From the Guidelines
I strongly advise against proceeding with the lumbar spine x-ray as initially planned, given the patient's presentation of nonspecific low back pain without signs of radiculopathy or spinal stenosis, as evidenced by the American College of Physicians and the American Pain Society's joint clinical practice guideline 1. The patient's complaint of pain in the lower right side of the back, without any reported injury or red flags, suggests a case of nonspecific low back pain.
- The patient's history of celiac disease, which is under control, and previous right knee surgery, does not directly influence the decision for immediate diagnostic imaging for back pain.
- The guideline recommends against routine imaging or other diagnostic tests in patients with nonspecific low back pain, citing moderate-quality evidence that it does not improve patient outcomes and exposes them to unnecessary ionizing radiation 1. For immediate pain management, methocarbamol 1000 mg twice daily as needed for two weeks and ibuprofen 400 mg can be prescribed to help with muscle spasms and inflammation, respectively.
- Since the patient declined physical therapy but requested a steroid injection, it would be prudent to reassess the patient's condition after a period of conservative management before considering invasive procedures like steroid injections. A follow-up appointment should be scheduled to reassess the patient's symptoms and consider further diagnostic evaluation or treatment options if there is no improvement, as suggested by the guideline's recommendation for reevaluation after 1 month in patients with persistent, unimproved symptoms 1.
From the Research
Patient Treatment Plan
The patient is complaining of pain in the lower right side of the back and is requesting a steroid injection in his right hip. The treatment plan includes:
- Prescribing an x-ray of the lumbar spine to determine the cause of the pain
- Methocarbamol (1000 mg BID PRN) for two weeks to relieve muscle spasms and pain 2
- Ibuprofen (400 mg) to reduce inflammation and pain
- Scheduling a follow-up appointment to review the x-ray and give a steroid injection to his right hip
Rationale for Treatment Plan
The use of methocarbamol is supported by a study that found it to be an efficient and well-tolerated therapeutic option for patients suffering from acute low back pain and associated restrictions of mobility 2. The patient's denial of any injury to his back and his history of right knee surgery and problems with his knee for many years may be contributing factors to his back pain. However, there is a lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies 3.
Considerations for Steroid Injection
The effectiveness of steroid injections for radicular pain due to disc herniation is supported by strong evidence, with success rates ranging from 63% to 74% at one to three months 4. However, the effectiveness of steroid injections for radicular pain due to spinal stenosis is less clear, with a lack of high-quality evidence demonstrating their effectiveness 4. The choice of steroid type, particulate or non-particulate, may also affect the outcome, with triamcinolone being superior for severe lumbar radiculopathy and dexamethasone being equally effective for mild to moderate pain 5.
Patient Decline of PT
The patient declined physical therapy (PT), which may be a useful adjunct to steroid injections for improving quality of life factors such as emotional function, emotional well-being, and perception of general health 6.