From the Guidelines
The next step in managing this 44-year-old man with symptoms suggestive of lumbar radiculopathy is to obtain an MRI of the lumbar spine to confirm the diagnosis and identify the specific cause. Given the presence of radiating pain, positive straight leg raise test, sensory deficits, and difficulty walking, this presentation strongly suggests nerve root compression, most likely from a herniated disc. According to the American College of Radiology Appropriateness Criteria 1, MRI of the lumbar spine is the initial imaging modality of choice for patients with low back pain and radiculopathy.
While waiting for the MRI, the patient should be started on conservative management including:
- NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for pain relief
- A short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime if muscle spasms are present
- Physical therapy focusing on core strengthening and proper body mechanics The patient should avoid prolonged sitting, heavy lifting, and activities that exacerbate pain. If pain is severe, a short course of oral steroids (prednisone taper starting at 60mg daily for 5 days, then tapering by 10mg every 2 days) may be considered, as suggested by the American College of Physicians and the American Pain Society 1.
It is essential to note that the patient's symptoms and history should guide the decision for further testing or intervention. If symptoms worsen, particularly if the patient develops bowel or bladder dysfunction, foot drop, or progressive weakness, urgent neurosurgical evaluation would be necessary as these are signs of cauda equina syndrome requiring emergency intervention. The diagnosis and treatment of low back pain should be based on the clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs, as recommended by the American College of Physicians and the American Pain Society 1.
From the Research
Next Steps in Managing Low Back Pain
The patient presents with low back pain radiating down the left leg to the foot, associated with difficulty walking, sensory loss on the lateral aspect of the left leg and foot, and a positive straight leg raise test. Considering these symptoms, the next step in management should focus on confirming the diagnosis and identifying the underlying cause of the pain.
Diagnostic Considerations
- The patient's symptoms suggest lumbar disc herniation, which can cause nerve root compression and lead to radiating pain, sensory loss, and motor weakness 2.
- A positive straight leg raise test is indicative of lumbar disc herniation, particularly at the L4-L5 or L5-S1 levels 3.
- Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging modality for diagnosing lumbar disc herniation and nerve root compression 4, 5.
Recommended Course of Action
- Given the patient's symptoms and physical examination findings, an MRI of the lumbar spine is the most appropriate next step in management 4, 2, 6.
- MRI will help confirm the diagnosis of lumbar disc herniation and identify the level and extent of nerve root compression.
- Nerve conduction studies (NCS) may be considered as an adjunct to MRI, particularly if there are discrepancies between clinical findings and MRI results 2.
- X-ray of the lumbar spine may not provide sufficient information to confirm the diagnosis of lumbar disc herniation and is not recommended as the initial imaging modality 6.
- No further testing may not be appropriate at this stage, as the patient's symptoms and physical examination findings suggest a specific diagnosis that requires confirmation with imaging studies.