Disclosures: Matthew A. Cascio, DO: No financial relationships or conflicts of interest

Case Diagnosis: Severe Spinal Stenosis with Left Foot Drop

Case Description or Program Description: A 59-year-old Hispanic male presented to PM&R clinic with 20 years of progressive low back pain and lower extremity weakness with left foot drop. He had two recent hospitalizations for back pain, last discharged three weeks prior to clinic visit. Inpatient MRI revealed moderate L2-4 central canal narrowing with severe left and moderate right L2- L3 foraminal stenosis. He was evaluated by neurology inpatient and discharged. Following discharge, he noted increasing lower extremity weakness. He reported left thigh numbness and decreasing lower extremity muscle mass. He utilized a rollator since discharge with increasing falls.

Setting: Tertiary-care teaching hospital

Assessment/Results: He was referred directly from the clinic to the emergency room, and neurosurgery urgently performed L2-3, L3-4 laminectomies. Once stable, he was transferred to acute rehabilitation. He was prescribed an AFO for left foot drop. By discharge, he ambulated 200 feet independently with a rolling walker. He continued outpatient physical therapy, and at outpatient follow up 3 months later he ambulated well without assistive devices.

Discussion (relevance): Spinal stenosis is a narrowing of the spinal canal with neurologic or vascular impingement. Etiologies include degenerative changes, including spondylosis or disk herniation; however, other important considerations are surgery, trauma, or congenital malformations. Symptoms can range from low back pain with paresthesias, to foot drop to urinary incontinence, and may eventually lead to gait changes with falls.

Conclusions: Our clinic’s recognition of our patients’ rapidly progressive acute on chronic symptomatic stenosis allowed for prompt neurosurgical intervention. While his prognosis was guarded given the chronicity of his symptoms, surgery followed by aggressive rehabilitation with appropriate orthotics allowed for functional restoration. Outpatient physiatry clinics should maintain a low threshold for emergent neurosurgical evaluation in patients with severe radicular symptoms.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/get-him-to-the-er-a-case-of-emergent-neurosurgical-referral-for-acute-on-chronic-severe-symptomatic-spinal-stenosis/