A 70-Year-Old Man With Back, Buttock, and Thigh Pain

AFFILIATIONS:
¹Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
²Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

CITATION:
Rubin RN. A 70-year-old man with back, buttock, and thigh pain. Consultant. 2022;62(12):e12. doi:10.25270/con.2022.11.000014

DISCLOSURES:
The author reports no relevant financial relationships.

CORRESPONDENCE:
Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

Introduction. A 70-year-old man presents with lower back pain, bilateral buttock pain, and a sensation of bilateral leg weakness, most notably in the right ankle and foot.

Patient history. The patient’s pain has been present for about 2 months. Initially, the patient considered the pain a “nuisance.” Although acetaminophen previously helped soothe the pain, it became more severe in the last 10 days coincident with the patient helping a family member pack and prepare for a cross-country move.

The patient revealed that the pain is most severe in the morning and very severe when he stands. He can ease the pain somewhat by bending forward, but the pain when standing persists throughout the day. He’s capable of sleeping through the night reasonably well except when he wakes to urinate and needs to stand again. During working hours, regardless of pain intensity, the pain essentially vanishes when he sits down. He notes tingling in his great toe and the soles of his feet, particularly in the right foot. He presented to the clinic after a long, arduous, uphill walk, when his pain became quite severe. He also noted a feeling of weakness and poor control of his right ankle and foot. By the next morning, most of this neurology had resolved, but he felt that his right ankle and foot were weaker than the left.

His medical history is unremarkable other than mild hypertension, controlled with losartan 50 mg/d. He suffered two herniated discs, one at the age of 27 on the left side, and one at age 67 on the right side with full recovery. The patient is very active for his age. He had been participating in indoor activities at a YMCA and had noticed the previous month that the impact with the hard floor caused some mild stiffness and discomfort in his back. He also regularly goes to the gym and can ride the stationary bike for 20 minutes or more without symptoms.

Physical examination. The patient’s physical examination was unremarkable. But when I asked him to rise from a sitting position on the exam table, there was pain in his lumbar area, both buttocks, and into the back of thighs bilaterally. The pain resolved in seconds when he sat down. The patient’s strength was good except for bilateral paresis of dorsiflexion of the great toe, more so on the right, as well as flexion or extension of both ankles. The Achilles reflex was absent of the right. Straight leg raising was not painful.

Which of the following is the correct statement regarding management and prognosis of the presenting patient?

A. If the patient proceeds to immediate rather than delayed microdiscectomy surgery, he can expect prompt and long-lasting relief of symptoms.
B. If the patient proceeds to a course of injection corticosteroids, he can expect prompt and long-lasting relief of symptoms.
C. The patient should invest at least several months in a nonsurgical course of therapy, including appropriate and vigorous physical therapy (PT).
D. If surgery is chosen, it should be performed within 3 to 4 weeks for maximum efficacy, and to prevent the natural history of rapid and inexorable progression.

(Answer and discussion on next page)