A 60-year-old woman comes to the emergency department for acute onset of low back pain radiating down her left leg after lifting heavy boxes at home. She denies any muscle weakness and has no problems with bowel or bladder function. She states that her back pain worsens with coughing or bearing down. Her past medical history is significant for type 2 diabetes mellitus and hypertension. She recently received a flu shot which made her experience mild flu-like symptoms. She has smoked two packs of cigarettes daily for many years, but denies alcohol use.
Her temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 90/min and regular. Neurological examination reveals 5/5 muscle strength in all four extremities with 2+ reflexes. Straight leg raise sign is positive on the left. Sensory examination reveals reduced pinprick and temperature sensation along the posterolateral region of the left leg.
Basic metabolic panel is normal. Plain radiograph of the lumbar spine shows only degenerative changes.
Which of the following is the most appropriate next step in management?

Question

A 60-year-old woman comes to the emergency department for acute onset of low back pain radiating down her left leg after lifting heavy boxes at home.  She denies any muscle weakness and has no problems with bowel or bladder function.  She states that her back pain worsens with coughing or bearing down.  Her past medical history is significant for type 2 diabetes mellitus and hypertension.  She recently received a flu shot which made her experience mild flu-like symptoms.  She has smoked two packs of cigarettes daily for many years, but denies alcohol use.
Her temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 90/min and regular.  Neurological examination reveals 5/5 muscle strength in all four extremities with 2+ reflexes.  Straight leg raise sign is positive on the left.  Sensory examination reveals reduced pinprick and temperature sensation along the posterolateral region of the left leg.
Basic metabolic panel is normal.  Plain radiograph of the lumbar spine shows only degenerative changes.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9658_9d2f_853d_9b68431a1ba6_MD0002_00 This patient's symptoms - back pain radiating down the leg which is worsened with coughing or bearing down - are consistent with an acute lumbosacral radiculopathy (ALSR). ALSR is most often due to a mechanical compression of the L5 and/or S1 dorsal root, usually by a herniated disk. ALSR typically presents with low back and leg pain (sciatica), often with associated numbness and/or weakness in the leg. Reproduction of radicular pain with flexion at the hip and dorsiflexion at the ankle (positive straight leg raise) is relatively specific for the diagnosis. Most patients with ALSR will have spontaneous improvement, and can be managed with conservative measures for comfort. Studies of various medications in ALSR have largely been mixed, though non-steroidal anti-inflammatory drugs (NSAIDs) are often effective and are well tolerated. Anti-spasmodics/muscle relaxants may also be considered, but they are associated with significant sedation and inconsistent benefits. Opioids appear to be less effective and are associated with sedation and a significant risk of dependence. Pain-modifying drugs such as gabapentin are primarily used for chronic symptoms and also cause significant sedation (Choice B). Patients with ALSR should usually be advised to maintain light-normal activity. A brief period of bed rest (<3 days) is also acceptable, but extended bed rest has been shown to provide no benefit and may prolong recovery. If the patient's symptoms fail to improve, or there are new neurological deficits at follow-up, magnetic resonance imaging of the lumbo-sacral spine and surgical referral may be indicated. (Choice A) Bone density testing should be considered if there is evidence of compression fracture or sacral insufficiency fracture. This patient's x-rays show no evidence of fracture. (Choice D) Early magnetic resonance imaging (MRI) should be considered for patients with low back pain or ALSR who have clinical features to suggest a malignant or infectious etiology (eg, fever, history of malignancy, intravenous drug abuse) or significant neurologic deficit (eg, saddle anesthesia, urinary retention, gross motor weakness). But MRI has been shown to not improve care in patients with uncomplicated back pain or ALSR. (Choice E) Physical therapy and spinal manipulation have shown inconsistent results in treatment of ALSR. They may be considered for patients who do not improve with initial therapy but do not wish to pursue invasive interventions. Educational objective: Acute lumbo-sacral radiculopathy is characterized by low back pain associated with radiating pain and/or numbness along a dermatomal distribution (most commonly L5 and S1). Activity modification and nonsteroidal anti-inflammatory drugs for pain are effective in up to 90% of patients. Magnetic resonance imaging is reserved for patients with acute neurological deficits (i.e., weakness, problems walking, or bowel/bladder difficulties), suspicion for infection or malignancy, or failure to improve with initial management. __________ References: Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. (http://www.ncbi.nlm.nih.gov/pubmed/16244269) Lumbosacral radiculopathy. (http://www.ncbi.nlm.nih.gov/pubmed/17445735) Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22331277)

A 60-Year-Old Woman Comes to the Emergency Department for Acute