From Subjective History:

Provisional Hypothesis

Not D1-4 (symptoms below knee); not ANR (symptoms constant); not simple

dysfunction; not central canal stenosis (no neurogenic claudication)

Possible D5 (did not have acute deformity, I had benefit of seeing the

patient);

possible entrapment (constant symptoms); Possible lateral foraminal stenosis

(has

constant pain in nerve root ditribution); Unknown problem

Some points to consider: the history is not suggestive of a mechanically

reducible problem. The patient has constant symptoms which cannot be made

significantly better or worse. He has been unchanging for several months.

Despite

this he has remained at work as a plumber so must have placed significant

mechanical stress on his spine. This does not sound like a mechanically

active

problem making a D5 less likley. However, D5 cannot be ruled out completely.

Remember with an active derangement it is likley that mechanical stress will

increase, worsen, peripheralise, decrease , centralize symptoms. None of this

appears to be occurring.

I see no significant red flags aside perhaps age. As far as mechanical testing

procedures I think we can proceed quite aggressivley. As stated above this has

not changed in several months despite the fact he has remained at work. I

think

its unlikley we can mechanically stress his back more than he has being doing

at

work?.

I would also want to know why he is seeking treatment after one year? He also

states that he has had constant back pain for several years so clearly he is

seeking help for the leg pain. I would not try to find a fix for his

longstanding

back pain.

Things to check during mechanical testing:

Rule out neurological signs: determine effect of repeated flexion - this is

the

best way to differentiate between derangement 5 and entrapment (refer to

McKenzie

texts).

Objective Findings

No deformity (not D6) - that was clear during history)

No relevant movement loss of extension and minimal flexion. By relevant I mean

the movement loss that has occurred as a result of this episode.

RFIS: Increased leg: not worse and no mechanical change (ROM) - NOT ENTRAPMENT

All Repeated Movements: Increased, not worse with no mechanical change: NOT

DERANGEMENT

No dural tension, myotomal weakness or sensory changes despite symptoms.

Conclusion: Possible lateral foraminal stenosis. This is only a hypothesis.

Porter et al (1984) describes a series of patients with lateral foraminal

stenosis. The typical presentation is age > 50 years, Male >female, severe

unrelenting leg pain, usually nerve root symptoms, often lonstanding back

pain,

major loss of spinal extension and dural tension rare. This patient fits this

picture to a tee (yes this was an actual real patient). On follow up Porter

reported that these patient will usually improve over time -- 78% reported

some

improvment after one year.

No further mechanical testing procedures required. I would not explore the

lateral compartment because mechanically this does not present as a

Derangement.

I educated this pateint and was quite up front that I did not think I could

change his leg symptoms. He was very gracious, thanked me for being honest and

decided that he could manage quite nicely on his own (which he already had

been

doing for the past year).

I chose this case because it really highlights the value of the McKenzie

assessment. By following a logical mechanical testing procedure you can

quickly

establish if the problem is suitable for mechanical therapy. If the

symptomatic

and mechanical respone does not fit then do not try to make it fit --that is

the

real beauty of McKenzie. Sometimes you cannot alway fit the problems into a

mechanical diagnoisis but these cases are genrally easy to identify. Of

course

my final conclusion may be wrong I have no way of proving this. However, I

have

ruled out several other treatable mechanical possibilties.

References - Lateral Stenosis

Lee CK, Raunschning W, Glenn W. Lateral lumbar spinal canal stenosis:

classification, pathologic anatomy and surgical decompression. Spine 1988: 13:

313-320

Porter RW, Hibbert C, Evans C. The natural history of the root entrapment

syndrome. Spine 1984: 9: 418-421

Porter RW. Spinal stenosis and neurogenic claudication. Spine 1996: 21:

2046-2052

Porter RW. Spinal stenosis in the central and root canal. In: Jayson MIV, ed.

The

lumbar spine and back pain. 4th ed. Edinburgh: Churchill-Livingstone, 1992:

MacNab I : backache also has a good chapter (I think) but I don't have the

reference on hand.

Also read these two references for quite a nice explanation ofwhy lateral

senosis

does not necessarily produce tension signs.

Olmarker K, Rydevik B. Pathophysiology of Sciatica. Otho Clin N Amer: 1991:

22:

223-234.

Rydevik B, Brown MD, Lundborg G. Pathoanatomy and Pathophysiology of nerve

root

compression. Spine: 1984: 9: 7-15.