What is the best course of treatment for a male adult patient with a history of diabetes (Diabetes Mellitus) and nephrolithiasis, presenting with left-sided back pain?

Management of Left-Sided Back Pain in a Male Adult with Diabetes and Nephrolithiasis

First, rule out the kidney stone as the primary pain source—nephrolithiasis is the most likely cause of acute unilateral back pain in this patient and requires immediate evaluation with urinalysis and imaging before attributing symptoms to musculoskeletal causes. 1, 2

Immediate Diagnostic Priorities

Rule Out Renal Colic First

• Obtain urinalysis to assess for hematuria, which is present in most cases of acute nephrolithiasis 1
• Order non-contrast CT scan of the abdomen/pelvis if renal colic is suspected—this is the gold standard for stone detection 1
• Assess for fever, which could indicate concurrent pyelonephritis or infection, though fever is absent in up to 55% of serious infections 3
• Note that diabetic patients have increased risk specifically for uric acid stones due to characteristically acidic urine from insulin resistance 4

Screen for Red Flag Conditions

• Assess for urinary retention (90% sensitivity for cauda equina syndrome), saddle anesthesia, fecal incontinence, or progressive motor deficits 3
• Perform careful spinal percussion to evaluate for vertebral osteomyelitis, particularly given diabetes as a risk factor 3
• Obtain two sets of blood cultures and baseline ESR/CRP if infection is suspected 3
• Remember that vertebral osteomyelitis presents insidiously over 2-4 months and fever is present in less than half of cases 3

If Nephrolithiasis is Confirmed

Acute Stone Management

• Provide NSAIDs for pain control (superior to opioids for renal colic) 5
• Ensure adequate hydration while monitoring for hyponatremia risk in patients with fluid balance issues 6
• Refer to urology for stones >5mm, persistent obstruction, or infection 1

Address Underlying Metabolic Risk

• Optimize glycemic control to reduce uric acid stone formation risk 4
• Screen for metabolic syndrome components (hypertension, obesity, dyslipidemia) as uric acid nephrolithiasis is a manifestation of insulin resistance 4
• Implement long-term stone prevention with increased fluid intake to maintain urine volume >2L/day 6

If Musculoskeletal Back Pain is the Primary Diagnosis

Initial Management Approach

• Start with acetaminophen or NSAIDs as first-line pharmacologic therapy 5
• Add skeletal muscle relaxants for short-term pain relief if needed 5
• Advise the patient to stay active rather than bed rest 2
• Apply heat therapy, which has good evidence for effectiveness 2

Non-Pharmacologic Interventions

• Initiate spinal manipulation for acute back pain (<4 weeks duration), which provides small to moderate short-term benefits 5
• Begin physical therapy and exercise therapy if pain persists beyond 4 weeks 5
• Consider cognitive-behavioral therapy for chronic pain (>3 months), which provides sustained relief 5

Diabetic Neuropathy Considerations

• If neuropathic pain component is suspected (burning, tingling, allodynia), start tricyclic antidepressants (amitriptyline, nortriptyline) or SNRIs (duloxetine) as first-line agents 5
• Alternatively, use pregabalin or gabapentin for neuropathic pain 5
• Duloxetine is FDA-approved specifically for diabetic neuropathy 5
• Topical agents (lidocaine, capsaicin) may provide relief for peripheral neuropathic pain 5

What to Avoid

• Strongly avoid epidural steroid injections, facet joint injections, and radiofrequency ablation—these have no proven benefit for chronic spine pain and are not recommended 5
• Do not use systemic corticosteroids, as they are no more effective than placebo 5
• Avoid benzodiazepines due to abuse potential and lack of evidence 5
• Reserve opioids only for severe cases unresponsive to other therapies, using extended-release formulations if needed 5

Critical Pitfalls to Avoid

• Do not assume musculoskeletal pain without first excluding nephrolithiasis—unilateral back pain with known kidney stones demands urologic evaluation 1
• Do not miss early vertebral osteomyelitis in diabetic patients; maintain high suspicion even without fever 3
• Do not delay imaging if red flag symptoms develop, particularly urinary retention or progressive neurologic deficits 3, 1
• Do not attribute all pain to diabetes-related neuropathy without considering mechanical or structural causes 7
• Avoid routine imaging for nonspecific back pain without red flags—delay imaging for at least 4-6 weeks 2