Clinical Crossroads: A 45-Year-Old Man With Low Back Pain

To the Editor: As a neurologist, I have noticed over the past several years there has been an increasing trend for spine specialists to rely only on physical findings and radiological studies to manage patients with lumbar radiculopathy. Mr S¹ has an abnormal physical examination finding (absent ankle jerk) and a history of weakness in the leg. Physical examination might also show decreased calf circumference on the affected leg. In my opinion, an electromyogram and nerve conduction study are essential in the management of patients such as this, since the MRI scan shows structure only, while the electrodiagnostic studies measure function. These are complementary tests that are useful tools in the management of a case like this and are both essential. If the electromyogram shows only old (chronic) nerve damage then Mr S may be counseled that continued jogging may eventually damage the S1 nerve root irreversibly, but that at this time there is no evidence that he is doing anything to cause nerve death. If the electromyogram shows active, ongoing nerve damage, then he should be counseled that continued jogging will probably result in progressive damage to the S1 nerve root with possible permanent nerve damage. He then might choose to adjust his lifestyle (quit jogging and use a stair stepper) or consider surgical intervention. In my opinion, it is then up to the patient to decide the best course of action, but it is a mistake to not use the technological resources available to help him make this decision.