A 36-year-old male suffered from\u00a0 severe low back pain. His pain diagram indicated a localized region of\u00a0 pain around his left lower lumbar region, sacroiliac joint and buttock.\u00a0 He states that he occasionally feels a slight tingling sensation in his\u00a0 left posterior thigh, but not distal to the knee. This tingling\u00a0 sensation only occurs for a few moments once or twice a week. The lower\u00a0 back pain is daily, and worse in the mornings upon rising from bed.\u00a0 After he gets to work the pain subsides; but then worsens again by\u00a0 mid-afternoon. The patient is employed as a car mechanic and must\u00a0 frequently work bent over the hoods of cars in a flexed position, which\u00a0 aggravates his pain. He says that occasionally he will get \u201cstuck\u201d in a\u00a0 position where he is leaning forward and to the right, and that he must\u00a0 slowly work out his back to be able to straighten up again. He does not\u00a0 recall any specific low back injury that set off this particular episode\u00a0 of acute pain, which began insidiously about 3 wks before his first\u00a0 visit. How- ever, he has had such episodes about once or twice a year\u00a0 for over 10 yr, and has previously seen chiropractors with fairly good\u00a0 results.<\/p>\n
Physical examination began with lumbar ranges of motion, which\u00a0 were restricted into flexion at 25 degree, left lateral bending at 15\u00a0 degree, and left rotation at 10 degree. He exhibited a mild antalgic\u00a0 lean to the right. He does not walk with an obvious limp, but is\u00a0 observed to avoid full weight-bearing on his left leg. Kemp\u2019s maneuver\u00a0 elicited sharp but localized left low back pain over the left L5\/SI\u00a0 facet and sacroiliac joint, with only mild left buttock pain. There was\u00a0 no reproduction of any left thigh symptoms. Static palpation of the L5\u00a0 and Sl spinous processes elicited sharp local pain, and motion palpation\u00a0 P-A over- pressure on the left L5\/Sl facet joint also caused sharp\u00a0 local pain. Muscle palpation revealed some hyper tonicity of the left\u00a0 erector spinae, quadratus lumborum, and gluteus medius \/ minimus muscle;\u00a0 however, no true spasm was detected. Repeated extension in the standing\u00a0 position elicited some increased pain over the left lumbar facets, but\u00a0 repeated extension in the prone position afforded the patient some\u00a0 relief of his low back pain.<\/p>\n
Plain film radiographs of the lumbar spine demonstrates about\u00a0 50% narrowing of the L5\/Sl disc space, and a mild right lateral lean of\u00a0 the lumbar spine. There is no apparent loss or accentuation of the\u00a0 lumbar lordosis. There is slight rotation of the 15 spinous toward the\u00a0 left, but no other gross malalignments were noted. He was scheduled for\u00a0 an MRI by his primary care physician, but the insurance company denied\u00a0 authorization for the test, citing \u201clack of compelling medical\u00a0 necessity\u201d to perform advanced diagnostic imaging tests. Tentative\u00a0 diagnosis by his primary care physician was lumbar sprain, and he was\u00a0 given a prescription for Ibuprofen 800 mg t.i.d.<\/p>\n