Lumbar Spinal Stenosis with 6mm Thecal Sac Narrowing in 40-Year-Old Patient

Case at a Glance

A 40-year-old male presents with bilateral lower back pain and right lower extremity weakness. MRI reveals significant lumbar spinal stenosis at L4-5 with thecal sac narrowing to 6mm, raising questions about the severity of degenerative changes for his age group.

Patient's Story

The patient, a 40-year-old male, presented with a chief complaint of bilateral lower back pain accompanied by weakness in his right lower extremity. He was concerned about the progression of his symptoms and questioned whether the degree of spinal narrowing found on imaging was typical for someone his age. The patient expressed particular worry about a 6mm thecal sac measurement and its implications for his condition.

Initial Assessment

Physical examination revealed bilateral lower back pain with notable right lower extremity weakness. The patient's symptoms were consistent with potential nerve root compression. Given the bilateral nature of the pain and the presence of neurological symptoms, advanced imaging was warranted to evaluate for structural abnormalities of the lumbar spine.

The Diagnostic Journey

MRI of the lumbar spine without contrast was performed, revealing straightening of normal lumbar lordosis and degenerative disc disease at L4-5. The imaging showed a broad-based disc protrusion with mass effect on both traversing L5 nerve roots (right greater than left). The anteroposterior diameter of the thecal sac measured 6mm, indicating significant central canal stenosis. Modic type II changes were noted in the endplates surrounding the L4-5 intervertebral disc. Comparison with previous imaging from 10 years prior showed progression of the degenerative changes.

Final Diagnosis

Lumbar spinal stenosis at L4-5 with central canal narrowing (thecal sac AP diameter 6mm), degenerative disc disease, and bilateral L5 nerve root compression, right greater than left. The condition showed progression compared to prior imaging studies.

Treatment Plan

The treatment approach focused on conservative management initially, including physical therapy, anti-inflammatory medications, and activity modification. Patient education was provided regarding the degenerative nature of the condition and realistic expectations for improvement. The patient was counseled that while imaging findings may not significantly improve, symptoms could potentially be managed effectively with appropriate treatment. Referral to a spine specialist was considered for evaluation of potential interventional options if conservative measures proved inadequate.

Outcome and Follow-up

The patient was reassured that degenerative spine changes, while concerning, are not uncommon in the fourth decade of life. Research indicates that various degrees of degenerative findings can be present even in asymptomatic individuals of similar age. Follow-up appointments were scheduled to monitor symptom progression and treatment response. The patient was advised to return if symptoms worsened or new neurological deficits developed. Long-term management would focus on maintaining function and preventing further deterioration through appropriate lifestyle modifications and ongoing medical care.