A 35-year-old man comes to the office with a 5-day history of back pain, which began as he was carrying heavy boxes while moving to a new apartment. Since then, he has had sharp pain in the low back radiating to the posterior aspect of the left calf and foot. The patient has no associated bladder or bowel incontinence. Vital signs are normal. BMI is 38 kg/m². Examination shows intact motor strength, deep tendon reflexes, and light touch and pinprick sensation in the lower extremities. Anal reflex and perineal sensation are normal. Lifting the left leg to 70 degrees with the knee held straight causes burning pain radiating from the low back to the left foot. Which of the following is the best next step in management?

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11ec25c8_d54b_e381_bc81_7dae110e45d9_MD0003_00 This patient has acute lumbosacral radiculopathy (LSR), also termed sciatica. LSR is most commonly caused by nerve root compression due to a herniated disc. Older patients or those with prior traumatic injury can also have nerve root compression due to lumbar spondylosis. Less common causes include infections (eg, epidural abscess), mass lesions, vascular disorders, and developmental anomalies. Patients typically experience shooting or burning pain in the low back radiating to the calf and foot; minor weakness can occur. Traction on the nerve root during the straight-leg raising test (ie, lifting the leg with the patient supine and the knee held in extension) causes worsening or reproduction of pain. nerve root compression The diagnosis is made clinically; because nearly all cases are due to benign etiologies and symptoms are typically self-limiting, neuroimaging is usually not required. MRI is recommended only for patients with severe, progressive, or bilateral neurologic deficits (eg, saddle anesthesia, urinary retention, severe weakness) or in those with high concern for malignancy or epidural abscess (eg, fever, intravenous drug use). In uncomplicated LSR, like that in this patient, initial management focuses primarily on alleviating symptoms. Nonsteroidal anti-inflammatory drugs and acetaminophen are the preferred first-line drugs. Activity modification is often advisable, but patients should maintain moderate physical activity. (Choices A and F) MRI can confirm disc herniation or other causes of LSR but is expensive and unlikely to change management in a patient with uncomplicated LSR (no neurologic deficits or history of malignancy). X-ray is considered for nonradicular back pain due to compression fracture or suspected vertebral metastasis but has limited use in LSR. (Choice B) Electrodiagnostics (eg, nerve conduction studies) are indicated for patients with persistent neurologic deficits, especially those who are being considered for surgery or have had previous spinal surgery. (Choice C) Physical therapy referral for a supervised exercise program can be considered for patients with persistent pain lasting more than a few weeks. However, the effectiveness is variable, and most patients with acute symptoms experience spontaneous improvement. (Choice D) Surgical intervention is indicated for patients with rapidly progressive neurologic deficits or severe, persistent symptoms who have not responded to conservative measures. Educational objective: Lumbosacral radiculopathy (sciatica) is due to nerve root compression, usually by a herniated disc or lumbar spondylosis. Most patients experience spontaneous resolution. Initial management is focused primarily on short-term relief of symptoms with nonsteroidal anti-inflammatory drugs or acetaminophen. References: Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. (http://www.ncbi.nlm.nih.gov/pubmed/24412033)

A 35-Year-Old Man Comes to the Office with a 5-Day