A 61-year-old woman comes to the office due to low back pain for the past 2 weeks. The patient has a constant, dull, aching pain that is more pronounced at night and has awakened her from sleep on several occasions. She has had no trauma or previous back conditions and attributes the pain to prolonged bending over while gardening. There is no associated fever, chills, bowel or bladder incontinence, or lower extremity weakness or numbness. Medical history is notable for hypertension and early-stage breast cancer at age 55, which was treated with lumpectomy, radiation therapy, and hormonal therapy. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 134/86 mm Hg, pulse is 76/min, and respirations are 12/min. Head and neck, cardiac, lung, breast, and abdominal examinations show no abnormalities. Spinal examination shows no deformities or focal tenderness. Lower extremity motor strength and reflexes are normal and symmetric. Straight-leg raising test is negative. Which of the following is the most appropriate next step in management of this patient?

Question

A 61-year-old woman comes to the office due to low back pain for the past 2 weeks.  The patient has a constant, dull, aching pain that is more pronounced at night and has awakened her from sleep on several occasions.  She has had no trauma or previous back conditions and attributes the pain to prolonged bending over while gardening.  There is no associated fever, chills, bowel or bladder incontinence, or lower extremity weakness or numbness.  Medical history is notable for hypertension and early-stage breast cancer at age 55, which was treated with lumpectomy, radiation therapy, and hormonal therapy.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 134/86 mm Hg, pulse is 76/min, and respirations are 12/min.  Head and neck, cardiac, lung, breast, and abdominal examinations show no abnormalities.  Spinal examination shows no deformities or focal tenderness.  Lower extremity motor strength and reflexes are normal and symmetric.  Straight-leg raising test is negative.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d2ea_73cb_bc81_43902daa78d2_MD0003_00 Most cases of acute (ie, <4 weeks) low back pain have a benign etiology and spontaneous resolution; imaging generally does not improve outcomes and is not recommended. However, spinal imaging is indicated for patients at risk for infection, malignancy, or bony abnormalities (eg, compression fracture). Red flag features that warrant imaging include: Sudden onset of pain with spine tenderness History of cancer Constitutional symptoms (eg, fever, unexplained weight loss) Trauma Significant or progressive neurologic deficits (eg, acute bowel/bladder incontinence, lower extremity weakness) Elevated risk of spinal infection (eg, recent infection, immunosuppression, intravenous drug use) This patient has features suggesting malignant back pain (nocturnal pain, history of malignancy) that warrants imaging; plain-film x-rays can be performed quickly and can often identify signs of malignancy. Inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) can increase sensitivity and are also advised. If the initial tests are abnormal, MRI is done for diagnostic confirmation. MRI without a preceding x-ray is indicated for patients with significant neurologic deficits or cauda equina syndrome (eg, saddle anesthesia, urine retention). MRI is also used for patients with suspected spinal infection (eg, epidural abscess, osteomyelitis). Different guidelines may recommend slightly different approaches to imaging modalities. (Choice A) Epidural corticosteroid injection is indicated for chronic radicular pain (eg, due to herniated disk) that has failed noninvasive treatment but not for acute nonradicular pain, as in this patient. (Choices C and E) Uncomplicated pain with no red flag features can be managed symptomatically with nonsteroidal anti-inflammatory drugs (NSAIDs). Opioids are not more effective than NSAIDs and are not recommended for initial therapy. Regardless, this patient requires additional evaluation first. (Choice D) Physical therapy referral for a supervised exercise program is used primarily for patients with persistent (ie, >4 weeks) back pain and can be considered for those with risk factors for chronic pain disorders (eg, poor functional status, psychiatric comorbidity). Educational objective: Although spinal imaging is not recommended for uncomplicated acute low back pain, imaging is warranted for patients with suspected malignancy, infection, or bony abnormalities. X-ray and inflammatory markers (eg, erythrocyte sedimentation rate) are recommended for patients with suspected malignant pain. MRI is indicated for patients with abnormal findings on initial tests, significant neurologic deficits, or cauda equina syndrome. References: Diagnosis and treatment of acute low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/22335313)

A 61-Year-Old Woman Comes to the Office Due to Low