. There was positive straight leg test. Muscle testing had the following results(see below). Deep tendon reflexes were diminished in lower extremities. The rest of the systemic findings were unremarkable. The lumbar x-ray showed disc herniation at the level of the 4th lumbar vertebra. This was confirmed by myelography. The orthopedic surgeon suggested that the author undergo surgery. A laminectomy to relieve disc herniation was done. Physical therapy was done after the surgery. In six months, the author was able to walk again and even run with some pain on the lumbosaccral area now graded as 1-3/10 on the pain scale. Summary This is a case of an eighteen year old Male who trained in the military. The patient felt sudden, severe , deep back pain after lifting heavy load. The pain was graded as 5-8/10 on the Visual Analogue Scale. Patient had a slight curvature of the lumbar spine to the left. There was a little weakness of muscles of the thighs. There was positive straight leg test. Deep tendon reflexes were diminished in lower extremities. Lumbosaccral radiography and myelography revealed herniation of disc at the level of L4. Hypothesis The diagnosis was quite outright given the history of previous injury and clearly evidenced by radiography and myelography. Disc herniation at the L4 level was evident. The shifting of the lumbar spine to the left which is the same side as the herniation gives a clue that the protrusion lies medial to the root. The abnormalities in the lower limbs were from the irritation and injury of the nerve root. The localization of the nerve root involved even without ancillary procedures was possible because of thigh pain and diminished knee jerk. This is due to involvement of the roots making up the femoral nerve The straight leg test is a commonly used method of increasing tension on the root, to demonstrate signs of nerve root irritation. Sacral plexus roots making up the sciatic nerve, join within the pelvis toe merge through the greater sciatic foramen posteriorly. Sciatic nerve passes down the posterior aspect of the thigh to continue as the tibial nerve and terminate as its medial and lateral plantar branches in the foot..As the limb, with the knee fully extended, is flexed at the hip, tension on the nerve is increased. SLR stretches the already taut root over the ruptured disk and causes increased pain. Prediction Level The prediction level for the diagnosis of disc herniation is >95%. The evidence obtained from the history, physical examination and ancillary findings are all confirmatory of the diagnosis. The myelography obtained clearly localized the exact location of the herniation. It also indicated the need for surgical intervention. The indication for surgical treatment was the intractable pain following maximal medical management. It consists of partial laminectomy, exposure of the protruding mass and excision of the mass and nuclear material remaining in the disc (Izci, et.al., 2004). The concern of the author is his involvement in sports at present. The author is worried of the possible effect of sports on the operated disc. To aid in the evaluation of risk, studies dealing with long-term outcome of surgery for herniated disc will be presented. The risk of recurrent disc herniation will also be studied. Yorimitsu, et. al. (2001) reported in his study that open surgical management of disc herniation showed favorable results. Japanese Orthopedic Association calculated average recovery scores to be scores was 73.5 +/- 21.7%. Low back pain which was residual was seen in 74.6% of the patients,. However, only 12.7% had severe low back pain (Yorimitsu, 2001). Although, the author underwent open surgery, modernization of surgical techniques has produced minimally invasive methods of surgical removal of herniated disc.Le, et. al (2003) published promising results of minimally invasive surgery for disc herniation. The study was long-term and saw patients ten years after surgery. Results were favorable . Pappas et. al., (1992) also found favorable outcomes for open surgery. Atlas, et. al. in 1991 and 2005 also commented that surgical treatment of herniated disc is faster than medical treatment. To address the concern of the author regarding participation in sports and the risk for recurrence of lumbar herniations, several studies will be presented. The over-all rate of recurrence after first surgery is 3-11% (Hakkinen, et. al., 2007).Exercise may even help in strengthening the fibers of the operated disc. This, though, has to be done carefully. Age, gender, symptoms felt before the surgery and even the employment of the patient does not contribute to the risk of possible re-operation (Kara, et. al., 2005). The lack of exercise increases risk for reoperation (Gaetanni, et. al., 2004). Patient may even work. His work may involve sitting, bending and even carrying of heavy objects. It was seen that none of the risk factors from occupational exposure predicts reoperation (Videman and Battie, 1999). Still, other journals argue that specific groups of people are naturally at risk for disc herniation (Laus, et. al., 1993). . Other people not genetically pre-disposed may be exposed to the same load but will not have disc herniation. They may be at greater risk because of smoking (An HS,et. al. 1994). Driving also pre-disposes a person to herniated disc (Kelsey, et. al., 1984). Weight lifting may also pre-dispose the patient to disc herniation. However, light sports with lifting of moderately heavy objects are even beneficial for the disc (Mundt, 1993). Regular follow-up to the physician is needed for constant reevaluation. Imaging studies may also be performed from time to time to monitor long term changes in the operated disc. Return to sports is possible provided that the weight bearing activities are well-monitored. The frequent exercise of back muscles and structures may cause the joints to be lubricated causing an eventual ease in movement. References: An HS, Silveri CP, Simpson JM, File P, Simmons C, Simeone FA, Balderston RA. (1994). Comparison of smoking habits between patients with surgically confirmed herniated lumbar and cervical disc disease and controls. J Spinal Disord.;7:369–73 Atlas SJ, et al. (2001). "Surgical & nonsurgical management of sciatica secondary to a lumbar disc herniation: Five year outcomes from the Maine Lumbar Spine Study." Spine - 26(10):pp. 1179-1187. Atlas SJ, Deyo RA, et al. (2005). Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine. Apr 15;30(8):pp. 927-35. Arja Häkkinen, Arja, , Kiviranta, Ilkka , Neva , Marko H, Kautiainen, Hannu and Jari Ylinen. (2007). 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