What assessment, investigations, and pharmacologic management are indicated for a 44‑year‑old woman with chronic low‑back pain radiating to the left buttock, thigh, and calf, who fell onto her right hip a week ago without bruising or swelling and has no red‑flag symptoms?

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Management of Chronic Low Back Pain with Radicular Symptoms and Recent Hip Trauma

Initial Clinical Assessment

This patient requires plain radiographs of the lumbar spine and pelvis as the first imaging step, followed by consideration of lumbar MRI if radicular symptoms persist, while initiating conservative management with NSAIDs and activity modification. 1

Key Clinical Features to Document

  • Radicular pattern: Pain radiating from the left buttock through the thigh to the calf suggests L5 or S1 nerve root involvement, consistent with lumbar radiculopathy rather than isolated hip pathology 2, 1

  • Red flag assessment: This patient has no red flags (no progressive neurologic deficits, no bowel/bladder dysfunction, no fever, no weight loss, no history of cancer, no significant trauma mechanism for her age) 3, 4

  • Chronicity: Years-long duration classifies this as chronic low back pain (>12 weeks), which changes the management approach compared to acute pain 2, 5

  • Recent trauma evaluation: The fall onto the right hip one week ago without bruising or swelling makes significant hip fracture unlikely, but the patient reports it may have aggravated her baseline back pain 1

Diagnostic Imaging Strategy

Initial Imaging

  • Plain radiographs of the lumbar spine should be obtained first, as this patient has chronic symptoms and is now requesting investigation after years of pain 1, 6

  • Plain radiographs of the pelvis and right hip are appropriate given the recent fall, rated 9/9 for appropriateness by the American College of Radiology for initial hip pain evaluation 2

  • Routine imaging is generally not recommended for nonspecific low back pain without red flags, but this patient's chronic radicular symptoms and specific request for investigation justify plain films as a reasonable starting point 2, 1

Advanced Imaging Considerations

  • Lumbar MRI without contrast should be considered if symptoms persist beyond 4 weeks of conservative management or if plain films show concerning findings, as it is the best modality to evaluate for disc herniation, spinal stenosis, or nerve root compression causing radicular symptoms 2, 1, 6

  • MRI is specifically indicated when radiculopathy is suspected and the patient may be a candidate for epidural steroid injection or surgical evaluation 1, 6

  • Hip MRI is not indicated at this time, as the patient's symptom pattern (buttock-to-calf radiation) is classic for lumbar radiculopathy, not hip pathology 2

Pharmacologic Management

First-Line Medications

  • NSAIDs are the initial medication of choice for chronic low back pain, with moderate evidence supporting their use for small to moderate pain reduction 2, 1

  • Examples include ibuprofen 400-600 mg three times daily or naproxen 500 mg twice daily 1, 4

  • Acetaminophen up to 3000 mg/day can be used as an alternative or adjunct, though evidence for chronic low back pain is weaker than for NSAIDs 2, 1

Second-Line Pharmacologic Options

  • Duloxetine 60 mg once daily should be considered if NSAIDs provide inadequate relief, as it has moderate evidence for chronic low back pain with small to moderate benefits 2, 7

  • Duloxetine is FDA-approved for chronic musculoskeletal pain including chronic low back pain, with demonstrated efficacy in reducing pain scores by clinically meaningful amounts 7

  • The 120 mg dose does not provide additional benefit over 60 mg and causes more adverse effects, so uptitration is not recommended for non-responders 7

Medications to Avoid

  • Systemic corticosteroids should not be used, as they have not shown greater efficacy than placebo for radicular or nonradicular low back pain 2, 1

  • Opioids should be avoided for initial management, as evidence is limited to short-term modest effects and serious harms including overdose risk outweigh benefits 2

  • Benzodiazepines are not recommended, with recent evidence showing no benefit and potentially increased pain in radiculopathy 2

  • Muscle relaxants have limited evidence for chronic low back pain and cause significant sedation 2

Nonpharmacologic Management (First-Line Treatment)

Strongly Recommended Interventions

  • Exercise therapy is a cornerstone of chronic low back pain management with good evidence of moderate efficacy, and should be initiated early 2, 1, 4

  • Structured, supervised programs incorporating stretching and strengthening produce the best outcomes for chronic pain 1

  • Spinal manipulation demonstrates moderate effectiveness for pain relief and functional improvement in chronic low back pain 2, 1

  • Cognitive-behavioral therapy has good evidence of moderate efficacy for chronic low back pain and should be considered, especially if psychosocial factors are present 2, 1

Additional Effective Options

  • Superficial heat application for 20-30 minutes, 3-4 times daily, can provide symptomatic relief 1

  • Massage therapy shows moderate benefits for chronic low back pain 2, 1

  • Acupuncture may provide modest benefits for chronic low back pain 2, 1

  • Yoga has strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness in chronic low back pain 4

Activity Guidance

What to Advise

  • Remain active and avoid bed rest, as bed rest leads to deconditioning and slower recovery 1, 3

  • Continue ordinary activities within pain limits, as maintaining normal activities is associated with better outcomes than activity restriction 1

  • Gradually increase activity intensity as pain permits, with progressive resumption of normal function 1

  • The recent fall does not require activity restriction given the absence of bruising, swelling, or significant trauma mechanism for her age 1, 3

Follow-Up and Escalation Plan

Short-Term Management (4-6 Weeks)

  • Initiate NSAIDs and nonpharmacologic interventions (exercise therapy, heat, consider spinal manipulation) 2, 1

  • Obtain plain radiographs of lumbar spine and pelvis/hip to establish baseline and rule out structural abnormalities 1, 6

  • Reassess in 4 weeks for symptom improvement 1

If Symptoms Persist Beyond 4-6 Weeks

  • Consider lumbar MRI without contrast to evaluate for disc herniation, spinal stenosis, or other structural causes of radiculopathy 2, 1, 6

  • Add duloxetine 60 mg daily if not already initiated and NSAIDs alone are insufficient 2, 7

  • Refer to physical therapy for structured exercise program if not already engaged 2, 1

  • Consider epidural steroid injection if MRI confirms nerve root compression and conservative measures have failed, though evidence shows mixed results 6, 5

Surgical Referral Indications

  • Progressive motor or sensory deficits 3, 4

  • Cauda equina syndrome (new bowel/bladder dysfunction, saddle anesthesia) 3, 4

  • Persistent functional disabilities and pain despite 3-6 months of comprehensive conservative management, with MRI-confirmed structural pathology amenable to surgery 6, 5

Common Pitfalls to Avoid

  • Do not order MRI immediately without first attempting conservative management, unless red flags are present 2, 1

  • Do not prescribe opioids as initial therapy for chronic low back pain, as harms outweigh benefits 2

  • Do not use systemic corticosteroids, as they are ineffective for both radicular and nonradicular low back pain 2, 1

  • Do not focus solely on the recent hip fall when the primary complaint is chronic radicular low back pain—the symptom pattern points to lumbar spine pathology, not hip pathology 2, 1

  • Do not recommend bed rest, as it worsens outcomes compared to staying active 1, 3

References

1
Guideline

Guidelines for Managing Back Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Diagnosis and treatment of acute low back pain.

American family physician, 2012

4
Research

Mechanical Low Back Pain.

American family physician, 2018

6
Research

Chronic low back pain: evaluation and management.

American family physician, 2009

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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