From the Guidelines
The most appropriate next step in management is to advise the patient to continue with normal activity as tolerated.
Key Considerations
- The patient's symptoms are consistent with acute sciatica, likely due to a lumbar disc herniation, but he does not have any "red flag" symptoms such as fever, recent trauma, or significant neurological deficits 1, 2, 3.
- The patient should be encouraged to stay active, avoiding heavy lifting and bending, and to use over-the-counter pain medications such as acetaminophen or ibuprofen as needed for pain management 4, 5.
- If the patient's symptoms worsen or do not improve within 4-6 weeks, further evaluation with an MRI of the lumbar spine may be considered 6, 7.
Additional Recommendations
- Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1, 2.
- General advice on self-management for nonspecific low back pain should include recommendations to remain active, which is more effective than resting in bed for patients with acute or subacute low back pain 3, 4.
- Spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for patients who do not improve with self-care options 8, 9.
- Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, because they have not been shown to be more effective than placebo 9, 10.
From the Research
Management of Acute Low Back Pain
The patient's symptoms of acute low back pain radiating to the right lower extremity, worsened by sitting, and a positive straight-leg raise test, suggest a possible lumbar disc herniation or other musculoskeletal injury.
- The first-line treatment options for acute mild to moderate pain include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) 11.
- Topical NSAIDs are not recommended for low back pain, but oral NSAIDs can be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 11.
- Adjunctive medications, such as muscle relaxants, may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 11.
- The patient's symptoms do not suggest a need for immediate neurosurgical intervention or intensive care unit management, as seen in comatose patients 12.
- A "next steps" approach to supporting patient self-management may be effective in encouraging small steps towards a larger goal of recovery 13.
- Care transitions and coordination of care among providers and settings are crucial to ensure high-quality transitions and improve patient outcomes 14.
- Palliative care symptom management approaches may not be directly applicable to this patient's condition, as the focus is on aggressively managing symptoms of critical life-limiting illness or terminal disease 15.