Differential Diagnosis for Lower Back Pain with Sciatica

The patient's symptoms and history suggest a range of possible diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Lumbar Disc Herniation (L4-L5 or L5-S1): The patient's history of trauma, symptoms of sciatica, numbness, tingling, and a positive straight leg raise test are highly suggestive of a lumbar disc herniation. The loss of disc height at L4-L5 on the lumbar spine X-ray further supports this diagnosis, as it indicates possible disc degeneration or herniation.

• Other Likely Diagnoses

  • Lumbar Spondylosis: Given the patient's symptoms and the presence of mild lower lumbar facet arthropathy, lumbar spondylosis is a plausible diagnosis. This condition involves degenerative changes in the spine that can cause pain and neurological symptoms.
  • Degenerative Disc Disease: The loss of disc height at L4-L5 and the presence of facet arthropathy suggest degenerative disc disease, which can cause chronic back pain and sciatica.
  • Lumbar Facet Syndrome: The worsening of facet arthropathy at L5-S1 could indicate lumbar facet syndrome, where the facet joints in the spine become inflamed and cause pain.

• Do Not Miss Diagnoses

  • Cauda Equina Syndrome: Although less likely, cauda equina syndrome is a medical emergency that must be considered, especially with symptoms like sciatica, numbness, and tingling. It involves compression of the nerves in the cauda equina and can result in severe neurological deficits if not promptly treated.
  • Spinal Infection (e.g., Discitis or Osteomyelitis): Infections of the spine can present with back pain and neurological symptoms. While less common, these conditions are critical to diagnose early to prevent serious complications.
  • Spinal Tumor: Tumors in the spine can cause back pain, sciatica, and neurological symptoms. Although rare, this diagnosis is crucial not to miss due to its significant implications for treatment and prognosis.

• Rare Diagnoses

  • Spondylolisthesis: This condition involves the slipping of one vertebra over another and can cause back pain and sciatica. While it could be a consideration, especially with trauma, it's less likely without specific findings on imaging.
  • Arachnoiditis: Inflammation of the arachnoid membrane surrounding the spinal nerves can cause pain, numbness, and tingling. This condition is rare and usually associated with previous spinal surgery, infection, or trauma.