karusmle
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a 77 yr old women comes to the physician because of low back pain for 3 months, she has hypertension controlled with calcium channel antogonist and type 2 DM controlled with diet. her vital signs r within normal limits. examination shows no spinal or costovertebral angle tenderness, straight leg produces pain in the low back at the L2 -L4 range., knee jerk and ankle reflexes are 2 + bilaterally .babinski's sign is absent bilaterally. urinalysis shows 5-10 epithelial cells /hpf, 2- 5 leukocytes /hpf and few bacteria, which of the folowwing is the most appropriate pharmacotherapy??
A) acetaminophen
B)gold
C)methotrexate
D)prednisolone
E)prbenecid
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| achilles
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a-acetaminophen.
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| Jinx
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a
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| drsap
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a
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| karusmle
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what is the diagnosis???
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| chemamr
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A
disc herniation?
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| AAAAA
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Lumbar herniated disc
How a herniated disc causes pain
As a disc degenerates, it can herniate (the inner core extrudes) back into the spinal canal, which is known as a disc herniation (or a herniated disc). The weak spot in a disc is directly under the nerve root, and a herniated disc in this area puts direct pressure on the nerve, which in turn can cause pain to radiate all the way down the patient’s leg to the foot (see Figure 1).
Approximately 90% of disc herniations will occur at L4- L5 (lumbar segments 4 and 5) or L5- S1 (lumbar segment 5 and sacral segment1), which causes pain in the L5 nerve or S1 nerve, respectively.
L5 nerve impingement from a herniated disc can cause weakness in extension of the big toe and potentially in the ankle (foot drop). Numbness and pain can be felt on top of the foot, and the pain may also radiate into the rear.
S1 nerve impingement from a herniated disc may cause loss of the ankle reflex and/or weakness in ankle push off (e.g. patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot (see Figure 2).
Conservative treatment for a lumbar herniated disc
In most cases, if a patient’s low back and/or leg pain is going to resolve after a lumbar herniated disc it will do so within about six weeks. While waiting to see if the disc will heal on its own, several conservative treatment options can help reduce the back pain, leg pain and discomfort caused by the herniated disc.
Physical therapy
Osteopathic/chiropractic manipulations
Non-steroidal anti-inflammatory drugs (NSAIDs)
Oral steroids (e.g. prednisone or methyprednisolone)
An epidural (cortisone) injection
If the pain continues after six weeks, it is reasonable to consider microdiscectomy surgery as an option to alleviate the pain from the herniated disc. A microdiscectomy essentially acts as a microdecompression of the nerve root to provide the nerve with a better healing environment.
Surgical treatment for a lumbar herniated disc
Using microsurgical techniques (a small operation using a microscope) to treat a lumbar herniated disc, a microdiscectomy can usually be done on an outpatient basis or with an overnight stay in the hospital, and most patients can return to work full duty in one to three weeks. For more information on this procedure, please see Microdiscectomy (microdecompression) back surgery.
With an experienced surgeon, the success rate of surgery for a lumbar herniated disc should be about 95%. Usually, only the small portion of the disc (5-8%) that is pushing against the nerve root needs to be excised, and the majority of the disc remains intact.
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| sachida
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Acetaminophen and steroid both should go togehter.
As a pharmaco-therapy acetaminophen can only releive pain but not alleviate the cause of nerve trapping.
Steroid can decrease inflammation and swelling therefore, nerve trapping.
I would choose steroid first if I have to choose only one drug. But I may be wrong.
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| achilles
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but she does not have any compression symptoms or any neurological signs and so acetaminophen should be appropriate. steroids would have been useful if it was the spinal compression syndrome.(but this is what i thought)
pls guys chip in with your opinions on this so that we can come to the right answer.
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| sachida
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The Q described "straight leg produces pain in the low back at the L2 -L4 range., knee jerk and ankle reflexes are 2 + bilaterally" are signs of nerve compression.
If spinal compression is present she needs drugs (NSAIDS not acetaminophen), surgery if chronic, and other therpay http://www.webmd.com/content/article/111/110110.h....
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| achilles
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sachida, i'd say that those two presentations do not imply nerve compression. nerve compression would be more implied if any of these were present -
weakness in the extremities, sensory or other motor neurological abnormalities, shooting pain down the leg, paraesthesias, loss of reflexes, babinski +ve, urinary incontinence, urinary retention, fecal incontinence.
maybe others will add more to this discussion.
Edited by achilles on 06/13/06 - 03:32 PM
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