Wellington Case Report.Degenerative disease of the lumbosacral spine

MEDICAL REPORT

 S.S, 63YEARS, FEMALE


 

 

Diagnosis:  Degenerative disease of the lumbosacral spine

 

Background Information: The above-named is a 63yr old female known but controlled hypertensive and diabetic presenting today with 10yrs history of insidious onset of low back pains which has become increasingly radicular. Pain is exacerbated by standing and walking a distance and relieved by sitting and resting.  Recently, her walking distance has reduced considerably and thus affecting her quality of life significantly. This has become a source of concern for herself and her family. Hence, she is seeking medical help now. It is also important to note that there’s history of trauma to the back 25yrs ago. 

 

Neurological Examination

O/E: normal tone, power, reflexes and sensation on both lower limbs. However, there’s significant limitation in a straight leg raising due to pain on her low back.

Radiological investigation:

X-ray of spine shows reduction in disc height at L3/L4, L4/L5, L5/S1, but worse at the last lower levels. There’s associated straightening of the lumbar spine.

MRI of the lumbosacral spine shows disc herniation at the above mentioned level bilaterally. This features are in keeping with advanced degenerative disease of the lumbosacral spine.

 

     

 

 

 

Management Plan:

·         To counsel on surgery as definitive treatment

·         Ensure Blood Pressure, Blood Sugar, Lipid Profile, and General medical condition to be normal.

·         Antiplatelet to be stopped if we are planning for surgery

·         To consider less invasive options if patient is undecided at this time:

1.      Medications (pain relievers)

2.      Physiotherapy

3.      Epidural injection

Pros and cons of different surgical and medical treatment has been explained but she has a preference to consider surgical options at the moment.

She will further discuss with her family. And following this, we also had a meeting with the family on this matter after which they needed time to think through and take a definitive stand and advice us accordingly.

Kindly revert for further clarifications if need be.

Sincerely Yours,

 

 

Dr. Halima Ibrahim

For Team Wellington Clinics

----------electronically signed to prevent delay in transmission

14 Jul, 2023
© 2024 Wellington Clinics Abuja. All Rights Reserved.