A 35-year-old male presents with the onset of acute low back pain.

Full Answer Section

• "Sharp, lightning sensation" pain: This description is characteristic of neuropathic pain, often seen with nerve compression.
• No "Red Flag" symptoms: He denies fever, chills, weight loss, bowel/bladder dysfunction, or saddle anesthesia, which are crucial to rule out more serious conditions like cauda equina syndrome, infection, or malignancy. His age (<50) and absence of trauma beyond the exertional activity also lower the suspicion for fracture or malignancy.
• Smoking history and current vaping: While he quit smoking, his past history and current vaping are risk factors for disc degeneration.
• Sedentary work (8 hours sitting per day): Prolonged sitting can contribute to spinal stress.

Differential Diagnosis:

While lumbar disc herniation is the most probable diagnosis, other possibilities to consider, though less likely given the presentation, include:

• Lumbar Strain/Sprain: Less likely to cause significant radicular pain and positive SLR.
• Piriformis Syndrome: Can mimic sciatica but typically doesn't have a clear mechanical event like disc herniation and may not have a positive SLR in the same way.
• Spinal Stenosis: More common in older individuals and typically presents with neurogenic claudication (pain with walking, relieved by leaning forward), which is not his primary complaint.
• Spondylolisthesis: Could cause nerve compression, but typically presents with chronic back pain and may have a "step-off" deformity on physical exam.
• Facet Arthropathy: Usually causes localized back pain, sometimes with referred pain to the buttock or thigh, but less commonly distinct radiculopathy with positive SLR.
• Non-spinal causes: Less likely given the radicular pain and positive SLR, but always considered in back pain (e.g., renal colic, hip pathology, retroperitoneal mass).

Plan (General Principles):

1. Reassurance: Given the absence of red flags, reassure the patient that most acute disc herniations improve with conservative management.
2. Pain Management:
   • Continue NSAIDs (e.g., ibuprofen 800mg 3 times daily with food, or consider naproxen).
   • Consider adding a muscle relaxant for short-term use if muscle spasm is significant.
   • Neuropathic pain medication (e.g., gabapentin or pregabalin) could be considered if NSAIDs are insufficient, though typically reserved for more persistent or severe radicular pain.
3. Activity Modification:
   • Advise relative rest initially, avoiding activities that aggravate pain (like prolonged sitting or heavy lifting).
   • Encourage gentle movement and gradually increasing activity as tolerated. Complete bed rest is generally not recommended.
   • Emphasize "let pain be your guide" for activity levels.
4. Physical Therapy Referral: Crucial for education on proper body mechanics, stretching, strengthening core muscles, and nerve gliding exercises.
5. Patient Education:
   • Discuss the likely cause of his pain (disc herniation) and its natural history of improvement.
   • Explain the importance of avoiding provocative activities.
   • Advise on smoking cessation and healthy weight management (if applicable, though he appears to be active).
   • Emphasize the importance of good posture, especially for his desk job.
6. Follow-up: Re-evaluate in 1-2 weeks.
7. Imaging:
   • Given the acute nature and absence of red flags, imaging (MRI) is generally not indicated at the initial presentation. Most guidelines recommend waiting 4-6 weeks of conservative treatment before considering imaging, unless red flags emerge or there is progressive neurological deficit.
   • An MRI would be indicated if:
     • Symptoms do not improve with conservative management after 4-6 weeks.
     • He develops any red flag symptoms (e.g., worsening neurological deficit, bowel/bladder changes).
     • Consideration for surgical intervention arises.

This patient's presentation aligns well with an acute lumbar disc herniation with radiculopathy, and conservative management should be the initial approach.

Sample Answer

This 35-year-old male presents with a classic picture of acute low back pain with radiculopathy, most likely due to a lumbar disc herniation.

Key Findings Supporting This Diagnosis:

• Acute onset after strenuous activity: Pulling large bushes is a common mechanism for disc injury.
• Low back pain radiating down the back of the left leg: This distribution strongly suggests nerve root involvement, specifically sciatica, which commonly originates from the L4-L5 or L5-S1 levels.
• Difficulty bearing weight on the leg: This indicates significant pain and possibly some motor inhibition due to nerve irritation.
• Positive Straight Leg Raise (SLR): This is a highly sensitive test for nerve root irritation, especially due to disc herniation. The pain with active movement and minimal pain with passive movement further supports a musculoskeletal/nerve root issue rather than a primary joint problem.