What should be done for sudden onset severe lower back pain radiating down the left leg, exacerbated by movement, unrelieved by Paracetamol (acetaminophen)?

Telephone Triage for Acute Lower Back Pain with Sciatica

Immediate Assessment for Red Flags

This patient requires same-day evaluation, but does not need emergency ambulance transport based on the information provided. 1, 2

You must immediately assess for cauda equina syndrome by asking about:

• Saddle anesthesia (numbness around the buttocks, perineum, or inner thighs) 1, 2
• Bowel or bladder dysfunction (loss of control, urinary retention beyond normal voiding patterns) 1, 2
• Progressive bilateral leg weakness or inability to stand 1, 2
• Severe or rapidly worsening neurological deficits 1, 3

The patient mentions not passing urine since pain started (1 hour ago), but this appears related to immobility rather than true urinary retention. Clarify if he has the urge to void but cannot, or simply hasn't needed to void yet. True urinary retention would be a red flag requiring immediate emergency department evaluation. 1, 2

Clinical Reasoning for This Case

This presentation is consistent with acute lumbar radiculopathy (sciatica) - the electric shock-like pain radiating down the left leg following heavy lifting is classic for nerve root compression, likely at L5 or S1 level. 4, 1

The patient does NOT require a home visit for an injection. This expectation should be respectfully redirected, as:

• Injectable medications offer no proven superiority over oral medications for this condition 4
• Home visits are not indicated for uncomplicated acute back pain 1, 2
• The severe movement-related pain will improve with appropriate oral medication and time 1, 3

Recommended Management Plan

Immediate Medication Adjustment

Add an NSAID immediately - the paracetamol alone is insufficient for acute sciatica. 4, 1, 3

• Ibuprofen 400-600mg every 6-8 hours with food (or naproxen 500mg twice daily) provides moderate efficacy for acute sciatica 4, 1, 3
• NSAIDs show moderate efficacy specifically for opioids in patients with acute sciatica, whereas NSAIDs show no difference from placebo in sciatica 4
• Continue paracetamol 1g every 6 hours (maximum 4g/day) in combination with the NSAID 1, 3
• Screen for NSAID contraindications: history of peptic ulcer disease, cardiovascular disease, renal impairment, or concurrent anticoagulation 3

Add Muscle Relaxant for Severe Spasm

Prescribe a skeletal muscle relaxant for short-term use given the severe movement-related pain and likely muscle spasm. 4, 3

• Options include cyclobenzaprine 5-10mg three times daily or methocarbamol 1500mg four times daily 4, 3
• Warn about sedation - this is the most common side effect and may impair his ability to work 4, 3
• Prescribe for 3-5 days only, not extended courses 4, 3

Activity Guidance - Critical Component

Advise him to remain as active as pain permits, but bed rest is explicitly contraindicated. 1, 2, 3

• He should move gently and frequently rather than staying completely still on the floor 1, 2, 3
• Prolonged immobility will worsen outcomes and delay recovery 1, 2, 3
• Apply heat using a heating pad or hot water bottle to the lower back for 15-20 minute intervals for symptomatic relief 1, 2, 3
• Most patients experience substantial improvement within 4-6 weeks regardless of treatment 1, 2

Work Expectations

He should not go to work today. 1, 2

• The severity of pain with movement makes safe job performance as a police officer impossible and potentially dangerous 1
• Reassure him that 90% of acute low back pain episodes resolve within 6 weeks, and staying active within pain limits promotes faster recovery than pushing through severe pain 2
• Provide a sick note for 3-5 days with plan to reassess 1, 2

Opioid Consideration

Opioids should be reserved only if the above regimen fails to provide adequate relief after 24-48 hours. 4

• The American College of Physicians and American Pain Society recommend opioids only for severe, disabling pain not controlled by acetaminophen or NSAIDs 4
• If needed, prescribe the lowest effective dose for ≤3 days (rarely more than 7 days) 4, 3
• Early opioid exposure increases risk for long-term use and disability 4
• Options would include oxycodone 5mg every 4-6 hours as needed (not extended-release formulations) 4

Follow-Up Plan

Arrange telephone follow-up in 48 hours to assess response to treatment. 1, 3

If no improvement or worsening symptoms:

• Schedule in-person evaluation within 1 week to assess for progressive neurological deficits 1, 2
• Imaging (MRI) is NOT indicated unless symptoms persist beyond 4-6 weeks or there are progressive neurological deficits 1, 2
• Refer for spinal manipulation by appropriately trained provider if medication fails, as this shows small to moderate short-term benefits 1, 3

Key Pitfalls to Avoid

• Do not prescribe bed rest - this delays recovery and worsens disability 1, 2, 3
• Do not order imaging now - findings are often nonspecific and do not improve outcomes in the absence of red flags 2
• Do not prescribe systemic corticosteroids - they are no more effective than placebo for acute low back pain with or without sciatica 3
• Do not provide false reassurance about immediate return to full duty - realistic expectations improve patient satisfaction and compliance 1, 2