Constant, Nonradiating Low Back Pain

Patient History

The patient is a 49-year-old female with intermittent low back pain two to three times per year for the last 10 years. Since moving into a new house, her low back pain has become constant, but does not radiate. Activity and sitting increases her back pain however, standing does not exacerbate symptoms.

Examination

The examination is normal.

Prior Treatment

Bed rest, nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, chiropractic, and acupuncture failed to adequately relieve the patient's symptoms.

Images

The patient's posterior / anterior and lateral extension / flexion radiographs are below. (Figs. 1A, 1B, 1C)

Figure 1A. Posterior anterior

Figure 1B. Extension

Figure 1C. Flexion

Lumbar sagittal MRI demonstrates a small disc bulge / herniation (Fig. 2A) and axial MRI shows a small right-sided disc herniation (Fig. 2B).

Figure 2A. Sagittal MRI demonstrates small disc bulge / herniation.

Figure 2B. Axial MRI demonstrates small right-sided disc herniation.

Diagnosis

Lumbar degenerative disc disease, L5-S1 herniated nucleus pulposus.

Selected Treatment

Continued nonoperative treatment.

Outcome

The patient experienced gradual improvement in her back pain, but continues to have intermittent exacerbations.

Case Discussion

I agree with Dr. Fessler's treatment plan for this patient with two-level degenerative disc disease at L4-L5 and L5-S1. The vast majority of patients with lumbar disc degeneration will improve with nonoperative treatment modalities. Occasionally, exacerbations of discogenic low back pain are commonly seen in this population. Without leg symptoms, observation is also appropriate for the right-sided disc herniation at the L5-S1 segment. I would avoid epidural steroid injections unless radicular symptoms are present.

Nonoperative treatment should consist of aggressive core stabilization and aerobic reconditioning. The axial MRI confirms advanced atrophy of the erector spinae musculature, which is common in this group of patients.