NEUROPATHIC PAIN (E EISENBERG, SECTION EDITOR) Back Pain with Leg Pain Simon Vulfsons 1,2 & Negev Bar 3,4 & Elon Eisenberg 1,2 # Springer Science+Business Media New York 2017 Abstract Purpose of Review The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very com- mon. In relation to back pain that radiates to the leg, the International Association for the Study of Pain (IASP) states: “Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb.” Recent Findings Bogduks’ editorial in the journal PAIN (2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging. Summary In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syn- drome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or in- deed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made. Keywords Sciatica . Somatic referred pain . Radicular pain . Neuralgia . Back pain . Leg pain Introduction Mr. A.B. is a 45-year-old healthy white male. He is a heavy smoker, not physically active, and works in a sedentary job. He presents to his primary family physician, due to 2 weeks of mild low back pain that started after lifting a heavy weight. He reports that for the last 2 days, his low back pain has become more severe and has developed right leg pain (both are 8/10 on Visual Analogue Scale for pain—VAS). He describes the back pain as dull, mainly in the mid-line at the level of L5. Walking and coughing increase this pain and bed rest alleviates it. He also describes the leg pain as lancinating, radiating along the posterior thigh and calf (above the ankle) as well as a sensation of numbness in a typical L5 dermatomal distribution. On physical examination: The patient is obese (BMI = 32), walks with an antalgic gait, and has reduced range of motion of the lumbar flexion but no muscle weakness. He has normal ten- don reflexes. The “straight leg raising” (SLR) is limited at 40° on the right and 60° on the left. The “jump sign” (sensitive trigger points) is positive above the gluteus muscle. No red or yellow flags were identified in a systematic history and phys- ical exam overview. What is the most likely diagnosis? What should be the next step taken by the primary physician (GP or the orthopedic surgeon) to evaluate the patient’ s pain? What should be the first-line treatment to help this patient? This article is part of the Topical Collection on Neuropathic Pain * Simon Vulfsons s_vulfsons@rambam.health.gov.il 1 Institute for Pain Medicine, Rambam Health Care Campus, 11 Ephron Street, Bat Galim, 3109601 Haifa, Israel 2 Rappaport Faculty of Medicine, Technion Institute for Technology, Haifa, Israel 3 Department of Family Medicine, Haifa, Israel 4 Clalit Health Services, Haifa, Haifa and Western Galilee, Israel Curr Pain Headache Rep (2017) 21:32 DOI 10.1007/s11916-017-0632-x