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Old 12-13-2012
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Rheumatology/Orthopedics Herniated nucleus pulposus

A 42-year-old man presents to urgent care with back pain for 2 days that began while he was moving furniture during home remodeling. The pain is sharp, travels down his left leg, and feels “like an electric shock.” It is relieved with rest and aggravated with walking. His temperature is 36.9°C (98.5°F), blood pressure is 122/70 mm Hg, heart rate is 68/min, and respiratory rate is 12/min. The patient appears uncomfortable, and when asked to describe the location of the pain, places his entire hand flat on lumbar region to the left of the spine. Straight leg raise on the left is positive for replication of the pain. Reflexes are decreased in the left lower extremity. Which of the following is the most appropriate next step in the care of this patient?

(A) CT of the spine
(B) Lumbar series x-ray
(C) MRI of the spine
(D) Neurosurgical consultation
(E) Rest and nonsteroidal anti-inflammatory drugs
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C) MRI of the spine
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My pick....E.........wanna give a trial of conservative management before proceeding with MRI...although deceased reflexes in left lower extremity alone would warrant Imaging , not sure.
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Default (E) Rest and nonsteroidal anti-inflammatory drugs

(E) Rest and nonsteroidal anti-inflammatory drugs
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C) MRI of the spine
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Default (C) MRI of the spine

Quote:
Originally Posted by fadi551 View Post
(E) Rest and nonsteroidal anti-inflammatory drugs
the right answer is
(C) MRI of the spine

to exculde cord compression
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The correct answer is E.
The patient’s symptoms are consistent with a herniated nucleus pulposus. Spontaneous improvement is the rule; > 90% of patients have resolution within 6 weeks of pain onset. Conservative treatment involves rest: 1–2 days of bedrest (longer is counterproductive, as deconditioning begins) followed by 2–3 weeks of activity limitation (reduce lifting and twisting) with reassessment prior to lifting activity restriction. Nonsteroidal anti-inflammatory drugs, moist heat, and gentle exercise to promote joint mobility are all typically helpful.

Imaging is reserved for patients with systemic symptoms(fever and weight loss) when cancer or infection is high on the differential, in patients with trauma(e.g., motor vehicle accident), and in patients who do not improve with more conservative measures.
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