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Spondylolisthesis
Classic Presentation
The patient, a female aged 67 years, presents with signs of stenosis coupled with pain over the fibrocartilaginous mass at the defect, and facet pathology at the L5 level of the lower spine. In addition, the patient seems to be symptomatic. The most presenting complaints include lateral recess stenosis and disk herniation, resulting in repeated instances of back pain, which worsens with activity but subsides with rest. According to the presentations compiled by Souza (2005), particularly the signs of stenosis, pain at the L4 or L5 joints, and the age factor, this may be a classical case of degenerative lumbar spondylolisthesis.
Cause
With the progression in age, bones, joints, and tendons supporting the spine tend to weaken and are no longer capable of embracing the spinal column in alignment (Yadla, 2008). As the facet joints (L4 or L5) age, they, on most occasions, become inept and permit too much flexion (the act of allowing the spine to bend forwards), giving rise to a situation where one vertebral body slips forwards onto the other (Yochum & Rowe, 1996).
Evaluation
The patient experience elevated levels of back pain when a one-legged balance test is performed on her. According to Souza (2005), this physical examination test involves requesting the patient to balance on one leg and hyperextend at the lumbar area. Radiological evaluation reveals a slippage of the vertebrae of two-fourths the AP length, implying that the condition is at grade 2. Souza (2005) observes that “…each slip of one-forth the length of the anterior to the posterior body is considered a grade” (p. 60). Lastly, the patient is female and over 60 years old. Yochum & Rowe (1996) note that degenerative lumbar spondylolisthesis is three times more common in old women than in old men
Management
Physical/manipulative therapy involving stretching and strengthening coupled with a proactive aerobics program, such as biking or undertaking water exercises, may offer the much-needed reprieve (Yadla, 2008) Since the condition is at Level 2, there is no need for surgical consultation (Souza, 2005), therefore allopathic medicine can only prescribe epidural steroids for short-term relief.
Thoracic Compression Fracture
Classic Presentation
The patient, a male of 77 years, presents with mid-back pain, particularly after engaging in minor events such as coughing or sneezing. Spine experts reveal that this type of disorder affects the thoracic spine, which forms the back of the chest wall, and “…consists of 12 vertebras, 10 of which have ribs attached, intervertebral discs separating each vertebra, supporting soft tissue, and twelve thoracic nerves” (PainDoctor.com, 2010 para. 2).
Cause
According to Souza (2005), the fracture may be caused by weakness in bones, sufficient trauma to a bone, early menopause, sustained usage of corticosteroids, and hyperthyroidism. The risk factors include the age of 40 years or greater; history of injury and/or deformities; poor posture; heavy physical work, and; lack of exercise (PainDoctor.com, 2010).
Evaluation
When medical history is evaluated, evidence demonstrates that “…long-term corticosteroid use or age greater than 70 years is suggestive of a compression fracture in patients with thoracic or lumbar complaints” (Souza, 2005 p. 100). Upon physical examination, the patient experience acute pain when deep pressure is placed over the involved vertebral area. Radiographic images will characteristically reveal “… wedge-shaped defect, with the anterior height being lower than the posterior” (PainDoctor.com, 2010).
Management
This is a chiropractic case. In addition to encouraging the patient to avoid flexion exercises, a restrictive corset may be placed over the involved region to remind the patient not to bow forward or engage in making abrupt movements (Souza, 2005). In terms of Allopathic medicine, non-steroidal anti-inflammatory drugs can be used for short-term relief.
Rheumatoid Arthritis
Classic Presentation
The patient, a female of 52 years, presents with acute pain emanating from the hip coupled with periarticular soft tissue swelling, muscle pain, stiffness, fatigue, and flu-like symptoms. Souza (2005) observes that the presentation of pain over the hip may sometimes be bilateral.
Cause
According to Souza (2005), “…the cause is a synovial inflammatory process that creates a destructive pant” (p. 313). While genetic composition and a weak immune system do not cause rheumatoid arthritis, they can make individuals progressively more vulnerable to the environmental factors believed to either cause or exacerbate the condition.
Evaluation
Radiographic evaluation reveals consistent, symmetric joint space attenuation superiorly, which may over time become bilateral, leading to other negative conditions such as subchondral cysts and osseous destruction (Souza, 2005). According to this author, laboratory evaluations may reveal “…elevated erythrocyte sedimentation rate (ESR) and a positive rheumatoid factor” (p. 313). Physical examination may reveal enlarged liver and/or spleen, joint swelling and redness, and joint tenderness (Yochum & Lowe, 1996).
Management
Depending on the scope of severity, rheumatoid arthritis may either be a chiropractic case or a medical referral. For less acute cases, a chiropractor may perform physical therapy, warm compresses, encourage the patient to engage in mild, passive movements to maintain hip motion and reduce tenderness and swelling (Souza, 2005). For acute cases, as is witnessed here, allopathic medicine can be used to prescribe non-steroidal anti-inflammatory drugs, interleukin receptor inhibitors, immunomodulators, or, in extreme cases, prescribe joint replacement surgery.
Reference List
PainDoctor.com. (2010). Thoracic Pain (Mid-Back Pain). Web.
Souza, T.A. (2005). Differential diagnosis and management for the chiropractor: Protocols and Algorithms, 3rd Ed. Sudbury, MA: Jones and Bartlett Publishers.
Yadla, S. (2008). Degenerative Lumber Spondylolisthesis. Web.
Yochum, T.R., & Rowe, L.J. (1996). Essentials of skeletal radiology, volume 1. Baltimore, MD: Lippincott Williams & Wilkins.
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