Clinical Course
This 39 year old male injured his back at work when he bent over and lifted a large pallet weighing 60 pounds and felt immediate pain in the right leg. He tried to continue to work but after a month was unable to continue. When he was referred for surgical consultation, he had severe right leg pain in a sciatic nerve distribution, weakness in his leg when walking and rated his pain as 9 on a scale of 10. 90% of the pain was localized in his leg and 10% in his back. On physical exam, raising his right leg caused severe pain in his right leg. His treatment consisted of physical therapy, narcotics, muscle relaxants and epidural steroid injections without relief of his symptoms.

Diagnostic Tests
His MRI scan was consistent with a left L5-S1 disc herniation. Due to the dominant right leg pain and clear history and physical exam, further diangostic testing with a lumbar myelogram and contrast C.A.T. scan was performed revealing the disc herniation to be central and more right sided than left sided.

Decision
Two points are clear with this presentation: the MRI is not always an accurate reflection of the clinical circumstance and a patient does not necessarily have to have surgery on the side of the spine not causing symptoms even if there is a suggestion of abnormality in the area.

Surgical Treatment
A lumbar microsurgical discectomy was used to decompress the S1 nerve and the extruded fragment was removed. The patient did well after surgery with complete resolution of the leg pain.

Surgeon's Comment
The patient had surgery about 4 months after the onset of his leg pain which is still in an optimum range for good results from surgery. He never experienced leg pain on the left side and his initial MRI suggested that the disc herniation was more left sided. This clearly didn't fit the clinical picture of this patient warranting further diagnostic testing. Microsurgery was a good fit for this patient with decompression of the nerve easily accompished.