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A 45-Year-Old Man With Low Back Pain and a Numb Left Foot

James N. Weinstein, DO, MS, Discussant
JAMA. 1998;280(8):730-736. doi:10.1001/jama.280.8.730.
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DR DALEY: Mr S is a healthy, active 45-year-old attorney and father of 5 children who has low back pain and a numb left foot. He lives in a suburb of Boston and his medical insurance is through a managed care plan in Massachusetts.

Mr S has experienced intermittent episodes of low back pain after exertion or physical activity for 17 years. He remembers first having an episode of low back pain after playing basketball. During ensuing years, he had occasional episodes of low back pain that responded to treatment with 1 or 2 days of bed rest and nonsteroidal anti-inflammatory agents. He has never had a trauma resulting in a back injury.

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Figure 1.—Sagittal (A) and axial (B) magnetic resonance images of Mr S. Arrows indicate moderate spinal stenosis at L4-5 with a focal disk protrusion and a diffusely bulging annulus with concomittant foraminal narrowing on the left side. There is also an L5-S1 disk protrusion with apparent impingement of the L5 nerve root.
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Figure 2.—Rates of back surgery by hospital referral region, 1994-1995. Back surgery is a very high variation procedure. Regions with the most back surgeries per 1000 enrollees are red (Northwest and mountain states and parts of Texas, Florida, North Carolina, South Carolina, Alabama, and California). Rates are lower in the Northeast and parts of the Midwest (blue). Reprinted with permission from the Dartmouth Atlas of Health Care 1998.38 Copyright 1998, American Hospital Association Publishers Inc.

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