History:
The patient, previously in normal health, developed dull, constant low back pain that progressively worsened. The pain later began to radiate to both legs, more prominently on the left side, following the L5-S1 nerve pathway.
He began experiencing weakness in both legs, which made walking and climbing stairs difficult. Along with this, he reported numbness and tingling in the buttocks and inner thighs, known as saddle anesthesia.
He also developed urinary difficulties, such as trouble starting urination, weak urine flow, and occasional dribbling. There is no history of trauma, fever, or complete urinary retention.
Spine Examination:
Posture: May show guarded movement or stooped posture
Inspection: No obvious deformity
Palpation:
Tenderness over lower lumbar vertebrae (especially L4-L5, L5-S1 region)
Range of Motion:
Restricted forward flexion due to pain
MRI:
Condition on Discharge:
Patient is conscious, oriented, and hemodynamically stable.
Low back pain has been partially relieved.
Radicular symptoms in the lower limbs are present but improved.
Lower limb weakness is persistent but shows signs of gradual recovery.
Perianal numbness and saddle anesthesia still present.
Urinary complaints (hesitancy, dribbling) persist; patient advised to monitor voiding pattern and perform timed voiding.
Bowel control is satisfactory; no incontinence reported.
Wound site (if surgery performed) is clean and dry with no signs of infection.
Physiotherapy and neuro-rehabilitation have been initiated.
Advised to avoid lifting heavy weights, prolonged sitting, and strenuous activities.
Follow-up scheduled with Neurosurgery and Urology departments.