A 28-year-old man presents to urgent care with a chief complaint of low back pain for 3 days after lifting a heavy box at work in a warehouse. He describes the pain as a sudden onset, dull ache in his lumbar region, and he rates his pain as 6/10. He denies radiation to the legs, numbness or tingling, or any prior history of back pain. The pain is worse with movement, especially bending forward. He has slight improvement with rest. His past medical history is unremarkable.
On physical examination, the patient’s vital signs are stable and normal. There is normal spinal alignment with no bruising or swelling detectable. There is no tenderness over the lower lumbar paraspinal muscles and no midline spine tenderness. He exhibits pain on flexion, limited range of motion, and normal gait. The straight leg raise test is negative.
What is the most appropriate next step in the management of this patient?
- Discharge this patient home with over-the-counter ibuprofen 600 mg PO every 6 hours for pain and instructions to resume activity as tolerated and seek further medical evaluation if symptoms worsen or do not improve.
- Refer this patient to the emergency department for intravenous pain control and imaging.
- Take 3-view x-rays and prescribe methocarbamol 1000 mg PO 4 times per day for 5 days before discharge.
- Inform the patient that he’s young and the pain will eventually go away.
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Correct Answer: a. Discharge this patient home with over-the-counter ibuprofen 600 mg PO every 6 hours for pain and instructions to resume activity as tolerated and seek further medical evaluation if symptoms worsen or do not improve.
Your diagnosis is acute mechanical low back pain from a muscle strain. Because the patient had no warning signs for serious conditions such as cauda equina syndrome, fracture, infection, or cancer, there was no need for imaging. You reassured the patient that although the pain is uncomfortable and may seem better with rest, he should avoid staying in bed for long periods. You advised him to not lift anything heavier than 10 pounds for the next 7 to 10 days and to use proper lifting techniques.
You also discussed nondrug treatments that might help with the pain, such as massage, physical therapy, yoga, and heat or ice therapy. Finally, your discharge instructions included warning signs to look out for (eg, leg weakness, numbness, or problems with bladder or bowel control) and advice to return if these symptoms develop.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
