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  #1  
Old 02-06-2013
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Rheumatology/Orthopedics Back Pain with Positive Straight Leg Test

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 the 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 management?
(A) CT of the spine
(B) Lumbar series x-ray
(C) MRI of the spine
(D) Neurosurgical consultation
(E) Rest and nonsteroidal anti-infl ammatory drugs

plz answer with explanation , thanks
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(E) Rest and nonsteroidal anti-inflammatory drugs

Clearly a case of sciatica. Just need rest initially with NSAIDS followed by gradual EARLY return to activity & exercises.
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D) Neurosurgical consultation

Although usually you would recommend NSAIDS and early return to activity in this case the patient has a very acute picture with signs of root compression (decreased reflexes on the left extremity) therefore i think he needs a Neurosurgical consultation for the decompression of his nerve root.
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Quote:
Originally Posted by goulartmd View Post
D) Neurosurgical consultation

Although usually you would recommend NSAIDS and early return to activity in this case the patient has a very acute picture with signs of root compression (decreased reflexes on the left extremity) therefore i think he needs a Neurosurgical consultation for the decompression of his nerve root.
Yeah.......I missed that.
But what about an MRI.
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I think the answer is (C) MRI of the spine in view of radiculopathy.

D) Neurosurgical consultation would be the right answer if he had features of Cauda Equina syndrome.

(E) Rest and nonsteroidal anti-inflammatory drugs if there were no features of nerve root compression.


Quote:
Surgery is generally considered only as a last resort, or if a patient has a significant neurological deficit.[40] The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.
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Quote:
Originally Posted by Novobiocin View Post
I think the answer is (C) MRI of the spine in view of radiculopathy.

D) Neurosurgical consultation would be the right answer if he had features of Cauda Equina syndrome.

(E) Rest and nonsteroidal anti-inflammatory drugs if there were no features of nerve root compression.
Exactly.. that what i think
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Old 02-07-2013
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that Q was confusing me as the answer is rest and NSAIDS the explanation was that 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 or 2 days of bedrest (longer is
counterproductive as deconditioning begins)
followed by 2 to 3 weeks of activity limitation
(reduce lifting, twisting) with reassessment
prior to lifting activity restriction. Nonsteroidal
anti-infl ammatory drugs, moist heat, and gentle
exercise to promote joint mobility are all
typically helpful.
Imaging is reserved for
patients with systemic symptoms (fever, weight
loss) when cancer or infection is high on the
differential, in patients with trauma (i.e., motor
vehicle accident), and in patients who do not
improve with more conservative measures.
,, what do u think
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Good explanation but should add this

Quote:
Originally Posted by Novobiocin View Post
C) MRI of the spine in view of radiculopathy.

D) Neurosurgical consultation would be the right answer if he had features of Cauda Equina syndrome.

(E) Rest and nonsteroidal anti-inflammatory drugs if there were no features of nerve root compression.
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So the take home points:

Trial of conservative management even with features of radiculopathy (without progressive neurological deficit).

MRI of the spine in view of progressive neurological deficit, failure of conservative management, symptoms>3 months.

Neurosurgical consultation: Cauda Equina syndrome, features of cord compression, failure of conservative management.
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