A 45-year-old woman presents to urgent care with severe low back pain that started suddenly 2 days ago. She reports that the pain radiates down her left leg to her foot, and she describes it as sharp and constant, rating it 8/10 in intensity. She notes associated numbness and tingling in the same leg and has difficulty moving her left foot. Over the past 24 hours, she has noticed new-onset urinary incontinence and feels numbness in the area around her buttocks. She denies any recent trauma or heavy lifting. She has had intermittent back pain for months but never as severe as this episode. She denies fever, chills, or unexplained weight loss. Her past medical history is significant for type 2 diabetes and hypertension. She takes metformin and lisinopril and has no known drug allergies.
On physical examination, her vital signs are stable. She has marked tenderness over the lower lumbar spine. Motor testing reveals weakness in dorsiflexion of her left foot and decreased sensation in the left lower leg and perineal region. Reflexes are decreased on the left compared to the right. Rectal tone is reduced. The straight leg raise test is positive.
Which of the following is the most appropriate next step in managing this patient?
- Prescribe methylprednisolone dose pack PO 4 mg taper over 6 days and discharge her home with a referral to follow up with an orthopedist.
- Take 3-view x-rays, start IV analgesics, and observe her for 3 hours in the clinic.
- Prescribe tramadol 25 mg PO once per day, discuss using topical lidocaine as an adjunct treatment, and instruct her to follow up with her primary care provider.
- Refer this patient for urgent evaluation for advanced imaging and neurosurgical consultation.
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Correct Answer: d. Refer this patient for urgent evaluation for advanced imaging and neurosurgical consultation.
Given the presence of red-flag symptoms including new neurological deficits, saddle anesthesia, and urinary incontinence, urgent evaluation for cauda equina syndrome is necessary, and immediate referral to the emergency department for advanced imaging and neurosurgical consultation is indicated.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
