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Hal P. Kramer, MD
After 41 years of clinical medicine, 2025 became my “physician, heal thyself” year. I became a patient with a story.
Without challenge or feedback, many of us continue to repeat the same physical exams for a variety of complaints. We all develop our tools of the trade. However, we must remember that medicine is never all-known. Old ways can lead to new ways with a questioning and inquisitive mind.
How many patients have I treated while in the Navy, emergency departments, urgent cares, and private practice? Certainly more than a few, and I was good at what I did (at least per the fitness reports and patient and peer feedback). Retired, I am teaching innovative courses on healthcare skills at a university to premed and prephysician associate students.
For me, my role as a patient started at age 14 when playing football at a school built on my great-grandparents’ old farm. My teammate’s knee caught the back of my neck during a tackle. I had loss of consciousness for a few minutes, retrograde and antegrade amnesia, and a probable traumatic brain injury with an abnormal electrolencephalogram. Despite prolonged post-concussive symptoms, I did completely recover. Unfortunately, my neck pain from the injury persisted for the next 55 years, even with physical therapy.
In 2024, I began having bilateral arm and anterior leg paresthesias with neck flexion, issues with balance, loss of reflexes, and decreased grip strength. Imaging showed a C5-C6 disc osteophyte complex and arthrosis with severe right neural foraminal narrowing and anterior cord contact. Fortunately, an orthopedic spine surgeon performed successful surgery with almost immediate results. Almost pain-free, my grip strength returned and the paresthesias settled down.
Sleepless Nights
Unfortunately, in early 2025, I started experiencing soreness in my left anterolateral thigh, especially while driving, but I thought it was just from aggressive elliptical use. However, the pain started radiating below my inner knee. As I had no back pain, and as guidelines recommend no imaging for low back pain until after 6 weeks of symptoms (without red flags symptoms), I had waited to see my primary care provider to ask for an MRI, thinking that foraminal stenosis had developed, as with my cervical spine, causing a L4 radiculopathy.
With a prescription in hand and imaging scheduled, I went to work out. While bending to stretch, I experienced sudden back pain on my left side, which produced a primal scream and shut me down. But I still then mowed the yard on a ride-on mower, despite the worsening pain in my leg (“stupid is as stupid does”).
That night was the first of many sleepless nights to follow, in which I was unable to get pain relief or find a comfortable position. The radicular pain was persistent and even worse when simply urinating! Standing with my left hip flexed and, on my toes, helped some. Four days later, my MRI demonstrated a L4-L5 left disc extrusion causing severe stenosis of the L4 nerve root and L5-S1 severe left foraminal narrowing compressing the L5 nerve root.
My physical therapy evaluation showed marked quadricep and foot dorsiflexion weakness and loss of the patellar reflex. At no time did I have a positivestraight leg raise test. I did, however, have an excruciatingly positive femoral nerve stretch test.
My spine surgeon ordered a methylprednisolone dose pack (useful only if radicular symptoms) and pain medications and got me an epidural steroid injection (that was fun!). But all this was to no avail. Therefore, I had surgery, which included a L4 laminotomy, L4 nerve root disc fragment extraction, and a trimming of the L4-L5 disc extrusion.
Relief was immediate: no radicular pain, immediate improvement of weakness (I am doing my home exercise program), and my only back pain was the expected post-op discomfort. While many restrictions remain for now, I can drive and have started teaching again.
Wisdom of the Years
So, here is my list of pearls of wisdom learned over 41 years of trying to get it right, adding new knowledge recently gained as a patient. Borrowing from Alcoholic Anonymous: “Take what you need and leave the rest.”
- Cervical and lumbar disc disease are often related by multiple factors. Find a herniated disc in 1 area, likely you will find it in the other.
- Not all findings on an MRI are symptomatic. History, physical exam, and testing must all support each other.
- The final straw that causes a herniated disc might be minimal as damage may have been accumulating over time.
- Disc herniations that are more distal will impact that level’s exiting nerve, but posterolateral herniations can impact the lower level’s transversing nerve before it exits.
- Multiple events can cause nerve foraminal encroachment (eg, osteophytes, facet arthritis, uncovertebral arthrosis, ligament thickening, cysts).
- The straight leg raise test assesses nerve irritation predominantly at the L5 and S1 nerve roots, and poorly for more proximal levels (good sensitivity but poor specificity for disc herniations). It is considered positive if radicular pain to at least below the knee is elicited in a supine position before 45 degrees of hip flexion with the knee in full extension (sitting position uses the knee extension).
- The femoral nerve stretch test is designed to assess involvement of the L2, L3, or L4 nerve roots. It is considered positive if thigh/groin pain occurs when the knee is flexed to between 80-100 degrees (patient in prone position with stable pelvis).
Patient stories, including my own healing story, are a big part of my classes as I hope to help my students build their own framework for medicine, striving for a successful and rewarding career. As I turn 70, I hope to teach for many more years, sharing stories along the way, to motivate these new minds embarking on their own medical career journeys.
Hal P. Kramer, MD, is a retired Navy-trained family physician with 41 years of clinical practice in a variety of settings. He continues to teach undergraduate and graduate students in clinical skills at the University of Delaware.