From the Guidelines
I strongly recommend referring this 17-year-old patient for a lumbar spine MRI to investigate chronic low back pain with radiating pain to the legs and feet, given the limited relief from conservative management with NSAIDs and acetaminophen/ibuprofen, and the presence of normal Doppler and EMG tests. The patient's symptoms, including chronic lower back pain and radiating pain to the legs and feet, warrant further investigation to rule out underlying structural pathologies such as disc herniation, spinal stenosis, or other conditions that may be causing the pain.
According to the American College of Radiology Appropriateness Criteria, MRI of the lumbar spine is the initial imaging modality of choice for patients with subacute or chronic low back pain who have failed 6 weeks of conservative therapy and are believed to be candidates for surgery or intervention 1. The goal of imaging is to identify potential actionable pain generators that could be targeted for intervention or surgery.
The patient's history of chronic lower back pain and radiating pain to the legs and feet, despite normal Doppler and EMG tests, suggests the need for further evaluation to determine the underlying cause of the pain. A lumbar spine MRI is the most appropriate next step in the diagnostic workup, as it can provide detailed images of the spinal cord, nerve roots, and surrounding tissues, and help identify any structural abnormalities that may be contributing to the patient's symptoms.
In addition to imaging, the patient may also benefit from nonpharmacologic therapies such as exercise therapy, acupuncture, or cognitive-behavioral therapy, which have been shown to be effective in managing chronic low back pain 1. However, the priority should be to rule out any underlying structural pathologies that may be causing the pain, and a lumbar spine MRI is the most appropriate test to do so.
It is also important to note that the patient's age and symptoms suggest the need for a thorough evaluation to rule out any underlying conditions that may be causing the pain, and a lumbar spine MRI is a crucial step in this evaluation. The referral should specify the clinical history and symptoms, and highlight the need for urgent imaging to rule out any underlying structural pathologies.
- Key points to consider:
- The patient has chronic lower back pain and radiating pain to the legs and feet, despite normal Doppler and EMG tests.
- The patient has failed conservative management with NSAIDs and acetaminophen/ibuprofen.
- A lumbar spine MRI is the most appropriate next step in the diagnostic workup.
- Nonpharmacologic therapies such as exercise therapy, acupuncture, or cognitive-behavioral therapy may also be beneficial in managing chronic low back pain.
- The priority should be to rule out any underlying structural pathologies that may be causing the pain.