Review Question - QID 221217

This patient with lower back pain and a positive straight leg test after lifting most likely has a herniated disc. Given that she does not have any symptoms of cauda equina syndrome, the most appropriate next step in management is NSAIDs and activity as tolerated.

A herniated disc typically occurs in patients after significant exertion, in particular after lifting heavy objects. Patients will often complain of lower back pain or electrical pain that shoots down their lower extremities. The straight leg raise test is often positive in patients with a herniated disc. This is because the elevation of the leg compresses nerve roots, resulting in exacerbation of pain that can travel down the leg in a sciatic fashion. It is important to rule out cauda equina syndrome by ensuring that the patient is not experiencing any symptoms such as saddle anesthesia, loss of rectal tone, or urinary incontinence. Patients who have any warning signs of cauda equina syndrome should have their rectal tone examined, given that this is a surgical emergency. If a simple herniation of the nucleus pulposus is suspected, the patient can be discharged with NSAIDs and activity as tolerated.

Jordan et al. review the evidence regarding the management of herniated nucleus pulposus. They discuss how advice to stay active and NSAIDs are effective for this disease. They recommend avoiding chronic opioid use in these patients.

Figure/Illustration A is an MRI demonstrating a herniated disc (red circle). There is no compression of the cauda equina at this level so there is not likely to be complicating factors.

Incorrect Answers:
Answer 1: A microdiscectomy can be performed in patients who have unremitting pain that is refractory to conservative management. Other indications would be motor weakness or progressive loss of function. It would not be appropriate to go to surgical intervention without first trying conservative management in this case.

Answer 3: NSAIDs and bed rest are inappropriate because bed rest leads to disuse of the patient's injured lower back. This could result in increased stiffness and pain and a worsening of symptoms. It is important to recommend that patients engage in activity as tolerated while they recover.

Answer 4: Oxycodone and activity as tolerated represents an inappropriate initial method of pain control in this patient, as chronic opioid use has negative side effects.

Answer 5: Oxycodone and bed rest are inappropriate for managing this patient, as bed rest would result in atrophy and stiffness, while chronic opioid use is associated with adverse side effects such as sedation and constipation.

Bullet Summary:
A herniated nucleus pulposus without signs of cauda equina syndrome can be managed conservatively with NSAIDs and activity as tolerated.