Author: Samuel Galloway, MD
Senior Editor: Carolyn Landsberg, MD
Editor: Emily Miller, MD

Patient Presentation:
48 year old male food truck worker presenting with low back pain associated with left leg weakness and numbness.

History:
He had been in usual state of health prior to acute onset of symptoms several days prior to presentation. His symptoms started while at work. He denied any specific injury or doing any heavy lifting. His symptoms rapidly worsened over the following hours to the point where he was having difficulty walking and felt like his "left leg fell asleep and never woke up." He had no recent infectious symptoms.

He went to the Emergency Department for initial evaluation. Basic labs and a lumbosacral x-ray were obtained. He was diagnosed with a lumbar disc herniation with radiculopathy/sciatica. He was treated with ketorolac injection, tizanidine, lidocaine patch, and one dose of dexamethasone. He was instructed to follow up with Sports Medicine upon discharge.

He presented to Sports Medicine several days later. At that time, his back pain was improving. However, he continued to have symptoms down his left leg. He was now ambulating with a cane and had fallen several times. He reported noticing visible atrophy of his left thigh muscles.

He had no history of malignancy, diabetes, or thyroid disease. He denied fevers, chills, saddle anesthesia, bowel/bladder issues, or IV drug use.

He did have history of left Achilles tendon rupture several years prior which was surgically repaired.

Physical Exam:
Back: No spinal or paraspinal tenderness to palpation. Full range of motion in flexion, extension, rotation, and lateral bend. Positive straight leg raise and slump test on the left.
Left lower extremity:
Inspection: Visible atrophy of the quadriceps muscles.
Muscle strength: 4/5 hip flexors, 5/5 hip abduction and adduction, 2/5 knee extension, 5/5 knee flexion, 5/5 ankle dorsiflexion and plantarflexion.
Reflexes: Absent patellar and Achilles. No clonus. Down going Babinski.
Sensation: Decreased sensation in the anterior and medial thigh down to mid-calf with allodynia.

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