What is the appropriate management for a 26-year-old male with a history of vertebral fracture, back pain, paresthesia in the right leg, and a palpable breast mass with a family history of cancer?

From the Guidelines

I strongly recommend prescribing naproxen for the patient's back pain while pursuing further diagnostic evaluation for both the back pain with leg tingling and the breast mass. For the back pain, naproxen 500mg twice daily with food for 7-10 days is appropriate, as it has worked well for the patient previously 1. The patient should be scheduled for spinal imaging (MRI preferred) to evaluate the previous back fracture and potential nerve compression causing the right leg tingling, which suggests possible radiculopathy 1. Some key points to consider in the diagnosis and treatment of low back pain include:

• Evaluating patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1
• Providing patients with evidence-based information on low back pain with regard to their expected course, advising patients to remain active, and providing information about effective self-care options 1 For the breast mass, an ultrasound should be scheduled promptly given the patient's family history of cancer and the tenderness on examination 1. The patient should be advised about naproxen's potential side effects including gastrointestinal irritation and advised to take it with food. The combination of symptoms—previous back fracture, new neurological symptoms (tingling), and a breast mass with family history of cancer—warrants timely follow-up for both conditions. The naproxen will help manage pain in the short term while diagnostic workup proceeds to address the underlying causes of both concerns. Some key points to consider in the diagnosis of breast masses include:
• A new palpable breast mass is a common presenting sign of breast cancer, and breast cancer may present as a palpable mass in women not undergoing regular screening mammography 1
• Determining if a mass is present by physical examination can be difficult, and imaging evaluation is necessary in almost all cases to characterize the palpable lesion 1
• The negative predictive value of mammography with ultrasound (US) in the context of a palpable mass ranges from 97.4% to 100% 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient's Back Pain and Tingling Sensation

• The patient is experiencing back pain and tingling sensation in his right leg, which may be related to his previous broken back injury 2.
• Naproxen has been prescribed to the patient, which he has used in the past to control his back pain, but its effectiveness in treating back pain after spinal surgeries is limited compared to gabapentin 2.
• Further imaging has been recommended to assess any underlying issues related to the tingling sensation in his leg.

Gabapentin as an Alternative Treatment

• Gabapentin has been shown to be more effective than naproxen in treating persistent pain after spinal surgeries, with a significant reduction in back pain and leg pain 2.
• Gabapentin may be a viable option for treating chronic low back pain without radiculopathy or neuropathy, although more data is needed to support its use 3.
• Gabapentin has also been shown to be effective in reducing neuropathic pain after spinal cord injury, with no significant difference in efficacy compared to pregabalin 4.

Interaction between Gabapentin and Naproxen

• Gabapentin and naproxen can interact synergistically to produce antihyperalgesia, suggesting that the use of gabapentin in low-dose combinations with naproxen may afford therapeutic advantages for clinical treatment of persistent inflammatory pain 5.
• The combination of gabapentin and naproxen may be more effective than either drug alone in reducing thermal hyperalgesia associated with peripheral inflammation 5.

Patient's Breast Mass

• The patient has reported a mass in his right breast, which requires further investigation, particularly given his family history of cancer.
• An ultrasound has been suggested to investigate the mass further, ensuring early detection and appropriate treatment if necessary.