Case studies Who is “Disabled for Life” Ronald Kienitz, D.O. Case 1
Related searches for Differential Diagnosis : Back Disorders
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“Disabled for Life”
Ronald Kienitz, D.O.
40 y/o old male with history of injury after clearing beachfront of naupaka. Stated he made several trips carrying 75 lb+ bundles one in each hand, swinging them to try to maneuver through a gait without catching the branches. No initial pain but woke that night with excruciating low back pain, numbness and weakness of the left lower extremity. Despite resting two days, he remained unable to ambulate even short distance. History was positive for prior severe low back pain and sciatica eight years prior that had partially resolved except for intermittent exacerbations. MRI revealed massive L4/5 disc herniation with large, sequestrated fragments impinging L5 nerve root. Sent for micro-discectomy 6 days after the injury event. Post-operatively, continued to exhibit mild to moderate left L5 sensory radiculopathy and some recurrent back pain.
Care was conservative with NSAIDs, muscle relaxants and physical therapy. When pain continued, he was sent for MRI of the lumbar spine revealing:
1. L4/5 posterior anular tear and disc bulge along with chronic ligamentous and facet hypertrophy causing mild to moderate central stenosis.
2. L5/S1 posterior anular tear and mild bulge without stenosis
3. L3/4 mild diffuse disc bulge along with chronic ligamentous and facet hypertrophy causing mild central stenosis.
4. Multi-level mild to moderate foraminal stenosis
He was sent through a 12 week course of exercise rehabilitation therapy. Continued to complain of intermittent back ache.
48 y/o male complaining of gradually increasing low back pain and limping off of right leg over prior month. Uncertain of specific injury event, but recalls feeling a slight strain of low back as he lifted a heavy suitcase out of his deep taxi trunk. Prior history of on and off back pain for 20 years with occasional severe exacerbations. History of L4/5 discectomy some years prior. Examination findings significant for foot-drop gait and gross weakness of right ankle dorsi-flexion as well as sensory loss to antero-lateral right leg and foot. MRI showed L4/5 disc herniation impinging on right L5 nerve root, degenerative disc narrowing at L5/S1 and mild to moderate central disc bulge at L4/5. Because of prior surgery and multilevel findings, orthopedic consultant recommended and proceeded with L4/5 discectomy and cage fusion with partial lateral allograft fusions at L5/S1 and L3/4. Post-operatively, exhibited good return of ankle dorsi-flexion, but significant L5 sensory loss. Also had significantly reduced range of motion and pain with activities of daily living including some self-care.
52 year old male injured in cycle accident. Sustained concussion, neck torsion, and significant facial lacerations. Complained of immediate sensory deficit to radial left hand. CT scan of neck revealed no acute fracture but significant underlying degenerative disc disease with multi-level disc-osteophyte foraminal encroachments, moderate to severe at C6/7 and moderate at C5/6. Complained of ongoing significant pain from neck to left arm often affecting sleep. Examination findings later demonstrated tricep weakness and muscle wasting. Symptoms continued in spite of conservative care including NSAIDs, short course of prednisone, physical therapy, and extended exercise rehabilitation. Lyrica provided some benefit for neuropathic pain, but ongoing symptoms continued to impact quality of life. Surgery performed 2 years later with discectomy, fusion, and anterior instrumentation at C5/6 and C6/7. Post-operatively, demonstrated expected mild decrease in cervical range of motion and some residual radial sensory loss but decreased ache and increased strength in spite of continued visible atrophy.
Individual perceives self as incapacitiated despite minimal impairment or disorded
Individual is productive and interactive despite significant impairment.
Traditional medical training often ignores techniques to recognize and deal with illness behavior or to adequately communicate communicate it to patient and colleagues.
Iatrogenic disability can result
The concept of illness behavior. J Chronic
Disability 15a, 189-94, 1961
Unconscious symptom exageration recognize and deal with illness behavior or to adequately communicate communicate it to patient and colleagues.
Exaggeration or fabrication
Deny or minimize positive traits/abilities
Complaints diasability management; Occ Med STAR 15(4);739-54
Low back/ neck
Multiple chemical sensitivity
Toxic MoldDisorders prone to somatization