A 48-year-old man comes to the emergency department due to a 3-day history of worsening low back pain. He had no significant trauma to account for the pain, which started after he drove 12 hours in a day while returning from vacation. The patient says, "As long as I stay in bed or in a recliner, it's okay, but if I twist, bend over, or stand up too fast the pain is excruciating." He has tried using a heating pad with no relief. Medical history is unremarkable, and he takes no medications. Vital signs are normal. Examination shows reduced lumbar lordosis and tenderness in the right midlumbar paraspinal area. Motor strength, reflexes, and sensation in the lower extremities are normal. With the patient supine and the knee extended, lifting the right leg over 60 degrees elicits achy pain in the posterior thigh. Which of the following is the most appropriate next step in management?

Question

A 48-year-old man comes to the emergency department due to a 3-day history of worsening low back pain.  He had no significant trauma to account for the pain, which started after he drove 12 hours in a day while returning from vacation.  The patient says, "As long as I stay in bed or in a recliner, it's okay, but if I twist, bend over, or stand up too fast the pain is excruciating."  He has tried using a heating pad with no relief.  Medical history is unremarkable, and he takes no medications.  Vital signs are normal.  Examination shows reduced lumbar lordosis and tenderness in the right midlumbar paraspinal area.  Motor strength, reflexes, and sensation in the lower extremities are normal.  With the patient supine and the knee extended, lifting the right leg over 60 degrees elicits achy pain in the posterior thigh.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: This patient has acute, uncomplicated low back pain. He has no apparent neurologic deficits, and his examination shows nonspecific features (paraspinal tenderness, reduced lumbar lordosis) that are common in benign lumbosacral strain. In addition, the presence of hamstring pain (eg, achy pain in the posterior thigh) on the straight-leg raising (SLR) test represents a negative finding, suggestive of a nonradicular etiology of pain; positive findings on the SLR include the presence of shooting or burning pain radiating to the calf and foot. Most young (ie, age <50) patients with acute low back pain can be managed empirically based on clinical features; diagnostic testing (ie, laboratory studies, imaging) is not associated with improved outcomes and is not routinely recommended. Patients should be advised to maintain normal, moderate activity; bed rest is associated with prolonged recovery times and is not recommended (Choice C). Other nonpharmacologic interventions that may be considered include heat, massage, and spinal manipulation. If medication is needed for pain relief, nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen) are first-line analgesics and are adequate for most patients. Acetaminophen is less effective but can be considered for patients with contraindications to NSAIDs. If pain persists, nonbenzodiazepine muscle relaxants (eg, cyclobenzaprine, tizanidine) can be added. However, opioids are not more effective than NSAIDs and are not recommended. (Choice A) Inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) are used in the evaluation of inflammatory back pain (ie, chronic, progressive pain and stiffness that are worse at night and with prolonged rest) and in patients with increased risk of infection (eg, intravenous drug use) or malignancy. (Choice B) MRI of the lumbar spine is indicated for patients with significant neurologic compromise (eg, cauda equina syndrome, severe/progressive radiculopathy) or suspected epidural abscess (eg, fever, history of intravenous drug use). (Choice E) X-ray of the lumbar spine is useful in patients with suspected vertebral metastasis (eg, history of cancer, nocturnal pain, unexplained weight loss). It is also used to confirm an osteoporotic vertebral compression fracture (eg, postmenopausal woman, midline tenderness). Educational objective: For patients with acute, uncomplicated low back pain, diagnostic testing (eg, laboratory studies, imaging) is not routinely required. Patients should be advised to maintain regular, moderate activity. When needed, nonsteroidal anti-inflammatory drugs are the first-line medication. References: Non-specific low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/27745712)

A 48-Year-Old Man Comes to the Emergency Department Due to a 3-Day