Name

:
Age
:
Race
:
Sex
:
Address
Date of admission
Date of clerking
RN
:

Nursyafiqah binti Ali

25 years old
Malay
Female
:
Puchong Perdana
:
17/11/2015
:
19/11/2015
SD00356401

CHIEF COMPLAINT
A 25 years old Malay lady presented with back pain 5 days prior to admission
HISTORY OF PRESENTING ILLNESS
Patient was apparently well until 5 days prior to admission, she
complaint of lower back pain. It was sudden in onset upon waking from
sleep. The pain was throbbing and shooting in nature as the pain radiated
from the back, to the thigh, leg and sole of foot. The pain was not relieved by
pain killer or massage and exacerbated by movement. The pain was
associated with numbness and tingling sensation of foot. She scored the pain
10/10.
Besides, the pain disturbed her daily activities, as she had difficulty
walking and moving around. She could only stand for less than one minute
due to the pain. Previously she used squatting toilet, but now had to use
sitting toilet. Most of time, she had to hold the wall to move around, as she
felt pain. The pain also disturbed her sleep. She needed to take pain killer
first before getting sleep. Since pain, she had absence from work for several
days.
On further questioning, she had history of motor vehicle accident 2
years ago. She was the passenger of motorbike and out of sudden, the
motorcycle was skidded. She fell on her right side in sitting position.
However, only minor bruises were noted. She denied any heavy bleeding,
loss of consciousness and fracture. She even can ambulate well right after
the accident.
One day after trauma, she started to have back pain, more on right
side, associated with numbness and tingling sensation. The pain had similar
nature as current presentation but not severe as now. She went to klinik
kesihatan seri kembangan for medical attention. Xray was done at that time
and no abnormality was noted. She had given pain killer and physiotherapy
schedule. The pain was completely resolved after 2 days and one visit to
physiotherapy.
1

However, since the incident, she complaint of intermittent back pain

sometimes, with frequency once in three months, especially during heavy
lifting and doing heavy works. She could bear with the pain. Otherwise she
will take pain killer to resolve the pain. The back pain was started to worsen
since one month ago, as she doing part time job at 7eleven shop. She
needed to carry heavy loads and require much walking and standing most of
time.
Otherwise, she had history of TB contact, which is her late uncle, one
year ago. Her mothers aunt had history of bone malignancy and died due to
the malignancy. Otherwise, she had no history of fever, cough, shortness of
breath and night sweats. She denied any recent trauma and travelling. She
had no constitutional symptoms such as loss of weight and loss of appetite.
SYSTEMIC REVIEW
It was unremarkable.
PAST MEDICAL HISTORY
She is G-6-P-D patient since child. Otherwise, no hypertension, diabetes
mellitus or any underlying medical illness.
PAST SURGICAL HISTORY
No history of surgical intervention before
DRUG HISTORY
She only get allergy with food that are contraindicated for G-6-P-D patient.
No known drug allergy.
FAMILY HISTORY
She is single, not married yet. She is the first out of 2 siblings. Her mother
had died due to breast cancer 2 years ago. Her father and little brother are
healthy. Her mothers aunt has history of bony malignancy. Otherwise, no
diabetes, no hypertension running in her family
SOCIAL HISTORY
Currently, she stayed with her family in a single storey terrace house at
Puchong Perdana. She works as an administrative officer at Bukit Jalil and did
part time job since one month ago at 7 eleven shop. She is not a smoker, nor
a drinker.
SUMMARY

Miss Syafiqah, 25 years old Malay lady with history of trauma on right side 2
years ago presented with progressive worsening low back pain, associated
with numbness and tingling sensation on foot 5 days prior to admission. She
had family history of bone malignancy and had recent contact with TB
person one year ago.
PHYSICAL EXAMINATION
Generally, patient was alert and conscious. She couldnt lie comfortably as
she had pain on her lower back. She preferred to lie laterally, either right or
left side to be comfortable. However, shes not in respiratory distress. Not
cachexic looking. Capillary refillary time was less than 2 second. No
conjunctiva pallor and good oral hygience. No central cyanosis noted.
Hydration status was adequate.
Vital signs were:
Respiratory rate
: 20 breaths per minute
Pulse rate
: 74 bpm
Temperature
: 37.0oC (afebrile)
Blood pressure
: 117/68 mmHg (normotensive)
Spine Examination
Examination was done in standing and lying position. However, it was
restricted in standing position as patient was having pain to stand.
On inspection, there was no shoulder asymmetry and pelvic was not tilted
but she could only stand for a while as shes having pain. Inspection of back
revealed there was no surgical scar, no skin changes, no visible swelling or
no scoliosis noted. There was also no muscle wasting. From lateral side, there
was no gibbus, no excessive lumbar lordosis observed. Inspection from
anterior, there was no deformity of the chest, and no abnormal protrusion of
the abdomen. Otherwise, there was no muscle wasting of the quadriceps and
no deformity of the lower limbs. On gait examination, there was presence of
antalgic gait on her right side.
Palpation of the spine revealed tenderness over lumbar region, L5 area and
sacroiliac joint. The spine was centrally aligned. Step-off was absence. There
were also no temperature changes and no paraspinal muscle spasm.
For range of movement, forward flexion, active movement was from 0 o to
15o, which was limited (normally 0 o 90o), and it was same with passive
movement. Schobers test couldnt be appreciated as the patient was having
3

pain. Other movement such as extension, lateral and medial rotation could
not be done due to the pain. Special test, SLR was positive for the right
lower limb where the patient complaint of shooting pain at 10 degree. Patient
had positive FABERs sign on her right lower limb, whereas her left lower limb
is normal.
Neurological Examination
On inspection of lower limb, there was no surgical scar, no swelling, no
muscle wasting, no fasciculation or limb length discrepancy was noted. No
clonus was noted. On palpation, tone was normal bilaterally. Power of flexors
and extensors group muscle was normal bilaterally. There was presence of
ankle and knee reflex for both sides. Abdomen reflex was also intact.
Babinski was negative. However, there was reduced sensation and reduced
in pin-prick touch on S1 area of right foot. But, left side revealed normal
sensation. Coordination and proprioception were intact. All pulses were felt
bilaterally.
Anal sensation was intact.
Other examination was unremarkable.
SUMMARY
Miss Syafiqah, 25 years old Malay lady with history of trauma on right
side 2 years ago presented with progressive worsening low back pain,
associated with numbness and tingling sensation on foot 5 days prior to
admission. Physical examination revealed presence of antalgic gait and
patient lied uncomfortably due to pain. Spine examination showed
tenderness on L5-S1 area, together at right sacroiliac joint. There was
reduced sensation on right side of S1 area. Left lower limb revealed normal
finding
PROVISIONAL DIAGNOSIS
Prolapse intervertebral disc at lumbar area, L5 with nerve root compression
Points for :
chronic back pain, since 2 years ago
disturbance in daily activities
history of trauma and fall
history of heavy lifting within past one month
tenderness over lumbar area and sacroiliac joint
DIFFERENTIAL DIAGNOSIS
4

Points for
history of tuberculosis
contact one year ago
back pain, restriction of
movement, tenderness
of vertebrae

Points against
no prolonged
cough, no night
sweat, no loss of
weight or appetite
no tachypnea, no
fever, no muscle
spasm

Mechanical back
pain

Bone malignancy

Spine
tuberculosis

Pyogenic
infection of
spine

history of heavy lifting,

tenderness of lumbar
area, recurrent episode
Family history of bone
malignancy

history of trauma,
not relieved by
massage
No constitutional
symptoms such as
loss of weight, loss
of appetite

INVESTIGATION
Renal profile
Objective :To look for the level of serum creatinine and urea for renal
function,
and any electrolytes imbalance.
Urea
Sodium
Potassium
Chloride
Creatinine
Impression :

Results
4.4
mmol/L
136
mmol/L
4. mmol/L
0
105
mmol/L
55
mmol/L
All parameters were normal.

Normal range
(1.7 8.3)
(135 145)
(3.5 5.0)
(98 108)
(53 - 97)

Urinalysis (ufeme)

Blood
Bilirubin

: Negative
: Negative
5

 Urobilinogen
: 2+
Ketone
: Negative
Protein
: 1+
Nitrite
: Nil
Glucose
: Negative
pH
: 5.0
S.G
: 1.030
Leucocyte : Negative
Impression : normal finding
Imaging
Plain X-ray of lumbo-sacral region (AP & lateral views)
- Reasons
- to look for evidence TB spine and other associated pathology
- to rule out other causes (e.g., malignancy)
- Result
- no abnormality finding
- no destruction on disc space
- no soft-tissue shadows on para-vertebral area
- no loss of lumbar lordosis
- no obvious fracture seen
- Comment
- normal finding
- no evidence of probable TB spine
- bone malignancy has been ruled out as there is destruction of the
intervening disc
Other investigations I would like to do
Full blood count
reason : infection, due to leukocytosis or pre-op assessment
Liver profile
Reason :
to rule out secondary bone tumor through increased
albumin/globulin ratio
Mantoux test and Sputum for acid-fast bacilli (AFB)
Reason : to diagnose TB infection
C-Reactive Protein (CRP)
Reason : If it is raised, it indicates acute inflammation

FINAL DIAGNOSIS
Prolapse intervertebral disc at lumbar area, L5 with nerve root compression
TREATMENT

Analgesic C.celebrex 200 mg BD, T PCM 1 g QID, C tramal 50 mg TDS

Iv ranitidine 50 mg TDS
T eprisone 50 mg TDS for 2/52
T neurobion
MRI scheduled on next month
To come again (TCA) 3/52 after MRI
MC for a week

DISCUSSION
Back pain is a vague presentation that comprises a wide range of
causes. They are probably due to infection, degenerative, traumatic,
malignancy, or congenital. Even the causes maybe localized cause such as
mechanical back pain or muscle spasm itself. The pathophysiology behind
this symptom can be either due to compression to the spinal cord, nerve
root, or the vertebral ligament
Regarding to this case, Ms Syafiqah started to experience sudden low
back pain accompanied with numbness and tingling sensation. The question
to be asked is, is it caused by trauma to the spine which then the fracture
fragment compressing the nerve root, or is it due to infection, particularly
tuberculosis or is it due tumour growth that compressing the nerve roots or
is it due to prolapsed intervertebral disc (PID), which then compressing the
nerve root? Therefore, here where history and physical examination come
and play its role.
From the history, Ms, Syafiqah claims that during the recent attack, she
could barely walk due to the pain. She denied on fall or injury to the back. By
having this, we can already rule out fracture of the spine. Typically in fracture
case, the patient will have pain just following an incident, and associated
with swelling at the fracture site, loss of function, and cant mobilize. Other
than that, she also denies having any fever, night sweats, or chronic cough in
recent period. This may give us an idea that tuberculosis infection is less
likely. For malignancy, the patient looked well, doesnt have any loss of
appetite or weight. Pyogenic infection also can be ruled out as there was no
fever. Here, prolapsed intervertebral disc (PID) is one of the possible
diagnoses which can lead to the compression the nerve roots. From the
history, patient was presented with low back pain together with numbness
and tingling sensation. But no emergency case was noted as she denied any
7

history of anal and bowel incontinence. This supports the diagnosis of PID.
However, PID is a MRI diagnosis, as PID can only be diagnosed just from the
history and physical examination. MRI was being scheduled in this patient.
Proplapse intervertebral disc (PID) is a condition where the gelatinous
nucleus pulposus of the disc squeezes through the fibres of the annulus
fibrosus and buldges posteriorly or posterolaterally beneath the posterior
ligament causing pressure on one of the nerve roots. The pathophysiology
beneath it is mainly due to nucleus degeneration associated with weakening
of the annulus fibrosus, follows with nucleus displacement, and then stage of
fibrosis where the extruded nucleus will become fibrosed. PID commonly
affect young adults, particularly age between 20 to 40 years old, and usually
affect lower lumbar and sacral region, which is between L4 L5 (in younger
patient) and L5 S1 (in older patient). From the history wise, the specific
symptom for PID is when patient complaining about aggravated low back
pain when straining or doing any activity that can increase intra-abdominal
pressure such as coughing, sneezing, passing motion, or lifting heavy things.
From the physical examination aspect, there is no specific sign for PID, even
for straight leg raising test (SLR). It is because SLR will be positive not only in
PID, but also in any condition that can cause compression to the sciatic
nerve. However, in physical examination of PID case, what is important for us
to look out is that either the patient having any associated motor and
sensory defect. By doing this, it can gives us an idea about which level is
affected, before we confirm it by MRI.
In this case, Miss Syafiqah has complained that the low back pain is
worsened when she tries to lift heavy things. This is the typical presentation
of prolapse intervertebral disc. This is already support the diagnosis of PID.
From the physical examination, it reveals that there was tenderness over L5
area. Nerve root was also involved as there was reduced sensation at S1.
Apart from that, SLR test also is also positive for right lower limbs, which
proved that there is compression of the sciatic nerve.
For investigation, PID only can be confirmed by MRI scan. The other
investigations that are usually done is mainly to rule out other differential
diagnosis, and is also for pre-operational assessment for patient who will
undergo surgery. PID can be treated either by conservatively, or later, if
conservative failed, operative treatment will come apart. For conservative
management, it is divided it into non-pharmacological and pharmacological
treatment. For non-pharmacological treatment, it includes bed rest where the
aim is mainly to reduce movement of the spine which can worsen the
problem, massage therapy, and warm pack. For pharmacological aspect of
conservative treatment, it is mainly to relieve the pain. The drugs that
usually used is such as tramadol (opiods), ibuprofen (NSAIDs group), or
celecoxib (COX-2 specific inhibitors). Those drugs are taken orally in tablet
8

form. There is sometimes where these analgesic tablets cannot relieve the
pain. Then, we can give intravenous injection of glucocorticoids (eg;
triamcinolone) to relieve the pain.
For operative treatment, the aims are; 1) to relieve nerve compression
especially in emergency cases, 2) relieve the back pain, and 3) restoration to
normal function. The principal method for operative treatment for PID is
decompression and if necessary, do stabilization. There are several surgical
options can be done, such as discectomy, laminectomy, or artificial disc
replacement. Post operative rehabilitation program is needed. It is important
for the patient to be taught about physiotherapy. Consultation on lifestyle
modification such as stop heavy lifting should be advised and change to a
more reasonable light duty.
REFERENCES
1. Apleys System of Orthopaedics and Trauma (7 th edition). A. Graham
Apley and Louis Solomon
2. Clinical examination, Ronald Mc Rae, Churchill Livingstone
3. http://www.emedicine.medscape.com