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Case presentation
M.R., a 42-year-old warehouse worker, presents with six days of aching lower back pain that began after lifting boxes. The pain is worse with bending and eases when lying down. He rates it 6/10 and has had partial relief from over-the-counter ibuprofen.
Focused history and red-flag screen
He denies pain radiating below the knee, numbness, weakness, saddle anesthesia, and bladder or bowel changes. He reports no fever, night sweats, unintended weight loss, history of cancer, injection drug use, recent infection, trauma or long-term steroid use. Without these red flags, serious causes such as cauda equina syndrome, malignancy, spinal infection or fracture are unlikely.
Focused examination
Vital signs are within normal limits. There is tenderness over the right lumbar paraspinal muscles, and flexion is limited by pain. Straight-leg raise is negative bilaterally. Lower-extremity strength is 5/5, patellar and Achilles reflexes are 2+ and symmetric, and sensation is intact across the L4 to S1 dermatomes. There is no costovertebral angle tenderness (Bickley et al., 2021).
Differential diagnosis
- Acute nonspecific (mechanical) low back pain from a lumbar strain: most likely, given the lifting mechanism, paraspinal tenderness and a normal neurologic exam.
- Lumbar radiculopathy from a herniated disc: less likely; there is no radiating leg pain, the straight-leg raise is negative and there are no dermatomal deficits.
- Renal causes such as nephrolithiasis or pyelonephritis: unlikely; there is no colicky pain, fever, urinary symptoms or costovertebral angle tenderness.
- Cauda equina syndrome, spinal infection or malignancy: not supported by the history or examination.
Diagnostic plan
No imaging is ordered. For acute low back pain without red flags or signs of serious neurologic involvement, routine imaging doesn't improve outcomes and adds cost and radiation exposure (Chou et al., 2011).
Management and follow-up
Most patients with acute low back pain improve over time regardless of treatment. First-line options are nonpharmacologic: superficial heat, massage, acupuncture or spinal manipulation. If medication is wanted, an NSAID or a skeletal muscle relaxant is appropriate (Qaseem et al., 2017). M.R. is advised to stay active and to return at once for new leg weakness, numbness, fever, or bladder or bowel changes. Follow-up is planned in four weeks if the pain isn't improving.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Chou, R., Qaseem, A., Owens, D. K., Shekelle, P., & Clinical Guidelines Committee of the American College of Physicians. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Annals of Internal Medicine, 154(3), 181–189. https://doi.org/10.7326/0003-4819-154-3-201102010-00008
Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., & Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367
