I recommend reading part 1 here and part 2 here prior to reading further on a challenging differential diagnosis case.

Below is a copy of this patient’s lumbar spine MRI.

Differential Diagnosis Low Back and Leg Case
Differential Diagnosis Low Back and Leg Case

Based on subjective and objective findings from part 1 and part 2, as well as a Normal MRI of lumbar spine as noted above, what is your impression of this patient?



  1. I gotta believe this is a case of sensitization given all that has transpired and the outcome of imaging.. Have you tried a pain science approach in conjunction with what you’ve already done with her?

  2. What do you think is causing the UMN signs? Are we just talking CNS hyperexcitability? Seems like the abodominal/pelvic region still needs imaging. Not sure if a brain MRI would be indicated, but MS still not 100% ruled out from the spine MRI. Curious to hear how this case turns out. Thanks again for sharing.

  3. This is one heck of an interesting case. Between the exhaustive exam you did and the comments that have already been given on this case, I don’t think I can add anything further. Based on the clear MRI, I would be worried about an UMNL or MS. Either way, I would be hesitant to do manual therapy on her. Have you done so Harrison? Have you made any changes either subjectively or otherwise yet?

    This is a tough one

    1. Thanks for commenting Jesse. Good question asking about manual therapy. Safe answer would say I haven’t touched her but I have performed 2 interventions:
      1. I did not think the LBP was the cause of her leg symptoms based on neurological exam. Therefore, mobilizations in this region were implemented but no change in symptoms.

      2. Thoracic manipulation in supine (T4-10) gives her short term relief (a few hours) of her LBP.

      I wouldn’t go any further north.


  4. ok, so I am going to ask your advice on reflexes. I had a pt today with weird reflexes again! 30 yo male truck driver involving pulling/lifting these large hoses onto truck/etc, (No Imaging and referred by Urgent Care one hr away). Workers comp pt with a shld injury. He gave a very detailed description of what his symptoms were, etc of his R shld which was very helpful but when I tried to palpate anterior shld in supine he would say it was a weird sensation (I kept asking if it was pain, bc he would wince but he just said NO, weird feeling). Hard to palpate structures as he is a previous weight lifter gone overweight. He would sort of shrug if I lightly put my hand on his anterior shld so very difficult to assess mobility. Agg factors are reaching shld height and above, lifting, etc but he felt if he pressed on ant shld then he could raise his arm above shld level and if he waited a while he could go further. Numbness in R arm only happened if he kept his arm in abducted position, random and intermittent.
    -So I took his reflexes and he was hyper-reflexive everywhere; negative Hoffmans, difficult to assess ankle clonus but think neg; BR reflex produced supination B and at one time his Cx spine flexed and he flexed forward towards my elicitation (he just said he has always been like this and he just feels he has to go towards the reflex), Biceps shld flexion, patellar tendon reproduced some delayed and hyper-reflexive responses and I believe some opposite sided knee ext. –
    –ANYWAY, just wanted to get your thoughts on this as he does not have a PCP. I was just going to treat shoulder for the workers comp issue, but wanted to know if I should refer him for follow-up for these reflexes?


    1. Hillary,
      Tough case. I would definitely be concerned here, especially if he hasn’t seen medical care.
      Without jumping to conclusions, I would check cranial nerves, balance and vascular profiling (HR, BP). This should aid in your diff dx.

      If DTRs are brisk but equal Bil, may not be pathological.

      Keep me updated!

  5. Hello Harrrison
    We met when hanging with Jake McCrowell after the TPTA meeting you taught months ago at ODU…brief comment is that I have had experience with antidepressants causing hyperreflexia, even minor provocation of primitive reflexes (flexion withdrawal/ flexor synergy). Mirtazapine/remeron may cause more than one of the sxs, but probably not the weird gait, I don’t think. Since so many are on antidepressants these days, maybe this relevant, maybe not:)

    1. Trey,
      Good to hear from you! Great insight and points here. I’ll check back with this patient when she returns as she doesn’t have antidepressants on her medication list…but definitely has some of the clinical signs of it IMO.

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