A 55-year-old man comes to the office with 3 weeks of persistent low back pain. The pain increases in severity at night and when he lifts heavy objects. Over-the-counter naproxen initially improved the patient's pain slightly. There is no history of trauma. He has had no fever, weight loss, muscle weakness, urinary retention, bowel incontinence, or night sweats. The patient has no other medical problems and takes no other medications. He is a construction worker, has a 40-pack-year smoking history, and drinks 1 or 2 beers on weekends. Vital signs are within normal limits. Physical examination shows moderate paravertebral muscular tenderness. The range of motion of the spine is normal, and there is no scoliosis or excessive kyphosis. Neurologic examination is normal. Which of the following is the best next step in management of this patient?

Question

A 55-year-old man comes to the office with 3 weeks of persistent low back pain.  The pain increases in severity at night and when he lifts heavy objects.  Over-the-counter naproxen initially improved the patient's pain slightly.  There is no history of trauma.  He has had no fever, weight loss, muscle weakness, urinary retention, bowel incontinence, or night sweats.  The patient has no other medical problems and takes no other medications.  He is a construction worker, has a 40-pack-year smoking history, and drinks 1 or 2 beers on weekends.  Vital signs are within normal limits.  Physical examination shows moderate paravertebral muscular tenderness.  The range of motion of the spine is normal, and there is no scoliosis or excessive kyphosis.  Neurologic examination is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0a6_cd3c_8f63_8f6b38f6c144_MD0005_00 Most cases of low back pain are due to benign, self-limited musculoskeletal conditions, and diagnostic testing to identify specific causes generally does not improve outcomes. However, some patients have red flag features that increase the risk of infectious, malignant, or inflammatory conditions and warrant more aggressive evaluation: Constitutional symptoms (eg, fever, weight loss) Age >50 Intravenous drug use, immune suppression, or recent bacterial infection Nocturnal pain History of malignancy Although this patient's examination findings suggest benign musculoskeletal pain, his age, nocturnal pain, and smoking history raise concern for malignancy. He therefore warrants further evaluation with plain film spinal x-rays, which can often identify lytic bone lesions. Erythrocyte sedimentation rate (ESR) is also indicated; although this test is nonspecific, ESR can be elevated in infection, malignancy, and inflammatory conditions. If x-ray or ESR is abnormal, advanced imaging with MRI is indicated (Choice C). MRI is also indicated for patients with suspected infection (eg, vertebral osteomyelitis), lumbosacral radiculopathy (sciatica) lasting >1 month, known malignancy, significant neurologic deficits, or features of cauda equina syndrome (eg, saddle anesthesia, acute urine retention, motor deficits). (Choice A) Most patients with back pain should maintain moderate activity. Physical therapy is not usually necessary, although it may be useful for patients with poor functional status who are at risk for prolonged or recurrent pain. However, this patient has indications for diagnostic testing, which should be performed first. (Choice B) HLA-B27 is associated with spondyloarthropathies, especially ankylosing spondylitis (AS). Although AS characteristically causes pain that is worse at night and with prolonged rest, it usually presents at age <40 and is often associated with limited spinal mobility, hip and shoulder pain, peripheral arthritis, and enthesitis, which are not present in this patient. (Choice E) Radionuclide bone scan can identify osteomyelitis or spinal metastases but has lower sensitivity than MRI. It is typically recommended for patients who are unable to undergo MRI or CT imaging. Educational objective: Most cases of low back pain are due to benign musculoskeletal conditions. However, red flag features that warrant diagnostic evaluation include constitutional symptoms (eg, fever, weight loss), age >50, intravenous drug use, immune suppression, recent bacterial infection, nocturnal pain, and history of malignancy. Spinal x-ray can identify lytic bone lesions. Erythrocyte sedimentation rate is often elevated in infection, malignancy, and inflammatory conditions. References: Treatment: current treatment recommendations for acute and chronic undifferentiated low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/22958557) An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/24044786)

A 55-Year-Old Man Comes to the Office with 3 Weeks