What is the next recommendation for a patient with lower back pain after lifting something heavy and complaining of subjective fever and chills?

Management of Lower Back Pain with Fever and Chills After Heavy Lifting

For a patient with lower back pain after lifting something heavy who is also complaining of subjective fever and chills, urgent evaluation for possible vertebral osteomyelitis is strongly recommended, including blood cultures, ESR/CRP testing, and spine MRI. 1

Initial Assessment and Risk Stratification

The combination of lower back pain with fever and chills raises significant concern for potentially serious underlying conditions beyond mechanical back pain:

• The presence of fever with new back pain is a strong indicator to suspect native vertebral osteomyelitis (NVO) 1
• This presentation requires different management than typical mechanical low back pain 1, 2

Key Diagnostic Steps:

1. Blood tests (urgent):

   • Two sets of bacterial (aerobic and anaerobic) blood cultures 1
   • ESR and CRP levels 1
   • Complete blood count to evaluate for leukocytosis

2. Imaging:

   • MRI of the spine is the preferred imaging modality 1, 2
   • If MRI is contraindicated or unavailable, consider combination spine gallium/Tc99 bone scan, CT scan, or PET scan 1

3. Physical examination focus:

   • Detailed neurological assessment (motor/sensory function) 1
   • Spine percussion tenderness
   • Signs of systemic infection
   • Assessment for potential entry sources of infection 1

Management Algorithm

If Red Flags Present (fever, chills):

1. Immediate steps:

   • Obtain blood cultures and inflammatory markers before starting antibiotics 1
   • Consider infectious disease specialist consultation 1
   • Spine surgeon evaluation may be warranted 1

2. If vertebral osteomyelitis is confirmed:

   • Appropriate antimicrobial therapy based on culture results
   • Pain management with NSAIDs or acetaminophen 1, 2, 3
   • Activity modification based on severity and neurological status

If Mechanical Back Pain Without Concerning Features:

If fever and chills resolve and infection is ruled out, management should follow standard guidelines for mechanical low back pain:

1. First-line medications:

   • NSAIDs as first-line treatment 1, 2
   • Acetaminophen as an alternative for those who cannot take NSAIDs 1, 2, 3
   • Topical NSAIDs with or without menthol gel 2

2. Activity recommendations:

   • Avoid bed rest 1, 2
   • Remain active with appropriate modifications 1, 2
   • Provide education on proper body mechanics for lifting 2

3. Second-line options (if pain persists after 2-4 weeks):

   • Consider muscle relaxants (e.g., cyclobenzaprine 5-10mg at bedtime) 2
   • For radicular component, consider neuropathic pain medications 2

Important Considerations and Pitfalls

• Don't delay appropriate imaging when red flags are present - fever with back pain is a significant red flag that warrants immediate investigation 1, 2
• Avoid premature use of antibiotics before obtaining cultures - this can reduce diagnostic yield
• Monitor closely for progression of symptoms - worsening neurological deficits or development of bowel/bladder dysfunction requires emergency evaluation 1, 2
• Avoid prolonged opioid use - there is limited evidence for long-term benefit and significant risk of dependence 2

Follow-up Recommendations

• Close follow-up within 48-72 hours to reassess symptoms and review test results
• If symptoms persist beyond 6 weeks despite appropriate management, consider additional imaging or specialist referral 2
• For patients with confirmed infection, regular monitoring of inflammatory markers to assess treatment response 1

The presence of fever and chills with back pain significantly changes the diagnostic approach from typical mechanical back pain management, necessitating a more urgent and thorough evaluation to rule out serious spinal infections.