Mrs. H, a 47-year-old woman, was well until 2 days ago, when she started having low back pain after working in her garden and pulling weeds for several hours. The pain is a constant, dull ache that radiates to her right buttock and hip. Yesterday, after sitting in a movie, the pain began radiating to the back of the right knee. She has taken some acetaminophen and ibuprofen without much relief. Her past medical history is unremarkable, and she takes no medicines. She has no constitutional, bowel, or bladder symptoms
On physical exam, Mrs. H is clearly uncomfortable. She has no back tenderness and has full range of motion of both hips. When her right leg is raised to about 60 degrees, pain shoots down the leg. When her left leg is raised, she has pain in her lower back. Her strength and sensation are normal, but the right ankle reflex is absent.
Mrs. H has sciatica, a positive straight leg raise test, and an absent ankle reflex, a combination that strongly suggests nerve root impingement at L5–S1. One option at this point would be to order an MRI or CT scan to confirm a herniated disk. However, there are 2 questions to consider before ordering a scan:
You decide not to order any imaging studies initially and prescribe ibuprofen (800 mg 3 times daily) and activity as tolerated. Mrs. H calls the next day, reporting that she was unable to sleep because of the pain. You then prescribe acetaminophen with codeine, which provides good pain relief. Two weeks later, she is rarely using the codeine, and is only using ibuprofen 1 to 2 times a day. Two months later, she is pain free and back to her usual activities, although her ankle reflex is still absent—a common and not significant finding. She is fine until about a year later, when identical pain develops after a bad bronchitis. Her pain resolves with a few days of acetaminophen with codeine
Soap Note
S: Mrs. H is 47 y/o female with no significant PMHx.
Complains of a low back pain x 2 days.
Begin after working in the garden.
Pain is vague and constant and spread to R. buttock and hip.
After prolong sitting, pain radiated to the popliteal area.
No relief with acetaminophen and ibuprofen
No current medication
Denies bladder, bowel or constitutional symptoms (fever, vomiting, chills, weight loss and shaking)
O: no back tenderness, positive straight leg test, negative crossed straight leg test, absent of ankle reflex,unremarkable strength and sensation, intact bilateral hip motion.
A: Mrs. H is a 47 y/o female with no PMHx, positive straight raise leg test and absent ankle reflex, likely sciatica nerve impingement at L5-S1
P: -ibuprofen (800 mg 3 x per day)
-Activity as tolerated
– alternative acetaminophen with codeine
Summary
The facts that Mrs. H’s pain radiated from the back to lower leg and was aggravated after prolong sitting were red flags for sciatica, which is a pain that spreads from the back to buttock and leg, and occasionally to foot or ankle. Sciatica is a herniated disc impinging on the nerves at the level of L5-S1. Pain caused by nerve impingement can be aggravated by coughing, sneezing or prolong sitting. To test for sciatica, the straight and crossed straight leg test can be performed by elevating the leg between 30 to 60 degrees. In the case of Mrs. H, she has a positive straight leg test, in which the pain spread down the leg. Along the positive straight leg test, she also has an absent of ankle reflex, which is considered an abnormal combination of symptoms. Moreover, Mrs. H describes the pain as “dull” which is another characteristic of the pain associated with nerve impingement or radiculopathy. Pain related to radiculopathy can be characterized as “sharp, shooting or burning but can also be described as throbbing, tingling, or dull”(1).
As first treatment option, the medication NSAIDs can be prescribed. The medications tramadol or opioids can be considered options for treatment. In case of acute or severe pain, the drugs corticosteroids might be effective at treating these symptoms. Bed resting might not be advisable since, it does not speedy up the recovery process and lastly surgery. The risk factors involve with herniated disk are inactive lifestyle, driving, poor physical activity, pregnancy and persistent coughing.
Source:
- https://accessmedicinemhmedicalcom.york.ezproxy.cuny.edu/content.aspx?bookid=1088§ionid=61697331#1102643254urce:
