What is the initial management for a patient with low back pain and radiculopathy, given the findings on the computed tomography (CT) scan of the lumbar spine?

Management of Low Back Pain with Radiculopathy Based on CT Findings

Conservative management should be the first-line approach for this patient with low back pain and radiculopathy, as the CT findings show only minor disc bulges without significant canal or foraminal stenosis. 1, 2

Interpretation of CT Findings

• The CT scan shows minor uniform disc bulges at L4/5 and L5/S1 with preservation of facet joints and no significant canal or foraminal stenosis 1
• There is prominent sclerosis with degenerative changes around the sacroiliac joints bilaterally, which may suggest osteitis condensans ilii or sacroiliitis requiring further investigation 3
• The absence of significant canal or foraminal stenosis suggests that the radicular symptoms may be due to mild nerve irritation rather than significant compression 4

Initial Management Approach

Conservative Therapy (First 6 Weeks)

• Pharmacologic Management:

  • NSAIDs are recommended as first-line medication for pain control 2, 4
  • Muscle relaxants can be considered for associated muscle spasms 2
  • Short-term opioids may be used judiciously only for severe pain that is unresponsive to other treatments 2, 4

• Non-Pharmacologic Approaches:

  • Activity modification without complete restriction - remaining active is more effective than bed rest 2, 5
  • Heat/cold therapy as needed for symptomatic relief 2
  • Patient education about the favorable prognosis of low back pain with radiculopathy 2, 6
  • Supervised exercise therapy tailored to the patient's condition 5
  • Manual therapy may be beneficial in certain clinical situations 4

Follow-up and Further Management

• Reassess after 4-6 weeks of conservative management 7, 3
• If symptoms persist or worsen despite conservative management for 6 weeks, consider:
  • MRI (preferred) or CT for further evaluation of radiculopathy 1, 2, 3
  • Referral for epidural steroid injections may be considered for persistent radicular symptoms 4
  • Surgical consultation for patients with persistent functional disabilities or refractory pain despite multiple nonsurgical treatments 4

Special Considerations

• Regarding SI Joint Findings: The prominent sclerosis and articular bony irregularity at SI joints warrants further investigation if the patient has symptoms suggestive of sacroiliitis 3
• Incidental Renal Calcification: The 4mm non-obstructing calcification in the right kidney should be noted in the patient's record but is likely an incidental finding not related to the back pain 3

Important Caveats and Pitfalls

• Routine imaging early in the course of low back pain provides no clinical benefit and can lead to increased healthcare utilization 1
• Many imaging abnormalities, such as disc bulges, are common in asymptomatic individuals and may not correlate with symptoms 1, 6
• The majority of disc herniations show some degree of reabsorption by 8 weeks after symptom onset 1, 2
• Immediate imaging is only warranted in the presence of "red flags" such as cauda equina syndrome, suspected malignancy, infection, or fracture 2, 3
• Surgical intervention is not recommended for routine disc bulges without significant neural compression or progressive neurological deficits 2, 4