Importance of Clinical Correlation and the Potential Detrimental Reliance on Radiologist Reporting of MRI Studies in Clinical Chiropractic

A 42-year-old female presented to a chiropractic office with acute low back pain radiating down the left leg to the dorsum of the foot, beginning the day after exercising with a yoga wheel and gradually worsening over approximately one week despite anti-inflammatory medication, ice, massage, acupuncture, and cupping. Examination revealed Minor's sign, 3/5 weakness of the extensor hallucis longus, hypoesthesia of the L5 dermatome, a diminished (1+) left medial hamstring reflex, and positive supine and seated straight leg raise tests, findings consistent with left L5 radiculopathy. A non-contrast magnetic resonance imaging (MRI) study of the lumbar spine was ordered. The radiologist's report described disc desiccation at every lumbar level and, at L5-S1, circumferential disc bulging with facet arthropathy, thecal sac flattening, and moderate bilateral neural foraminal stenosis. Review of the images, directed by the clinical findings, instead showed well-hydrated discs through L4, a normal L4-L5 disc, and a left paracentral protrusion-type disc herniation at L5-S1 affecting the left L5 nerve root. Following correct interpretation, the patient underwent a left L5/S1 epidural steroid injection with only temporary relief and subsequently required an urgent L5/S1 microdiscectomy. This case highlights the value of the medial hamstring reflex in localizing L5 radiculopathy and the importance of correlating the history, physical examination, and imaging findings rather than relying solely on the radiology report when making clinical management decisions.