Patient Profile:
- Age: 45-year-old male
- Occupation: Office worker
- Presenting Symptoms: Persistent lower back pain radiating to the left leg, accompanied by numbness in the left foot, and difficulty performing daily activities.
Initial Assessment:
The patient reported the onset of lower back pain six months prior, which gradually worsened, leading to radiating pain down the left leg and numbness in the foot. Physical examination revealed tenderness over the lumbar paraspinal muscles, a positive straight leg raise test on the left side, and reduced range of motion due to pain.Diagnostic Imaging:
Magnetic Resonance Imaging (MRI) of the lumbar spine demonstrated a bulging disc at the L4-L5 level, impinging on the left L5 nerve root.Treatment Plan:
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Medications:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Ibuprofen 400 mg orally every 8 hours as needed for pain.
- Muscle Relaxants: Cyclobenzaprine 5 mg orally at bedtime to alleviate muscle spasms.
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Physical Therapy:
- Exercise Therapy: A structured program focusing on strengthening the core and lumbar musculature, improving flexibility, and promoting proper body mechanics.
- Manual Therapy: Techniques including soft tissue mobilization and joint mobilization to reduce pain and improve mobility.
- Patient Education: Instruction on posture correction, ergonomics, and activities to avoid exacerbating symptoms.
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Epidural Steroid Injection (ESI):
- Procedure: Administration of a corticosteroid combined with a local anesthetic into the epidural space at the L4-L5 level to reduce inflammation and alleviate nerve irritation.
Outcomes:
- Post-Medication and Physical Therapy: After four weeks, the patient reported a significant reduction in pain intensity and improved functional abilities. The numbness in the left foot diminished, and he could perform daily activities with minimal discomfort.
- Post-ESI: The patient experienced additional pain relief following the epidural steroid injection, with further improvement in mobility and a return to regular exercise routines.
Conclusion:
This case illustrates that a multimodal treatment approach, combining medications, physical therapy, and epidural steroid injections, can effectively alleviate pain and improve function in patients with lumbar disc bulging. The patient’s adherence to the treatment plan and active participation in rehabilitation were crucial in achieving a positive outcome.Note: This case study is a hypothetical scenario based on common clinical practices for managing lumbar disc bulging.
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