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Orthopedics & Traumatology

Lumbar Disc Herniation with Radiculopathy, L4-L5, Left Lower Extremity

ICD-10 Code
M51.16_2

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with acute/chronic left-sided low back pain radiating into the left lower extremity in an L5 dermatomal distribution. Symptoms include sharp, lancinating pain, paresthesia, and subjective weakness in the left foot. Pain is exacerbated by flexion, prolonged sitting, and Valsalva maneuvers. No bowel or bladder dysfunction reported.

Clinical Examination Findings

Lumbar spine exam reveals restricted range of motion with paraspinal muscle spasm. Neurological exam of the left lower extremity demonstrates diminished sensation in the L5 dermatome, 4/5 strength in the extensor hallucis longus, and a diminished/absent patellar reflex. Positive straight leg raise (SLR) test at 45 degrees on the left, reproducing radicular symptoms.

Treatment Protocol

Initiate conservative management including activity modification, physical therapy (core stabilization/McKenzie exercises), and a course of NSAIDs or muscle relaxants. Consider epidural steroid injection if symptoms persist beyond 6 weeks. Monitor for progressive neurological deficit or cauda equina syndrome symptoms.

Detailed clinical guide coming soon.