Upper lumbar disc herniation presenting as chronic right lower abdominal pain in a patient with multilevel lumbar degeneration: a case report.

Upper lumbar disc herniation (ULDH) is relatively uncommon and may present with atypical symptoms, including lower abdominal pain, which can complicate clinical diagnosis. The diagnostic challenge is even greater when multilevel lumbar degeneration is present and the symptomatic level is unclear. We report the case of a 65-year-old woman with right lower abdominal pain for more than 5 years. The pain worsened during the 3 months before admission and was accompanied by low back pain and radiating pain in the left lower limb. Repeated abdominal evaluations, including abdominal ultrasonography and gynecological and urological assessments, did not reveal any abnormality sufficient to explain her symptoms. Lumbar magnetic resonance imaging showed multilevel degenerative changes, including L2-3 disc herniation and L4-5 spinal canal stenosis with degenerative spondylolisthesis. Because the imaging findings did not fully correspond to the clinical presentation, fluoroscopy-guided right L2-3 selective nerve root block (SNRB) was performed to help identify the responsible level. After the block, the visual analogue scale (VAS) score for right lower abdominal pain decreased from 7 to 3, although the pain returned to the pre-block level 2 days later. The patient subsequently underwent right L2-3 transforaminal endoscopic lumbar discectomy (TELD), after which the VAS score for right lower abdominal pain decreased further to 2. Persistent low back pain and left lower-limb radiating pain were then treated with L4-5 posterior lumbar interbody fusion (PLIF), and the VAS score for left leg pain decreased to 2. This case suggests that radicular referred pain caused by ULDH should be considered in patients with long-standing lower abdominal pain and repeatedly negative abdominal evaluations, particularly when spinal symptoms coexist. In patients with multilevel degeneration and discordant clinical and imaging findings, SNRB may help localize the symptomatic level and support a staged, symptom-oriented surgical strategy.