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 evaluation for both the back issue and breast mass. For the back pain with tingling in the right leg, naproxen 500mg twice daily with food can be prescribed, along with scheduling an MRI of the lumbar spine to evaluate for possible disc herniation or nerve impingement causing the radicular symptoms, as recommended by the American College of Physicians and the American Pain Society 1. The patient's history of a broken back that wasn't fully treated warrants imaging to assess current structural status. For the breast mass, an ultrasound should be scheduled promptly given the patient's family history of cancer and the noted tenderness on examination, as suggested by the American College of Radiology 1. The tingling in the right leg suggests possible nerve involvement which could indicate progression of his previous back injury. The breast mass requires evaluation to rule out gynecomastia versus a more concerning lesion, particularly with the family history of cancer. Both conditions require prompt attention - the back pain for pain management and to prevent potential neurological complications, and the breast mass for early detection of any malignancy. Some key points to consider in the evaluation and management of the patient's back pain include:

• The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management 1
• Magnetic resonance imaging (preferred if available) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions 1
• Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1
• For the breast mass, the American College of Radiology recommends that any woman presenting with a palpable lesion should have a thorough clinical breast examination, and imaging evaluation is necessary in almost all cases to characterize the palpable lesion 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.