What is the most appropriate next step in managing a 38-year-old man with left hip and low back pain, exacerbated by walking and standing, and with tenderness to palpation of the left iliolumbar ligament and sacroiliac joint?

MRI of the Lumbar Spine is the Most Appropriate Next Step for Left Hip and Low Back Pain

MRI of the lumbar spine is the most appropriate next step in addition to osteopathic manipulative treatment for this 38-year-old man with left hip and low back pain. 1

Clinical Presentation Analysis

This patient presents with several key findings that guide our imaging decision:

• Left hip and low back pain exacerbated by walking and standing
• History of similar pain with increased walking/standing
• Tenderness to palpation of the left iliolumbar ligament and sacroiliac joint
• L1-L5 neutral, sidebent right, rotated left
• Normal and symmetrical reflexes and strength in lower extremities
• Past medical history of left ankle fracture 12 years ago

Imaging Selection Rationale

Why MRI of the Lumbar Spine:

1. Sacroiliac Joint Involvement: The patient has tenderness at the sacroiliac joint, suggesting possible inflammatory or mechanical pathology. MRI is the preferred imaging modality for evaluating suspected sacroiliitis or spondyloarthropathy when radiographs are negative or equivocal 1.

2. Lumbar Spine Findings: The patient's L1-L5 being sidebent right and rotated left suggests somatic dysfunction that may be contributing to his symptoms. MRI can evaluate for potential disc pathology, facet arthropathy, or nerve impingement that could explain his symptoms 1.

3. Appropriate Sequencing: According to the ACR Appropriateness Criteria, after initial radiographs (which we can assume have been done or would be done first), MRI of the spine without IV contrast is rated as highly appropriate (rating of 7-8/9) for patients with suspected inflammatory back pain 1.

4. Comprehensive Evaluation: Given the patient's symptoms involve both the hip and low back, MRI can evaluate both the lumbar spine and visualize portions of the sacroiliac joints, providing a more comprehensive assessment 1.

Why Other Options Are Less Appropriate:

• CT scan of the pelvis: Less appropriate as initial advanced imaging unless there is suspected fracture in a patient with spine ankylosis 1. CT is more radiation-intensive and less sensitive for soft tissue pathology.

• Electromyography: Not indicated as first-line testing when there are no neurological deficits. The patient has normal reflexes and strength in the lower extremities.

• Postural radiography of the hips: Limited in evaluating soft tissue pathology and would not adequately assess the sacroiliac joint and lumbar spine involvement.

• Ultrasonography: While useful for specific soft tissue abnormalities around the hip, it has limited utility in evaluating deeper structures and the lumbar spine 1.

Management Algorithm

1. Initial Assessment: Osteopathic manipulative treatment is appropriate for the somatic dysfunction noted in the lumbar spine.

2. Next Step: MRI of the lumbar spine without IV contrast to evaluate for:

   • Disc pathology
   • Facet joint disease
   • Nerve impingement
   • Sacroiliac joint inflammation
   • Soft tissue abnormalities

3. Follow-up Based on MRI Findings:

   • If inflammatory sacroiliitis: Consider rheumatological evaluation
   • If disc pathology: Consider targeted physical therapy and pain management
   • If normal findings: Focus on functional rehabilitation and osteopathic treatment

Important Considerations

• The patient's history of left ankle fracture may have led to compensatory gait mechanics affecting the hip and low back.

• The exacerbation with walking/standing suggests a mechanical component that could be related to either the hip or lumbar spine.

• The combination of osteopathic manipulative treatment with appropriate imaging provides both immediate intervention and diagnostic clarity.

• Non-pharmacological approaches including exercise therapy should be emphasized in the treatment plan following diagnostic clarification 2.

MRI provides the most comprehensive evaluation of both osseous and soft tissue structures that could be contributing to this patient's pain pattern, making it the most appropriate next step in management.