Review Question - QID 102726

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Low Back Pain Treatment In the absence of 'red-flag' symptoms, treat conservatively QID: 102726 (M3.NE.15.8)

QID 102726 (Type "102726" in App Search)

A 48-year-old man presents to his primary care physician with a complaint of lower back pain that has developed over the past week. He works in construction but cannot recall a specific injury or incident that could have led to this pain. He denies any pain, weakness, or change/loss of sensation in his legs. The patient also reports no episodes of incontinence and confirms that he has not noted any changes in his bowel movements or urination. His temperature is 97.6°F (36.4°C), blood pressure is 133/82 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical examination reveals no focal spine tenderness and demonstrates 5/5 strength and intact sensation to light touch throughout the lower extremities. Which of the following is the most appropriate next step in management?

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CRP level

0/5

CT spine

0/5

Ibuprofen and bed rest

0/5

MRI spine

0/5

Naproxen and activity as tolerated

100%

5/5

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This patient is suffering from lower back pain without any associated red flag symptoms suggesting a diagnosis of lumbago or a muscle strain. NSAIDs (such as naproxen) and activity as tolerated are an appropriate management of lower back pain.

A musculoskeletal strain is the most common cause of lower back pain. Most cases of back pain resolve completely without any intervention. The treatment of lower back pain includes NSAIDs or acetaminophen for pain relief and activity as tolerated with avoidance of bed rest. Red flag symptoms that warrant further workup, laboratory studies, or imaging include the following:

1. Trauma
2. Neurologic symptoms (such as weakness or changes in sensation)
3. Incontinence or urinary retention
4. History of cancer
5. Fever/chills
6. Saddle anesthesia or loss of anal sphincter tone
7. Focal spine tenderness
8. IV drug use or immunosuppression

If there are any red flag symptoms in a patient with back pain, careful consideration for more serious diagnoses should be considered.

Incorrect Answers:
Answer 1: CRP level could be useful in differentiating a muscle strain from an infectious etiology of back pain. For example, back pain in an IV drug user may warrant a CRP/ESR level. If these levels are elevated, it could suggest discitis, osteomyelitis, or an epidural abscess.

Answer 2: CT spine could be indicated in blunt trauma with focal spine tenderness to rule out a fracture.

Answer 3: Ibuprofen and bed rest is inappropriate in the management of lower back pain as bed rest could actually lead to a worsening of this patient's long-term back pain.

Answer 4: MRI spine would be indicated for an alarming presentation of back pain such as cauda equina syndrome (back pain, urinary/bowel incontinence, and saddle anesthesia) or an epidural abscess (an IV drug user with fever, chills, focal back pain, and an elevated ESR/CRP).

Bullet Summary:
The management of lower back pain without alarming findings is NSAIDs, acetaminophen, and activity as tolerated.

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