1. What is your diagnosis for this patient?
My diagnosis for the patient is Facet Joint Syndrome. Facet Joint Syndrome is when the facet joints between two vertebrae in your spine become restricted in movement or develop too much movement; this results in pain of the lumbar region and can affect your legs and hip, and pelvic region as well. Symptoms include nonspecific pain in the lower back, hips, thighs, and buttocks. Pain may also radiate to the foot because of the mimicking of sciatic pain (Perolat, R., Kastler, A., Nicot, B., Jean-Michel Pellat, Tahon, F., Attye, A., … Krainik, A. 2018). The patient’s symptoms include difficulty sitting and rising from sitting position and pain that radiated to the right thigh, then down the leg to the foot. Pain may appear worse in the morning and it is uncomfortable to sit or stand for certain amounts of time. Sitting and standing can also cause lumbar spine extension and/or rotary trunk motions (Perolat, R. 2018). The patient’s pain is intensified with extension, lateral bending, and rotation of the vertebral column. Facet Joint Syndrome entails inflammation of the facet joints and steroids are anti-inflammatory and work to decrease inflammation. The patient was prescribed oral steroids by the orthopedic surgeon, so this presents that the orthopedic surgeon most likely prescribed the patient the oral steroids in order to reduce the inflammation of the facet joints.
2. What part of the initial diagnosis was immediately dismissed by the attending orthopedic surgeon and why? Defend your answer.
The family physician’s initial diagnosis was a prolapsed intervertebral disc in the vicinity of the L2. A prolapsed intervertebral disc may be caused by excess body weight and genetics to inherit a predisposition of a prolapsed intervertebral disc (Perolat, R. 2018). Frank does not have excess body weight and his body mass index (BMI) is in the normal range. The patent history does not present any family history of musculoskeletal or skeletal problems. The patient history would help to provide details about family history and the patient’s own medical history. The family medical history would present the likelihood of the patient acquiring any hereditary medical condition. His genetics would give the probability and it would also provide information about any conditions that might relate to the patient’s current matter. This information makes it unlikely that he would be suffering from a prolapsed intervertebral disc, so the orthopedic surgeon most likely dismissed this from the initial diagnosis. Once an MRI was performed, it proved to show no intervertebral disc abnormalities in any region of the lumbar spine.
3. Are any of the results listed above aberrant? If so, why, and if not, why not?
Yes, the result of no intervertebral disc abnormalities in any region of the lumbar spine is aberrant. The intervertebral discs bind the vertebral bodies together, and the facet joints are located between and behind adjacent vertebrae. This means that inflammation or any abnormality of the facet joints would have most likely affected the intervertebral discs. The result of the over-the-counter steroids not alleviating any of Frank’s pain is also aberrant because the steroid reduces inflammation, which should help to decrease the inflammation in the facet joints and relieve his pain.
4. Give a logical explanation for the abnormal pelvic tilt and rotation of the hip secondary to tight hamstrings, hip rotators and quadratus.
When there is severe lower back pain in relation to the spine, it can misalign the pelvis and cause problems with posture. The hips and spine are both connected to the pelvis, so these structures can be affected as well. Depending on the spinal and femoral alignment, the pelvis will tilt. The change from a standing to a sitting position in patients with spine stiffness is finite and this means that patients tend to counterbalance their finite spine flexion in the lumbar region with more flexion through the hip, causing more rotation of the hip (Esposito, C. I., Miller, T. T., Kim, H.J., Barlow, B.T., Wright, T.M., Padgett, D.E., … Mayman, D. J. 2016). Frank is having difficulty changing his position from sitting to standing and vice versa. Since his spine is affected in the lumbar region, it makes sense that his body would be trying to atone for the narrow range of flexion in the spine by putting more pressure on his pelvis and hips and causing for rotation of both. The rotations would cause an abnormal pelvic tilt. The facet joints are supposed to restrain against great amounts of rotation in the lumbar region. Since the joints are inflamed, they cannot effectively restrain. This, therefore, allows for rotation of the pelvis (pelvic tilts), forwards or backwards or up and down, and the for rotation of the hip.
5. Give a detailed anatomical description of the affected area.
The affected area is in the facet joints, synovial joints, between the vertebrae in the lumbar region of the spine. The facet joints connect the posterior arch between vertebral levels (Perolat, R. 2018). The patient was experiencing pain in the lower back, lumbar region. The facet joints are in close proximity of the intervertebral discs, which is what the family physician initially said was affected. This close proximity could be a possible reason for the misdiagnosis.
6. Describe the best possible course of treatment for this patient. What is the patient’s prognosis?
The patient should rest, maintain comfortable positions, stretch hamstring muscles, and stretch hip joints. This should manipulate the affected area and correct the posture (Borenstein 2013). Surgery is not typically recommended because there tend to be multiple vertebral levels affected and multiple fusions of the joint and/or bones may need to be performed (Borenstein 2013). This is not advised because of the damage it can cause to surrounding structures (Borenstein 2013). The most conservative treatment would be exercising, but if the pain continues Frank may need to undergo a spinal injection into his facet joint using cortisone or he may need surgery. The prognosis is that with the proper treatment, Frank’s condition can get better and is curable.