A 29-year-old woman comes to the office due to back pain. For the last week, she has had moderate, nonradiating pain in the low back that started after she spent the weekend raking leaves in her yard. The patient attempted treatment with a heating pad and ibuprofen but had no relief. She has no associated fever, lower extremity weakness, or urinary symptoms. Medical history is unremarkable, and the patient takes no other medications. Vital signs are normal. BMI is 34 kg/m². Examination shows tenderness in the right lumbar paraspinal region with normal neurologic findings in the lower extremities. Straight-leg raising test is negative. Which of the following is the most appropriate next step?

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11ec25c8_d22e_c4e8_bc81_2b2182070a5b_MD0003_00 This patient has acute low back pain (LBP) with no evidence of neurologic injury and no features (eg, fever, history of malignancy) that would suggest a potentially serious cause. Her pattern of moderate, nonradiating pain with paraspinal tenderness suggests a benign cause, likely paraspinal muscle strain. Most cases of acute LBP resolve spontaneously; management is focused primarily on interventions to provide temporary relief with minimal risk for adverse effects. Nonpharmacologic interventions include heat, massage, and spinal manipulation. In addition, patients should be advised to maintain normal, moderate activity and exercise (Choice C). Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen) are also useful as first-line drug therapy; acetaminophen is less effective but can be considered for patients with contraindications to NSAIDs (eg, chronic kidney disease). If NSAIDs are ineffective, a short course of a nonbenzodiazepine muscle relaxant (eg, cyclobenzaprine, tizanidine) can provide additional pain relief. Primary adverse effects include drowsiness and anticholinergic symptoms (eg, dry mouth, constipation). However, benzodiazepines (eg, alprazolam) and carisoprodol are less effective, carry a significant risk of abuse, and are not recommended. (Choice B) Opioid analgesics are not well-studied for acute LBP; however, available evidence suggests that they are no more effective than NSAIDs, and they are not recommended over muscle relaxants. (Choice D) Indications for MRI include significant neurologic deficits (eg, saddle anesthesia) or concern for epidural abscess (eg, fever, intravenous drug abuse). It is not recommended for patients with uncomplicated, acute LBP, who are highly unlikely to have a serious underlying etiology. In addition, incidental imaging findings are common, which can lead to further unnecessary interventions. (Choice E) X-ray is considered for patients with back pain due to compression fracture or suspected vertebral metastasis, but it has limited utility in uncomplicated LBP. Educational objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line drug therapy for acute, uncomplicated low back pain. If NSAIDs are ineffective, a short course of a nonbenzodiazepine muscle relaxant (eg, cyclobenzaprine, tizanidine) can provide additional pain relief. References: Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/28192789)

A 29-Year-Old Woman Comes to the Office Due to Back