Subjective:
The patient is a 45-year-old male presenting with complaints of persistent lower back pain that has been bothering him for the past two weeks. He reports that the pain is a dull ache that started gradually and has been worsening since it began. He describes the pain as being constant and affecting his lower back and right leg, with intermittent tingling and numbness in his right foot. He reports that the pain is aggravated by sitting or standing for prolonged periods, and alleviated by lying down. He denies any history of trauma, recent weight gain, or fever. His past medical history is significant for hypertension and hyperlipidemia, for which he takes lisinopril and simvastatin respectively.
Objective:
On examination, the patient’s vital signs are within normal limits. His BMI is 27. He has a limited range of motion in his lumbar spine, with pain elicited on extension and rotation. Sensation to light touch and pinprick is diminished in the L4-5 dermatomes on the right. Motor strength is intact in the lower extremities, with no signs of atrophy. Straight leg raise test is positive on the right side, reproducing the patient’s lower back pain.
Assessment:
The patient’s symptoms and examination findings are consistent with a diagnosis of lumbar radiculopathy. Lumbar radiculopathy is a common condition caused by compression or irritation of one or more spinal nerve roots. The most common cause of lumbar radiculopathy is a herniated disc, which can impinge on the nerve root and cause symptoms such as lower back pain, leg pain, and sensory and motor deficits.
Plan:
The patient will be referred to a physical therapist for conservative management, including therapeutic exercise and stretching to improve range of motion and flexibility, as well as education on proper body mechanics and posture. He will also be prescribed a short course of oral steroids to help alleviate the inflammation and swelling in the affected nerve root. If his symptoms persist despite conservative therapy, further imaging studies such as an MRI may be warranted to evaluate for the possibility of a herniated disc or other underlying structural abnormalities.
References:
Ropper AH, Zafonte RD. Sciatica. N Engl J Med. 2015;372(13):1240-1248.
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976). 2014;39(1):3-16.
Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120-131.
