Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a chief complaint of acute-on-chronic low back pain radiating into the right lower extremity in an L5 dermatomal distribution. Pain is described as sharp, electric, and shooting, exacerbated by flexion, coughing, or Valsalva maneuver. Associated symptoms include right-sided paresthesia and subjective weakness in the right foot. Symptoms are refractory to conservative management including NSAIDs and physical therapy.
Clinical Examination Findings
Physical exam reveals lumbar paraspinal muscle spasm with limited range of motion in flexion. Neurological exam: Right lower extremity demonstrates 4/5 strength in the extensor hallucis longus (EHL) and tibialis anterior. Sensory deficit noted in the right L5 dermatome. Deep tendon reflexes: Right patellar 2+, right Achilles 1+. Positive straight leg raise (SLR) test on the right at 45 degrees, reproducing radicular symptoms. Negative crossed SLR. Gait is antalgic favoring the right side.
Treatment Protocol
Plan: 1. MRI Lumbar Spine without contrast to confirm disc herniation morphology. 2. Initiate oral corticosteroid taper and gabapentin for neuropathic pain. 3. Referral to physical therapy for core stabilization and McKenzie exercises. 4. Discuss epidural steroid injection (ESI) if symptoms persist beyond 6 weeks. 5. Activity modification: avoid heavy lifting and prolonged sitting.