What is the appropriate initial treatment for a 50-year-old patient presenting to the emergency department with severe back pain, muscle spasm, severe right hand pain, and tenderness to the upper back area and right hand?

Emergency Department Management of Severe Back Pain with Muscle Spasm and Right Hand Pain

Initiate NSAIDs (such as naproxen) combined with a skeletal muscle relaxant (cyclobenzaprine preferred) for immediate pain control and muscle spasm relief, while simultaneously ruling out serious underlying pathology through focused examination and selective imaging based on red flag findings. 1

Immediate Assessment for Red Flags

Before initiating treatment, perform a rapid focused examination to identify serious underlying conditions that require urgent imaging:

• Assess for severe or progressive neurologic deficits including motor weakness, sensory loss, or bowel/bladder dysfunction, which mandate immediate MRI or CT 1
• Evaluate for cauda equina syndrome (saddle anesthesia, urinary retention, bilateral leg weakness) requiring emergency imaging 1, 2
• Screen for vertebral infection particularly if fever, recent infection, or immunocompromise present—look for paravertebral muscle spasm and tenderness which can indicate paraspinal abscess 1
• Consider malignancy in patients over 50 years with unexplained weight loss or cancer history 1, 2
• Examine the right hand specifically for signs of radiculopathy (dermatomal sensory loss, motor weakness) or referred pain patterns 3

Pharmacologic Management

First-Line Therapy

Administer NSAIDs as the primary analgesic agent:

• NSAIDs are more effective for pain relief than acetaminophen (approximately 10 points better on a 100-point visual analogue scale) 1
• Assess cardiovascular and gastrointestinal risk factors before prescribing, and use the lowest effective dose for the shortest duration 1
• Consider co-administration with a proton-pump inhibitor in higher-risk patients 1

Adjunctive Muscle Relaxant Therapy

Add a skeletal muscle relaxant for short-term relief of muscle spasm:

• Cyclobenzaprine is the preferred agent based on the most recent and largest clinical trials demonstrating efficacy independent of sedation 4, 5
• Cyclobenzaprine 5 mg three times daily is effective and has fewer side effects than the 10 mg dose 4
• The combination of cyclobenzaprine with naproxen is superior to naproxen alone for reducing objective muscle spasm, tenderness, and improving range of motion 6
• Warn patients about drowsiness as the most common side effect 4, 6
• Avoid carisoprodol due to abuse potential 5

Severe Pain Management

Reserve opioids or tramadol only for severe, disabling pain uncontrolled by NSAIDs and muscle relaxants:

• Use judiciously with careful consideration of abuse potential 1
• Failure to respond to a time-limited course should prompt reassessment and consideration of alternative diagnoses 1

Imaging Strategy

Do NOT routinely obtain imaging in the absence of red flags:

• Routine plain radiography or advanced imaging (MRI/CT) is not associated with improved outcomes in nonspecific low back pain 1, 2
• Unnecessary imaging exposes patients to radiation and identifies abnormalities poorly correlated with symptoms 1

Obtain immediate MRI (preferred) or CT if:

• Severe or progressive neurologic deficits are present 1
• Suspected vertebral infection, cauda equina syndrome, or cancer with impending spinal cord compression 1, 2
• MRI provides better visualization of soft tissue, vertebral marrow, and spinal canal without ionizing radiation 1

Consider MRI for radiculopathy evaluation if:

• The right hand pain follows a dermatomal distribution with positive straight leg raise (91% sensitivity for herniated disc) 3
• Patient is a potential candidate for surgery or epidural steroid injection 1, 3
• Symptoms persist after 4-6 weeks of conservative management 3, 2

Patient Education and Disposition

Provide evidence-based reassurance and activity guidance:

• Inform the patient that most cases improve substantially within the first month 2
• Advise the patient to remain active rather than bed rest, which is more effective for acute low back pain 1, 2
• Arrange follow-up within 1 month for patients without red flags 2
• Schedule earlier reevaluation if severe pain, functional deficits, or signs of radiculopathy develop 1

Critical Pitfalls to Avoid

• Do not delay imaging in patients with neurologic deficits—delayed diagnosis of cauda equina syndrome or spinal cord compression leads to poorer outcomes 1
• Do not prescribe opioids as first-line therapy—combination NSAID plus muscle relaxant is superior and safer 1, 7
• Do not obtain routine imaging without red flags—this leads to unnecessary interventions without improving outcomes 1, 2
• Do not overlook vertebral infection in patients with paravertebral muscle spasm and tenderness, especially with systemic signs 1