NursingCase studyHealth assessment

Low back pain case: nerve roots, AHRQ red flags, exam plan

The case hands you three load-bearing details — one leg, one month, and a named framework — and the AHRQ framework's central recommendation is to withhold imaging, so the diagnostic workup most students write contradicts the guideline they were told to cite.

Jul 26, 2026Updated Aug 10, 2026

Editorial process

Last reviewed · July 26, 2026

Written by

Aaron Bishop

MA, Education

assignment interpretation and research-methods coaching across disciplines

Reviewed by

Dr. Nathan Cole

PhD, Rhetoric & Composition

Argumentation and thesis development

On this page

Interpret the task
Assignment instructions
Deliverables
Proposed outline
Research plan
Reference shortlist
Final review

What is this lower back pain case actually testing?

This is a localisation task wearing the clothes of a back-pain write-up, and it carries a trap: the framework you are told to use forbids much of the workup students reflexively order. Two moves earn most of the marks — letting the anatomy generate the differential, and deciding what not to order under AHRQ, with reasons.

Notice the order the prompt asks its questions in: nerve roots first, differential diagnoses fourth. That sequencing is the instruction — the anatomy is meant to generate the differential, not decorate it after the fact. A response that opens with a list of conditions (herniation, stenosis, strain) and then bolts on generic exam manoeuvres has inverted the reasoning being assessed.

The second thing to notice is that 'using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework' is a constraint, not a citation prompt. The AHCPR/AHRQ approach to acute low back pain is a red-flag triage algorithm: it sorts a presentation into potentially serious spinal pathology, sciatica/radiculopathy, or non-specific mechanical back pain, and it states that in the absence of red flags, imaging and further testing are not usually helpful during the first four weeks of symptoms. So a response that names AHRQ and then orders a CBC, ESR, HLA-B27, bone scan, CT and MRI has contradicted the framework it invoked. Deciding what not to order, and saying why, is the part that demonstrates you understood the framework.

Third, the case details are diagnostic, not scenery. Radiation to the left leg only — unilateral — points toward a single-level lumbosacral radiculopathy rather than the bilateral, positional pattern of neurogenic claudication in spinal stenosis. One month of symptoms sits exactly on the four-week boundary the AHRQ algorithm turns on, which is worth naming explicitly rather than stepping over. A 42-year-old is below the age thresholds that raise suspicion of malignancy or fracture, and that absence is itself something you should state as part of the red-flag screen.

Finally, the prompt separates 'physical examination' from 'special maneuvers'. Treat those as two questions. The examination is the systematic dermatome-myotome-reflex screen; the special manoeuvres are the provocative tests, and naming them is not enough — the assessor is looking for what a positive or negative result actually licenses you to conclude.

Likely learning objectives

Inferred from the brief — check these against your own rubric.

01
Map candidate lumbosacral nerve roots to the specific reflex, myotome and dermatome that tests each one — the assessor is likely looking for L4/L5/S1 distinguished by patellar reflex, extensor hallucis longus and Achilles reflex respectively, not a single undifferentiated answer.
02
Apply a red-flag screen before proposing any workup, since the AHRQ framework makes triage the first step and everything downstream conditional on it.
03
Justify diagnostic testing decisions — including the decision to order nothing yet — against the four-week rule, rather than listing every test that could conceivably be run.
04
State what a provocative test result licenses you to conclude, which likely means citing sensitivity and specificity rather than reporting the manoeuvre as simply positive or negative.
05
Use the case's own details (unilateral radiation, one-month duration, age 42) as discriminating evidence between the differentials rather than restating them as background.

Assignment instructionsQuoted verbatim

Read the full question

Review every instruction before using the planning guidance that follows.

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? Respond to this #1 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? Patient Information: R.E, 42-year-old African American male Subjective CC: “Lower back pain” HPI: A 42-year-old black African American male who came to the clinic today for complaining of lower back pain which he reported started a month ago. The patient stated that the pain sometimes radiates to his left leg. Location: Lower back Onset: One month ago Character: Sharp, constant, radiating to left leg Associated signs and symptoms: None Timing: Starts when at work Exacerbating/ relieving factors: Any movement. Ibuprofen helps to relief the pain temporarily. Severity: 7/10 pain scale Medications: Ibuprofen 200mg 3 tablets every 6 hours PRN for lower back pain. Advanced Health Assessment Musculoskeletal Pain Amlodipine 10mg daily for hypertension x1 years. Allergies: No known drug allergy, no food allergy, no seasonal allergy and No known allergy to latex/rubber. PMHx: Hypertension diagnosed one year ago. Influenza vaccine November of 2020. Tdap vaccine 2018. Pneumonia: Not yet had any pneumococcal vaccine. Up to date on all childhood immunizations. Past surgical history: None. Social History: Mr. R.E is happily married with three children. He has a bachelor’s degree in medical laboratory and works in the hospital setting. Mr. R.E denies ever smoking, but he drinks Corona beer occasionally and during festive period with friends and family. He denies using any illicit drugs and the thought of suicidal ideation. He goes to the gym at least 1-2 times in a week and walk around his neighborhood to keep him physically active and healthy. He loves dancing as a hobby and going for vacations with his family. The patient reported that he loves to maintain his activities of daily living and dress according to weather, as for his instrumental Activities of Daily Living he said he manages his finances and financial assets by paying his bills early. Mr. R.E loves his traditional African food and occasionally eat out. The patient reported that he keeps to safety measures by putting on his seatbelt and not texting while driving, he also reported having a working smoke detector and a security camera in his house. He has a good family support system for his wife and children. He sleeps 6-8 hours per night. Family History: Mr. R.E mother is still alive, age 70, has hypertension and type 2 diabetes mellitus. The Father is still living; he is 72 years old who has asthma. Maternal grandmother deceased at age 78, had a stroke, she was diabetic. Maternal grandfather, deceased at age 80, had prostate cancer. Paternal grandmother deceased at age 70, from chronic obstructive pulmonary disease (COPD) Paternal grandfather age 95, still alive had asthma. Brother age 55 has type 2 diabetes mellitus. Son, age 20, no health issues Daughter age 16. No health issues. Daughter 12, no health issues. General: The patient is alert and oriented to place, person, time and situation, appropriate judgement, well-nourished black, African American, dressed according to the weather, no distress noted, mild discomfort due to pain in his lower back. Emotional and behavioral needs are appropriate at the present time considering patient clinical condition, no current home stress or abuse. HEENT: Denies itching eyes or any discharges. The patient said he uses glasses but does not use contact lens, he denies blurred vision. Denies ringing in his ears, hearing loss and discharged. Denies surgery to his ears and any recent infections. Denies epistaxis, discharges, congestion and sneezing, no loss or decreased sense of smell. Denies any sore throat or infection. Respiratory: Elevated respiratory rate, 30/min. Denies difficulty breathing, coughing, and wheezing. Denies secondhand smoking. Cardiovascular/Peripheral Vascular: Denies chest pain, heaviness, or heart palpitation, denies shortness of breath and edema to both lower extremities. Gastrointestinal: No complains of abdominal upset, no nausea or vomiting, have regular bowel movement. No changes in his appetite, no recent weight loss. Genitourinary: Denies difficulty voiding, changes in voiding pattern and denies any penile discharge. Neurological: Denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. Denise changes in his thinking. Skin: Negative for skin lesion, eczema, mole or rash and no skin changes. Musculoskeletal: Lower back pain that radiates to his left leg. Denies joint stiffness or joint pain. Hematologic: Denies any bleeding. Endocrine: Denies cold or heat intolerance, excessive thirst, or urination, does not have any issue with his thyroid. Psychiatry: Mr. R.E said he is fine, does not have any mental problems, denies depression, suicidal thought, patient states he loves his wife and his family and can never kill himself. Advanced Health Assessment Musculoskeletal Pain OBJECTIVE DATA: Physical Examination: Vital signs: BP 120/80 and regular, Heart rate: 65 and regular, Temperature: 98.2 F orally, Respiration 30; pulse oximetry 95% on room air, Weight: 160 lbs.; Height: 5’ 9”; BMI: 26 Neurological: Patient is alert and oriented to place, person, time and situation, appropriate judgement. Speech is clear, no facial drooping, no vision changes, follows movement. Understand clear, complex, comprehensive without cues or repetition. Skin: Not pale, cyanosis or ashen. Dry and warm to touch. No tear and non-tainting. Chest/Lungs: Tachypnea, the chest expands symmetrically, bilateral breath sounds are clear. Heart/Peripheral Vascular: The heart rate is regular with a normal rhythm, S1and S2 sound heard. All peripheral pulses are strong and palpable +3, Negative edema to all extremities. Capillary refill is less than/equal to 2 seconds in all extremities and no cyanosis noted. Abdomen: Soft and nondistended, bowel sound present and active in all four quadrants, no pain or rebound tenderness noted. Last Bowel movement was this morning. Musculoskeletal: Lower back pain radiating to the left lower extremity. No evidence of trauma to affected area. Pain increases with flexion, extension, and twisting. Decreased mobility due to pain. Diagnostic Tests: Complete blood count (CBC) may point to infections or inflammation. Erythrocyte sedimentation rate. HLA-B27 Bone scans X-Ray of the lumbar spine Computerized tomography (CT) cervical spine/lumbar w/without contrast. MRI of the lumbar spine Assessment. Differential diagnoses: · Lumbar disc herniation (LDH): The intervertebral disc consists of an inner nucleus pulposus (NP) and an outer annulus fibrosus (AF). The central NP is a site of collagen secretion and contains numerous proteoglycans (PG), which facilitate water retention, creating hydrostatic pressure to resist axial compression of the spine. The NP is primarily composed of type II collagen, which accounts for 20% of its overall dry weight. In contrast, the AF functions to maintain the NP within the center of the disc with low amount of PG; 70% of its dry weight is comprised of primarily concentric type I collagen fibers. In LDH, narrowing of the space available for the thecal sac can be due to protrusion of disc through an intact AF, extrusion of the NP through the AF though still maintaining continuity with the disc space, or complete loss of continuity with the disc space and sequestration of a free fragment. It is estimated that this condition has approximately 75% heredity origin, other predisposing factors includes dehydration and Axial Overloading. The role of inflammatory signaling in producing nerve pain in LDH has been well-established. The primary signs and symptoms of LDH are radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots. CT myelography and MRI are used to detect this condition (Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). · Lumbar spinal stenosis: Lumbar spinal stenosis is a narrowing of the spinal canal in the lower part of the back. Stenosis, which means narrowing, can cause pressure on the spinal cord or the nerves that go from the spinal cord to the muscles. Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. This condition is most usually categorized as either primary when it is caused by congenital abnormalities or a disorder of the postnatal development, or secondary (acquired stenosis) resulting from degenerative changes or as effects of local infection, trauma, or surgery. Degenerative LSS anatomically can involve the central canal, lateral recess, foramina, or any combination of these locations. Central canal stenosis may result from a decrease in the anteroposterior, transversal, or combined diameter secondary to loss of disc height with or without bulging of the intervertebral disc, and hypertrophy of the facet joints and the ligamentum flavum. Fibrosis is the main cause of ligamentum flavum hypertrophy and is caused by accumulated mechanical stress, especially along the dorsal aspect of the ligamentum flavum. The symptom most ascribed to LSS is neurogenic claudication, also known as pseudoclaudication. Neurogenic claudication refers to leg symptoms containing the buttock, groin, and anterior thigh, as well as radiating down the posterior part of the leg to the feet. In addition to pain, leg symptoms can include fatigue, heaviness, weakness and/or paresthesia. The symptoms can be unilateral or more commonly bilateral and symmetrical. The patient may suffer from accompanying back pain, but leg pain and discomfort are usually more troublesome. (Genevay, S., & Atlas, S. J. (2016). Advanced Health Assessment Musculoskeletal Pain

Turn the brief into deliverables

01
Identify which nerve roots might be involved, based on anatomy, given pain radiating to the left leg.
02
State how you would test for each nerve root you named.
03
Name the other symptoms that need to be explored.
04
Give your differential diagnoses for acute low back pain.
05
Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework.
06
Specify the physical examination you will perform.
07
Specify the special maneuvers you will perform.
08
Note: the brief states no word count, format or source minimum. Check your course shell for those before assuming any.

How should the nerve-root write-up be structured?

Anatomical localisation: which roots, and why these

Name the candidate roots — principally L4, L5 and S1, with L2–L3 considered if anterior thigh symptoms emerge — and tie each to the disc level that most often compresses it, establishing that unilateral leg radiation implicates a root rather than a peripheral nerve.

Testing each root: reflex, myotome, dermatome

Give each named root its own three-part test rather than describing a generic neurological exam — patellar reflex, ankle dorsiflexion and medial calf sensation for L4; extensor hallucis longus, great-toe dorsum sensation and the absence of a reliable reflex for L5; Achilles reflex, plantarflexion and sole sensation for S1.

Red-flag screen and further history

Set out the symptoms that must be explored before anything else: fever, unexplained weight loss, cancer history, prolonged corticosteroid use, IV drug use, recent trauma, and — most urgently — saddle anaesthesia, bladder or bowel dysfunction and progressive lower-limb weakness.

Differential diagnoses, discriminated against this case

Build the differential and, for each entry, state the feature of this case that raises or lowers it — lumbar disc herniation supported by unilateral radicular radiation; spinal stenosis weakened by the patient's age and the absence of a bilateral, walking-provoked pattern; also non-specific mechanical back pain, sacroiliac dysfunction, spondyloarthropathy and the serious red-flag causes.

The AHRQ framework applied, including what you will not order

Show the triage explicitly — this patient sorts into the sciatica/radiculopathy category with no red flags present — and then state the imaging decision that follows, including why a broad laboratory and imaging panel is not indicated at this point and what would change that.

Physical examination and special maneuvers

Separate the two as the prompt does: the systematic examination (gait, heel and toe walking, range of motion, palpation, the full neurological screen) and then the provocative manoeuvres — straight leg raise, crossed straight leg raise, slump test, femoral nerve stretch for upper roots, and FABER/Patrick's to interrogate the hip and sacroiliac joint as alternative pain sources.

Where is the AHRQ low back pain guidance found?

Recommended databases

NCBI Bookshelf (AHRQ/AHCPR guideline archive and StatPearls)
Cochrane Library
PubMed / MEDLINE
AHRQ Effective Health Care Program

Search sequence

1.
Retrieve the AHCPR Clinical Practice Guideline No. 14 quick reference on NCBI Bookshelf first, so the red-flag categories and the four-week imaging rule come from the framework the prompt actually names rather than from a secondary summary.
2.
Search Cochrane for the diagnostic accuracy review of physical examination in lumbar radiculopathy, and take the pooled sensitivity and specificity figures for the straight leg raise and crossed straight leg raise directly from it.
3.
Pull the StatPearls entries on radicular back pain and electrodiagnostic evaluation of lumbosacral radiculopathy for the autonomous sensory zones, so the dermatome claims you make are attributable.
4.
Check the current American College of Physicians guideline for where management has moved since 1994, and note explicitly where it agrees with or supersedes the AHRQ framework the prompt specifies.
5.
Do not cite the essay-mill and question-bank pages that dominate results for this exact case wording; they recycle each other and none is a primary source.

Reference shortlist

These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.

Nothing here is cleared for citation until you have read it.

01
Acute Low Back Problems in Adults: Assessment and Treatment (Quick Reference Guide Number 14)
Agency for Health Care Policy and Research (now AHRQ), via NCBI Bookshelf · 1994
The framework the prompt names. Source the red-flag categories and the statement that imaging is not usually helpful in the first four weeks of symptoms from here, so your triage is anchored to the guideline rather than paraphrased. It predates current imaging and treatment evidence, so do not use it for management recommendations.
02
Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain
Cochrane Database of Systematic Reviews · 2010
The operating characteristics for the special manoeuvres — pooled sensitivity of the straight leg raise against its poor specificity, and the inverse profile of the crossed straight leg raise. Use this to justify what each result lets you conclude. It is a diagnostic accuracy review, so it will not support any claim about treatment.
03
Radicular Back Pain (StatPearls)
StatPearls Publishing, via NCBI Bookshelf · 2024
Grounds the root-by-root testing section: which disc levels compress which roots, and the distinction between radicular pain and referred pain that the differential turns on.
04
Electrodiagnostic Evaluation of Lumbosacral Radiculopathy (StatPearls)
StatPearls Publishing, via NCBI Bookshelf · 2024
The autonomous sensory zones — anterior thigh for L2–L3, medial calf for L4, dorsum of the foot for L5, sole for S1 — so your dermatome mapping is attributable rather than recalled. Also useful for why L5 lacks a dependable deep tendon reflex.
05
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine · 2017
The contemporary counterpart to the 1994 framework. Cite it where you note that current guidance has moved on, which shows you know the AHRQ document's age without abandoning the framework the prompt required. It covers treatment, not diagnostic localisation, so it cannot support the nerve-root sections.

Review before submission

Common mistakes

Citing the AHRQ framework and then ordering the panel it advises against — CBC, ESR, HLA-B27, bone scan, CT and MRI all at once. Invoking a guideline whose central recommendation you have contradicted reads worse than not citing it.
Answering the nerve-root question with 'the sciatic nerve'. That is a peripheral nerve formed from L4-S3, not a root, and it does not tell the assessor which level you think is compressed.
Assigning L5 a deep tendon reflex. L5 has no dependable one, which is exactly why the myotome (extensor hallucis longus, great-toe extension) carries the weight at that level.
Naming the straight leg raise without stating what its result means. It is highly sensitive and poorly specific, so a negative test is the informative one — reporting a positive SLR as if it confirmed disc herniation misreads the evidence.
Leaving cauda equina syndrome out of the red-flag screen. Saddle anaesthesia, new bladder or bowel dysfunction and progressive weakness are the questions that have to be asked even when the presentation looks routine.
Treating 'radiates to his left leg' and 'for the past month' as scene-setting. Unilateral radiation is the evidence separating single-level radiculopathy from stenosis, and one month is the four-week threshold the imaging decision turns on.
Listing differentials without saying how you would discriminate between them in this patient — an enumeration is not diagnostic reasoning.

Submission checklist

Every root you named (L4, L5, S1, and L2-L3 if you included them) has its own reflex, myotome and dermatome test attached — not one generic neurological screen covering all of them.
The red-flag screen appears before the workup, and explicitly names the cauda equina questions you would ask.
You have stated which AHRQ triage category this patient falls into and what follows from that.
You have said what you are not ordering and why, not only what you are ordering.
Each differential carries the specific case feature that raises or lowers it.
The special maneuvers are separated from the routine examination, as the prompt separates them, and each provocative test is reported with what a positive or negative result licenses you to conclude.
The unilateral distribution and the one-month duration are each used somewhere as evidence, not just repeated as history.
Course-shell requirements for length, format and source count are confirmed, since the brief itself specifies none.

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