Nerve root pain

Patient: 37-year-old office worker

Case

• Has been taking otc co-codamol 8/500, qds some help.
• No bladder or bowel dysfunction - except constipated.
• PMH - left sided L4/5 microdisectomy four years ago - pains the same as then.
• Very worried - requesting private referral to neurosurgeon who operated four years ago.

Examination

Numbness over dorsum of foot, 4+/5 weakness of extension of big toe (? Related to pain), SLR limited to 30 degrees right, 70 degrees on left (some pain on right)

Action

• Changed to codeine phosphate 30mg (1-2 qds prn) , regular paracetamol, lactulose, diclofenac 50mg tds.
• Reassured to remain gently active, med3 1 week, review 1 week.

Review - 1 week

Pain slightly better, walking up to one mile, numbness and weakness the same.

Action

Med3 further 1 week, encourage to stay active, cont analgesia.

Review - 3 weeks

• Slowly improving, back at work, having to get up out of chair every 30 minutes, been to gym cautiously - some cycling and walking in the pool - not made pain worse.
• Still taking 2-4 codeine phosphate 30mg/day with paracetemol and diclofenac regularly.
• Accepts that does not need MRI/Surgical review.

4 months latter

Seen with emotional trauma related to relationship problems - reports occ right leg pain, but back to gym regularly and able to row and run gently. Taking occasional paracetamol for pain.