Orthopedic and other problems

The woman in my OPD has back pain.

“The pain is getting worse, doctor. Its been there for a long time but now it is unbearable. I can’t walk, can’t even stand for a short time.”

Where is the pain?

“Its starts here,” she gestures vaguely about the right lower back and hip, “and then it spreads down the thighs to the legs.”

What do you do when that happens?

“I sit down for a while.”

The pain goes away when you sit?

“Yes, after a while. And then I can walk.”

I look through her file. It is bulky, filled with the ghosts of a hundred consultations. Seventy years old. Diabetic, more or less controlled.

I ask her to lie down. The boy with her looks amused. I lift her legs straight to test for sciatica. Not much, some loss of flexibility. Motor power, normal in both legs. Pulses weak, a couple are absent, that’s normal in diabetics. Tendon jerks, weak on both sides but that is normal too at her age. She bends down reasonably well, after seventy years.

Have you taken medicines for this?

“I took some. But they don’t help much.”

She shows me a prescription. It is an anti-inflammatory, a “painkiller”.

You have claudication.

Claudication happens when blood vessels to her legs get so clogged up the muscles do not receive sufficient oxygen to work. Her leg muscles must work for her to walk, and for work they need energy, and this requires more oxygen than can arrive through half-clogged arteries. It may be alright when she rests, but when she walks her muscles ask for more. The pain she feels could be the pain of suffocating muscle tissue, of ischemia. An angina of the legs. This is vascular claudication.

Claudication can also be neurogenic in origin. The nerves in her spine which control the leg muscles are deprived of energy. The space inside her spinal canal might be too cramped, stenosed as the jargon is, to accommodate the increased blood flow required for activity.

I look at her X rays, and find that instead of the vertebrae lying one on top of the other, level as with a plump line, the fourth lumbar vertebra has slipped and moved forward from the fifth taking along the rest of the spine above it. She has a slipped vertebra, a spondylolisthesis. This woman has a grade two slip. Her claudication is probably neurogenic.

We need to confirm the diagnosis. Neurogenic or vascular? We need an MRI of the spine and a Doppler scan of the limbs.

“Doctor I just need to be rid of the pain. We are all alone, my boy and I.”

Who is he?

“My grandchild. He is eight.”

And your children?

“My son married and left and has never looked back at us after that. He is in Saudi now and doesn’t visit me when he comes.”

Her voice is unemotional but a tear forms in one eye.

“His father died because of that. And my daughter, this boy’s mother, is now in Dubai now looking for a job.”

Looking for a job?

“Yes. She went there last month and is searching for a job. She has a BA in literature.”

And her husband?

“He is no good. He is not with her now.”

There is silence now. These are her problems, not mine. My problem is her back pain. I don’t want to solve these add-ons.

“These days I can’t do anything. I stand for five minutes in the kitchen and then I must lie down until the pain goes before I can continue.”

Tears rolling down now.

“Give me medicines, doctor.”

Painkillers wont help for this kind of thing. We need the scans now before deciding what must be done.

“How much will the scans cost?”

Around 5000.

“I don’t have the money, doctor. 5000 rupees is a month’s budget for us.”

Her problems. Not mine.

You could go to Medical College. You can do everything for free there.

“No. We don’t know anyone there and its difficult for me, alone.”

We both sit, thinking.

“My daughter will arrive in a few months. We will get the scans then.”

Her daughter who is searching for work in Dubai. She will get a job and come back after a few months with money for scans.

I write her a prescription for painkillers.

I spend 5000 rupees sometimes at a restaurant for dinner with the family, I tell her.

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