What is the diagnosis for a patient presenting with intermittent lower back pain for 4 weeks, with lumbar X-ray showing no acute lumbar spine abnormality, but mild L5-S1 disc space narrowing?

From the Guidelines

For a patient with intermittent lower back pain for 4 weeks with X-ray showing mild L5-S1 disc space narrowing but no acute abnormalities, I recommend a conservative treatment approach. This approach is supported by the American College of Physicians and the American Pain Society's joint clinical practice guideline, which suggests that clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options 1.

The patient's X-ray results indicate no acute lumbar spine abnormality, and the mild L5-S1 disc space narrowing is a common finding that may not be directly related to the patient's symptoms. According to the guideline, early, routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses 1.

Key components of the conservative treatment approach include:

• Over-the-counter pain relievers such as ibuprofen (400-600mg every 6-8 hours with food) or acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) for pain management
• Applying heat therapy for 15-20 minutes several times daily to relax muscles, and considering cold packs for 15-20 minutes when inflammation seems prominent
• Maintaining gentle activity rather than bed rest, gradually incorporating core-strengthening exercises like gentle back extensions, pelvic tilts, and walking 20-30 minutes daily
• Practicing proper posture, avoiding prolonged sitting, using lumbar support when seated, and using proper lifting techniques by bending at the knees

Physical therapy may be beneficial if pain persists beyond 2-4 weeks. It is essential to monitor the patient's symptoms and adjust the treatment plan as needed. If the patient experiences worsening pain, radiating pain to the legs, or neurological symptoms like numbness or weakness, prompt medical reassessment is necessary 1.

From the Research

Patient Presentation

• The patient is complaining of intermittent lower back pain for 4 weeks
• X-ray lumbar results show "no acute lumbar spine abnormality evident" and "mild L5-S1 disc space narrowing"

Relevant Studies

• A study published in 2022 2 found that epidural steroid injections can be an effective treatment for radicular pain and may provide functional improvement
• Another study from 2002 3 showed that epidural steroid injections have a reasonable success rate for alleviating radicular symptoms from lumbar herniated discs, with 77% of patients experiencing significant relief
• A 2016 study 4 found that cervical interlaminar steroid injection is more effective in treating radicular pain than axial neck pain, but the differences in effect according to MRI findings are inconsistent
• A 2023 study 5 established consensus on effective conservative treatment modalities for lumbar radiculopathy across different stages of the disorder, including the use of epidural injections in the sub-acute stage
• A 1999 study 6 is not relevant to the patient's presentation, as it discusses conservative management of acute coronary syndrome

Potential Treatment Options

• Epidural steroid injections, potentially using a transforaminal approach, as suggested by studies 2 and 3
• Conservative management, including pain education, individualized physical activity, and directional preference exercises, as recommended by study 5