Introduction

Lumbar disc herniation is a very common disease [1]. In daily routine, it is one of the leading reasons for admission to health institutions and emergency services at all levels [2]. Chronic pain causes a certain reduction in the quality of life of the person causing it. Non-steroidal anti-inflammatory drugs, opioid analgesics, SSRIs, neuroleptics and integrative methods such as acupuncture, chiropractic, dry needling, cupping therapy, hirudotherapy have been widely used in recent years [3,4]. Until the surgical decision is made, there are various methods such as physical therapy and rehabilitation methods, home exercises, lifestyle changes, epidural steroid applications, hydrotherapy and pressurized water current applications. The aim of this case report is to recognize and manage the dermatological change in the body of a patient with pain and to raise awareness of this condition caused by a factor that we have never encountered in the literature.

Case report

A 42-year-old male patient with a two-year history of low back pain presented to the family medicine clinic. He said that his complaints had increased for the last 2 months and that he felt pain in his leg and that redness occurred in his leg in the same period. When the anamnesis was deepened, the patient stated that he put a heated brick on his leg when his left leg pain increased during this period and that he benefited. Physical examination revealed a lace-like appearance on the posterior aspect of the left thigh (Figure 1). On neurologic examination, the straight leg raising test was positive in the left leg and negative in the right leg. Sensory and motor examination revealed no pathology. She said that she had pain only with walking. It was learned that she was using Flurbiprofen 200 mg, Pantoprazole 40 mg, Betamethasone injectable suspension 1 ml, nimesulide + lidocaine topical liquid gel, fenyrhamidol 400 mg. The patient, who was previously recommended elective operation as a result of neurosurgical examination, stated that he did not want to have surgery and wanted to get an opinion about whether it would be possible to be treated with physical therapy. The patient was consulted to the dermatology department due to discoloration of the skin and the patient was diagnosed with “erythema ab igne” due to sudden temperature change in the skin and trichticum vulgare + ethylene monophenylether cream was prescribed and recommended to be applied on the skin.

When the axial sections for the discs were evaluated in the recent lumbar magnetic resonance imaging of the patient; diffuse mild bulging was observed at the L4-L5 level and slightly narrowed both lateral recesses. There was a posterior central-left paracentral broad-based protrusion at the L5-S1 level and the protruding disc was reported to have mild compression of the S1 nerve root on the left.

The patient was prescribed vitamin B1 (250 mg) - vitamin B2 (250 mg) - vitamin B6 (250 mg) and vitamin B12 (250 mg) complex (oral), magnesium 365 mg (oral), diclofenac (75 mg) - thiocolchicoside (8 mg) (oral) 500 mg (oral) and heparinoid (on the skin). Bed rest was recommended.

On further examination, it was observed that the patient started physical therapy exercises and her skin lesions improved. The patient stated that she also benefited from other treatments given for her pain and continues to attend physical therapy sessions.

Discussion

There is a cliché in the medical literature that anamnesis is everything; in this case, the truth of this cliché is once again clearly seen. For skin discoloration, prediagnoses such as morphea, cutis marmaratus, bleeding disorders come to mind and are evaluated in a wide range [5]. If tests for these prediagnoses had been ordered without first obtaining a good anamnesis, an unnecessary burden of unnecessary diagnostic orders would have occurred. Family physicians encounter dermatologic diseases in daily practice and should have sufficient knowledge about these diseases. Dermatology rotation is a mandatory rotation for family medicine specialty qualification in Turkey. The fact that the patient applied to the family medicine clinic after being admitted to the neurosurgery clinic shows his/her trust in family medicine. The family physician advocated for the patient in this case and coordinated the triangle of surgery, physical therapy and dermatology like an orchestra conductor. In this particular patient, the principles of person-centered care and primary care management, which are among the core competencies determined by the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians were applied in a way to come to the forefront [6].

Patients who are recommended surgery may hesitate from the operation and postpone the procedure or even refuse the procedure. Applying to several different physicians to get a different opinion is one of the common behaviors seen in patients. Recommendations of people, reading comments on the internet, social media and some websites can affect preferences.

Family medicine and surgery can make a joint decision to ensure better quality management of such patients and to make the best decision for patients and physicians. The importance of a multidisciplinary approach is also evident here [7].

The factors causing erythema ab needle when looking at the literature are electric blanket [8], laptop use [9] pellet stove [10] etc. in the literature. With this case, the use of bricks was identified for the first time in the literature. The struggle of patients to cope with pain provides new gains to the literature.

Conclusions

Lumbar disc herniation is a common disease in the society and it is known that patients try many different methods in the process leading to surgery. As primary care physicians, we should have a high level of knowledge and awareness about the conditions that arise as a result of these practices so that we can evaluate our patients with a holistic perspective by protecting them from unnecessary tests and time loss. It is a known fact that skin lesions can sometimes be a harbinger of many different diseases and require deep examination and costly analysis. With a holistic approach to the patient, good anamnesis and effective consultation, both clinician and patient satisfaction can be achieved.

References

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