Lower back pain… June 24, 2013

Posted by Andy Jagoda, MD in: Musculoskeletal Emergencies, Neurologic , trackback

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

How would you manage this patient?

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Comments »

1. Muhammad Shahzad - July 1, 2013

Lumbar disc herniation classically presents with sudden exacerbation of chronic backache in a construction worker. Analgesics and bed rest for 1-2 weeks is the first step in management. Neurological examination clearly rules out cauda equina syndrome which requires immediate surgical decompression after MRI scan.

2. Doctor Lock - July 1, 2013

A left sciatic nerve issue indicates similarly to this problem. X-rays of the lower back at the lumbar and sacral vertebra could indicate a compressed disc issue. Muscle relaxers would be advised over the next 10 days and no lifting or bending during that time to allow for the injury to correct itself. A test of traction to the lower back could elieviate the sensation and a DO or Chiropractor could be referred.

3. Krishna - July 1, 2013

Herniated disc

4. Joseph Capri - July 1, 2013

Is the antalgic gait towards the side of pain, or away? Since the SLR indicates a discogenic etiology, knowing if the protrusion (working dx) is lateral or medial. Honestly, research suggests that Chiropractic management would likely be the most effective treatment for this condition.

5. Eak - July 3, 2013

This patient who worked in construction industry presented with acute left sciatica pain and antalgic gait. With positive straight leg raising test that indicates left sciatic nerve root irritation, all of these suggest that the most probable diagnosis is “vertebral disc herniation”. It most commonly occurs at L4-L5 or L5-S1. Since there is no any risk factors in history and physical examination for serious disease other than sciatica pain, no need to perform any diagnostic test in ED. The general treatment of disc herniation in ED is similar to nonspecific back pain. Analgesic drugs (NSAID, paracetamol, opiates) and muscle relaxants are generally recommended. Routine daily activity is as good as bed rest. Local heat or cold compression may temporarily relief pain. Because of the normal neuro exams, the diagnosis should be confirmed by nonurgent MRI of L-S spines.

6. Harold Mayeri - July 4, 2013

Even though the patient presents with classic sciatic nerve symptoms there are other variables at work. SLR’s can sometimes be erroneous. The mention of a new job as well as a divorce could be stressors resulting in muscle involvement. In the absence of physical trauma as stated by the patient at arrival psychological stress should be considered a contributing factor in light of previous back injury. Muscle relaxers as well as a psych consult are indicated with a follow-up after 7 days

7. Eak - July 5, 2013

The most probable diagnosis is “vertebral disc herniation”. The general treatment in ED is similar to nonspecific back pain. Analgesic drugs (NSAID, paracetamol, opiates) and muscle relaxants are recommended. Routine daily activity is as good as bed rest. Local heat or cold compression may temporarily relieve pain. Because of no other risks except positive straight leg raising test, the diagnosis should be confirmed by nonurgent MRI of L-S spines.

8. rita cohen - July 6, 2013

The crossed straight leg raising test and a positive left straight-leg raise sign : a diagnostic sign of herniated disc.
as far as I know – MRI scans are similar to CT scans; in as far as these images provide serial slices through the spine, or other areas of interest. They use magnetism, instead of x-rays, to get the images. Besides showing information in additional planes, the MRI gives much better detail of the soft tissue anatomy of the spine, than does CT scans. Discs, nerve roots, and tumors are all seen more clearly. On the other hand, bone is seen better on CT scans.
It is usually fot the orthopedic spine specialist to decide .
Thank you .

9. G.Pfliegler - July 8, 2013

Protrusion disci in the region of LIII-IV

10. Fernando Cardona steadysword - July 8, 2013

the patient had a lower back pain without red flags, I ll start metocarbamol and another AINES, like naproxeno, for a week… I would explain to the patient that he need more a phisioterapy than a MRI, because the 80% lower back pain get well with my treatment; and I would explain to the patient that a normal neurologic examination make the MRI FOR NOW unnecesary, only I will do that MRI or another tests if the phisioterapy, and the expectant mannagement do no works, or if appear red flags form lower back pain (weigth loss, neurologic focalization, fever or urinary sintomps, intense dolor with mannagement, or >50 years old…), to stop his normal activity is not indicated.

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