Frank is a 68-year-old retired auto worker. He is being referred to this office from his primary care doctor. Frank reports a 20-year history of intermittent lower back pain that got much worse and more constant 2 years ago. He says that 2 years ago, for no apparent reason, he started having worsening lower back and buttock pain that was worse on the right than the left. The pain was mostly dull and aching and was worse when he would go for a walk. A year ago, it got to the point where he was having trouble walking his dog more than a block. At that time, he went to his primary care doctor who sent him to physical therapy.

Frank went to physical therapy and he felt that it was helpful for a while. He would do his stretches in the morning and that seemed to loosen him up so he could take his dog for longer walks. However, about 6 months ago the pain got much worse in his lower back and it began radiating into the right leg. Again he was unable to identify a trigger for the pain getting worse. The pain radiated into the posterior and lateral thigh and into the lower leg to the foot. He had numbness and tingling in the right foot whenever he would stand for more than a few minutes. He tried taking 800 mg of ibuprofen three times a day but it did not help the pain and his stomach started to hurt when he took the medication. He went back to his primary care doctor who told him to take Tylenol three times per day instead of the ibuprofen and sent him back to physical therapy.

This time the physical therapy was not able to help Frank at all. Tylenol did nothing for his pain. Frank reported that his pain limited him from participating with the physical therapy exercises and the passive modalities only made Frank feel better “for a few minutes.” Worse, Frank noticed that he was tripping over his feet. He denies any falls but he says that he has almost fallen several times. His primary care doctor then ordered an MRI of the lumbar spine. The MRI revealed a multilevel facet joint arthropathy, a central L4–L5 disc herniation, and an L5–S1 grade I spondylolisthesis and a superimposed right L5–S1 paracentral disc herniation. His primary care doctor then referred Frank to this office.

Frank says that the pain in his lower back is worse than the leg pain. When sitting, the pain is rated as a 2/10 on VAS. When standing for 1 min, the pain in the lower back is 4/10 on VAS. When standing for 10 min or walking a block, the pain is 8/10 and if he continues to stand and/or walk, then the pain will become a 10/10. Bending forward makes the pain better. As the pain gets worse, the numbness in his right foot gets worse. He says that both of his legs feel “a little weak.”

Frank reports that he has had increasing trouble with many activities of daily living such as tying his shoes and buttoning his shirts, and he has noticed that his handwriting has gotten much worse in the last couple of months and he has no idea as to why. He says that no one had asked him that previously and he had just figured that he was “getting old.”

For the pain, his primary care doctor has recently given him tramadol and he does find that a little helpful and he can function at home on the medication but he is uncomfortable driving while taking it because the tramadol does make him feel a little dizzy. He denies any change in bowel or bladder habits.