A Synopsis of AFPs "Acute Lumbar Disk Pain: Navigating Evaluation and Treatment Choices"

Acute Lumbar Disk Pain: Navigating Evaluation and Treatment Choices
DAVID S. GREGORY, MD; CRAIG K. SETO, MD; GEORGE C. WORTLEY, MD; and CHRISTINE M. SHUGART, MD, Lynchburg Family Medicine Residency, Lynchburg, Virginia, and University of Virginia, Charlottesville, Virginia 
Am Fam Physician. 2008 Oct 1;78(7):835-842.
http://www.aafp.org/afp/2008/1001/p835.pdf

     Low back pain is the leading cause of missing time at work and it is the most common reason that patients go to the doctor. Low back pain that radiates down the thigh and leg is known as sciatica. Patients who complain of this must first look for any red flags, which include saddle anesthesia, urinary retention, fecal incontinence, unexplained fever, chronic steroid use, history of cancer, IVDA, and focal neurological deficits. The most common cause of sciatica (in patients without red flag symptoms) is lumbar disk herniation. A full neurological exam needs to be completed including a straight leg raise test. Disk herniation can usually resolve with conservative management, which includes NSAIDs, acetaminophen, muscle relaxants, and opioids.
     Sciatica will present with a dermatomal pattern, depending on the level of involvement. A disk herniation at the L3/L4 level with affect the patellar reflex. The patient will have difficulty with ankle dorsiflexion and sensory loss along the medial malleolus and medial foot. A disk herniation at the L4/L5 level will cause difficulty with great toe dorsiflexion and sensory loss at the dorsal third MTP joint.  A herniation at the L5/S1 disk will  affect the achilles reflex and cause motor issues with ankle plantar flexion. Neurological symptoms will present as pain, numbness and a cold sensation. A late finding may also be calf muscle wasting.
    Imaging is not always required and the findings on MRI do not usually correlate with the neurological findings. If there are not red flags, then conservative management will be implemented. If there are red flags then then imaging will be done. If the imaging correlates with the symptoms, then the patient can be referred to surgery. If the patient is on conservative management for two weeks and there is still severe pain, then the patient can be referred for epidural steriod injections. Otherwise, the patient can continue conservative management and supplement it with physical therapy and manipulation. If there is no change after six weeks then imaging should be considered. Bed rest should be discouraged because it may lead to muscle deconditioning.
     Physical therapy and manipulation do not have high quality studies but it does appear to have benefit in pain relief. The is no long term benefit in disease outcome. The same goes with surgery where the patient does not have any long term benefit after two years.