A 48-year-old man presents with chronic back pain with radiation into the buttock, posterior thigh, and calf. Which of the following statement(s) is/are true?
- In the lumbar spine, more than half of clinical problems arise from L-2 to L-3 and L-3 to L-4 intervertebral discs
- Imaging studies with CT or MRI followed by myelography is necessary for the diagnosis in most patients
- Initially, medical management is indicated in all patients who do not have neurologic deterioration
- Surgical treatment is reserved for the patient with acute or progressive neurologic deficit, chronic disabling back pain, or both
- Anal sphincter muscle disturbances can be expected in most patients and are of no clinical significance
Medicine
c. Initially, medical management is indicated in all patients who do not have neurologic deterioration
d. Surgical treatment is reserved for the patient with acute or progressive neurologic deficit, chronic disabling back pain, or both
Herniated lumbar intervertebral discs often produce some degree of nerve compression. The severity of the syndrome depends on the degree of root compression. In the lumbar spine, more than 90% of clinical problems arise from the L-4 to L-5 and L-5 to S-1 intervertebral discs. Diagnosis is based on history of back pain usually with radiation into the buttock, posterior thigh, and calf at both levels. Pain may be exacerbated by coughing, sneezing, or straining. Bending and sitting accentuate the discomfort, whereas lying down characteristically relieves it. Thorough evaluation of back pain is necessary because of the multitude of causes for such symptoms. Plane films of the lumbosacral spine can identify congenital or bony changes. Disc space narrowing is an unreliable sign, however, of symptomatic disease since narrowing of the disc space can occur without clinical symptoms. Myelography can be diagnostic in symptomatic lumbar disc disease, but CT alone delineates the lesion in most cases. MRI has replaced myelography and CT at some centers in the workup of lumbar radiculopathy. With contrast, it can be extremely helpful in previously-operated cases.
Initially, medical treatment is indicated in all patients who do not have neurologic deterioration. Bed rest, local heat, analgesics, and skeletal muscle relaxants are usually effective within a few days. Physical therapy and limited exercise often help when the acute episode passes. With an aggressive conservative management, most patients improve sufficiently to return to full activity. Recurrent symptoms may be treated in a similar fashion, often successfully. Surgical treatment is reserved for a patient with acute or progressive neurologic function, chronic disabling pain, or both. The acute onset of weakness or sphincter disturbances constitute an emergency, demanding prompt diagnosis and early operation
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