This patient has chronic lower back pain and right leg numbness. Imaging shows a large herniated disc at L5-S1 compressing the right S1 nerve root, central stenosis at L3-4 and L4-5, and right foraminal stenosis at L3-4. The patient's symptoms of worsening pain with standing and walking and relief with sitting are consistent with spinal stenosis and disc herniation. His bending forward posture is likely due to flat back syndrome from degenerative kyphosis. The diagnosis that fits his clinical history and imaging findings is right S1 radiculopathy from an L5-S1 herniated disc, with contributing factors of spinal stenosis and flat back syndrome.

1. Clinical Case Studies

2. Look Forward-What do you find?
• You are trying to predict
what symptoms this
patient has based upon
imaging
• 21 degree scoliosis-
balanced (T12 over S1)
• Angular collapse at L5-S1
Right (could he have a
foraminal collapse)
• Lateral listhesis of L3 on
L4 to the right
• IDR at L2-3 Left

3. Lateral X-ray
• Lateral notes thoraco-
lumbar kyphosis and
multilevel IDR
• Significant retrolisthesis
of L3 on L4

4. Flexion
• Flexion notes no
instability. The spine is
stiff and only flexes at
the thoracolumbar
kyphosis

5. Extension
• Extension notes the
kyphosis can somewhat
correct to neutral

6. T2 Sagittal Left
• Scoliosis prevents
viewing whole spine on
one image
• No left foraminal
stenosis

7. T2 Sagittal Right
• Right does have
moderate foraminal
stenosis at L3-4
(expected?)
• Remember L3-4 Right
lateral listhesis

8. “Central T2 Sagittal”
• Extruded HNP L5-S1
• IDR at L2-3 and L3-4

9. STIR Sagittal
• Only mild inflammatory
changes at L2-3 and
L3-4

10. L5-S1 Axial
• Large extruded HNP
compressing R S1 root

11. Axial L4-5
• Moderate central
stenosis
• Mild degenerative facet
disease

12. Axial L3-4
• Moderate central
stenosis
• Mild degenerative facet
disease

13. Axial L2-3
• Mild degenerative
changes

14. Add up all the potential alignment and
discal pain generators
• 21 degree degenerative
scoliosis
• Angular 11 degree
collapse at L5-S1
(however no foraminal
stenosis on sag MRI)
• Thoracolumbar
degenerative kyphosis 13
degree
• IDR L2-4 without
significant Modic changes
• Scoliosis is balanced so no
penalty for alignment
pain
• Angular collapse L5-S1
without foraminal or
lateral recess stenosis can
cause L5-S1 facet pain
• Degenerative kyphosis
can cause flat back
syndrome
• IDR can cause localized
lower back pain

15. Add up all the neurological
compressive pain generators
• L5-S1 extruded right
HNP with S1 root
compression
• Central stenosis L3-4
and L4-5
• Right foraminal stenosis
L3-4
• Right S1 radiculopathy
increased with sitting
• Neurogenic claudication
or stenotic lower back
pain
• Right L4 radiculopathy
increased with
standing/walking

16. What is the history and what are the
patient’s symptoms?
• He currently describes
lower back "discomfort“
which tends to be worse
with walking any distance
and relieved with bending
forward. At times he may
have difficulty standing up
straight and will stand with
a bent knee flexed forward
posture
• His other symptom which is
currently more significant to
him, is numbness in the
right buttock radiating
down to the outside of the
right foot. This tends to be
aggravated with standing
still for any period of time
and may also be relieved
with sitting. He seems to be
reasonably comfortable
with walking but has
numbness in his right foot
which makes it difficult for
him to feel the ground

17. Patient Symptoms Con’t
• The right leg symptoms
started in May 2018 after
lifting a beam in his cabin.
By August 2018 he had his
first injection which was a
right L5-S1 epidural. This
actually caused worsening
right leg pain for the first 3
days.
• He rates the back pain as a
4–6/10. Buttock and leg
pain he rates a 3–5/10 in his
right side only.
• He normally likes to canoe,
hike, cross-country ski, and
bike. He has tried to do
these activities over the
past year since his
symptoms started but has
only been able to do so at a
limited level compared to
his normal. He is concerned
with a progressive
numbness in his right leg

18. What diagnosis fits with his imaging
findings?
• Stands with bent knee-
flexed forward stance.
Could be flat back
syndrome but has lower
back pain and R leg
numbness (antalgia)
• R leg pain started with a
loading action making
HNP more probable
• Lower back pain with
standing relieved with
bending forward-
kyphosis and IDR are
worse with bending
forward but stenotic
lower back pain
improves with flexion

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