What is the treatment for a patient presenting with lower back pain, diagnosed with slight lumbar levocurvature and preserved disc space, in the Emergency Department (ED)?

From the Guidelines

For lower back pain with a normal X-ray showing no significant abnormalities, I recommend starting with conservative management. The X-ray results indicate 5 nonrib-bearing lumbar vertebral bodies, slight lumbar levocurvature, which may be positional, and no significant facet arthropathy or acute fracture, suggesting that the pain is likely due to muscular or ligamentous strain 1. According to the American College of Physicians and the American Pain Society, clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain, and should instead provide patients with evidence-based information on low back pain and advise them to remain active 1.

Treatment Approach

• Take over-the-counter pain relievers like acetaminophen or nonsteroidal anti-inflammatory drugs (such as ibuprofen 400-600mg every 6-8 hours or naproxen 220-440mg twice daily) with food for 5-7 days to reduce inflammation and pain, as recommended by the guidelines 1.
• Apply ice for the first 48-72 hours (20 minutes on, 20 minutes off), then switch to heat therapy.
• Maintain gentle movement rather than strict bed rest, and try light stretching exercises for the lower back.
• Consider nonpharmacologic therapy with proven benefits, such as spinal manipulation, exercise therapy, or cognitive-behavioral therapy, if symptoms persist 1.

Monitoring and Follow-up

• If symptoms worsen (severe pain, numbness/tingling in legs, bowel/bladder issues), seek immediate medical attention.
• The patient's X-ray shows normal alignment with slight curvature that may be due to positioning during the test, with no fractures, arthritis, or disc space narrowing, suggesting that this is likely a self-limiting condition that should improve with conservative measures within 1-2 weeks 1.

From the FDA Drug Label

In three of these studies there was a significantly greater improvement with cyclobenzaprine than with diazepam, while in the other studies the improvement following both treatments was comparable The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

Treatment for Lower Back Pain:

• Cyclobenzaprine hydrochloride tablets may be used to treat lower back pain, as demonstrated by clinical trials showing significant improvement in patients with acute musculoskeletal conditions, including backache.
• The recommended dose is 5 mg, which has been shown to be effective in reducing muscle spasm and improving patient outcomes.
• It is essential to note that cyclobenzaprine should be used with caution in certain patient populations, such as the elderly and those with hepatic impairment 2.

From the Research

Diagnosis and Treatment of Lower Back Pain

• The patient's X-ray results show 5 nonrib-bearing lumbar vertebral bodies, slight lumbar levocurvature, and grossly preserved disc space, with no significant facet arthropathy or acute fracture 3.
• The diagnosis and treatment of lower back pain involve a comprehensive approach, including patient history, physical examination, and diagnostic testing 4.
• Treatment options for lower back pain include nonpharmacologic and pharmacologic interventions, with nonsteroidal anti-inflammatory drugs (NSAIDs) being the initial medication of choice 5.

Nonpharmacologic Treatment Options

• Nonpharmacologic treatment options for lower back pain include counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 3.
• A multidisciplinary approach to treatment is most effective for chronic back pain patients, and can include multimodal medical, psychological, physical, and interventional approaches 4.

Pharmacologic Treatment Options

• Pharmacologic treatment options for lower back pain include NSAIDs, duloxetine, and opioids, although the use of opioids is not recommended except for short-term symptom relief in patients with radicular pain 3, 5.
• The effects of paracetamol, muscle relaxants, antibiotics, and antidepressants for lower back pain are unclear or have limited evidence, and should only be prescribed after a discussion between the treating clinician and the patient 5.

Role of Imaging and Diagnostic Testing

• Routine imaging is not recommended for lower back pain, but may be indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy 3.
• Electrodiagnostic study (EDX) and magnetic resonance imaging (MRI) can be used to diagnose and evaluate lower back pain, with EDX having a higher specificity than MRI in terms of physical examination data 6.
• MRI interpretation becomes necessary when physical treatment is not working, and can help identify underlying conditions such as disc herniation or spinal stenosis 7.