What is the best treatment approach for a 79-year-old patient with acute back pain, insomnia, and a history of recent physical exertion (moving furniture), considering potential underlying medical conditions and the need for safe pharmacological interventions, such as muscle relaxants (e.g. cyclobenzaprine) or opioids (e.g. tramadol)?

Treatment of Acute Low Back Pain in a 79-Year-Old After Moving Furniture

Start with scheduled naproxen 500 mg twice daily for 7-10 days, add acetaminophen 650 mg every 6 hours around-the-clock, and avoid both muscle relaxants and tramadol in this elderly patient due to high risk of falls, confusion, and minimal evidence of benefit over NSAIDs alone. 1

First-Line Pharmacologic Approach

• NSAIDs are more effective than opioids for acute low back pain and should be the cornerstone of pharmacologic treatment 1, 2
• Naproxen 500 mg twice daily provides superior pain relief compared to acetaminophen alone and has the strongest evidence base for acute musculoskeletal pain 1
• Add scheduled acetaminophen 650 mg every 6 hours (not as needed) to provide multimodal analgesia without increasing sedation risk 1
• This combination approach is safer than adding muscle relaxants or opioids in elderly patients 1, 3

Why NOT Muscle Relaxants in This Patient

• Cyclobenzaprine should be avoided in patients over 65 years due to increased plasma concentrations, high risk of CNS adverse events (hallucinations, confusion), cardiac events resulting in falls, and anticholinergic effects 4
• A high-quality randomized trial of 323 ED patients with acute low back pain found adding cyclobenzaprine to naproxen provided zero additional benefit (mean RMDQ improvement difference 0.3,98.3% CI -2.6 to 3.2, P=0.77) 3
• All muscle relaxants increase CNS adverse events 2-fold (RR 2.04) and total adverse events 1.5-fold compared to placebo, with sedation being the primary concern 5
• The concept of "muscle relaxant" is a misnomer—these drugs do not directly relax skeletal muscle and likely work only through sedative properties 5
• In elderly trauma patients specifically, guidelines strongly recommend avoiding muscle relaxants due to excessive sedation and fall risk 1

Why NOT Tramadol in This Patient

• Tramadol should be avoided as first-line therapy because NSAIDs are more effective for acute low back pain with fewer risks 1, 2
• In the same randomized trial, adding oxycodone/acetaminophen to naproxen provided no meaningful benefit (mean RMDQ improvement difference 1.3,98.3% CI -1.5 to 4.1, P=0.28) 3
• Tramadol carries significant risks in elderly patients including dizziness, confusion, constipation, falls, and respiratory depression when combined with other CNS depressants 6, 7
• The FDA label specifically warns that tramadol should be used with caution and in reduced dosages in elderly patients, and it enhances effects of alcohol, barbiturates, and other CNS depressants 6
• Tramadol is only recommended as second-line therapy for chronic low back pain after failure of NSAIDs and nonpharmacologic approaches, not for acute pain 1

Critical Safety Considerations for This 79-Year-Old

• Screen for cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 2
• If the patient has significant cardiovascular disease, chronic kidney disease (eGFR <60), or history of GI bleeding, consider topical diclofenac gel instead of oral NSAIDs 8
• Co-prescribe a proton pump inhibitor if oral NSAIDs are necessary and the patient has GI risk factors 8
• Limit NSAID duration to 2 weeks maximum with close monitoring in elderly patients 8
• The insomnia is likely secondary to pain—treating the pain effectively will resolve sleep issues without adding sedating medications that increase fall risk 1

Nonpharmacologic Interventions (Essential, Not Optional)

• Advise the patient to stay active and avoid bed rest, as bed rest leads to functional decline, muscle weakness (10-15% per week), bone loss (2% per week), and increased risk of institutionalization in elderly patients 1, 9
• Recommend ice application to painful areas for the first 48-72 hours, then transition to heat therapy 1, 9
• Reassure the patient that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment 9
• Refer for goal-directed physical therapy if no improvement in 1-2 weeks, focusing on early mobilization and functional restoration 1, 9

Red Flags Requiring Immediate Evaluation

• Assess for cauda equina syndrome: new urinary retention, fecal incontinence, saddle anesthesia, or bilateral leg weakness 9
• Check for progressive neurologic deficits, fever, unexplained weight loss, history of cancer, or severe nighttime pain suggesting infection or malignancy 10, 9
• If red flags are present, obtain imaging immediately; otherwise, imaging is not indicated unless pain persists beyond 6 weeks 1, 9

Follow-Up Plan

• Reassess pain and function within 2-4 days after initiating NSAID therapy 2
• If no improvement after 1-2 weeks of conservative management, reconsider the diagnosis and evaluate for radicular symptoms that might warrant gabapentin 5, 2
• If pain persists beyond 4-6 weeks, obtain lumbar spine imaging and consider referral to physical medicine or spine specialist 10, 11

What This Patient Should NOT Receive

• No opioids beyond tramadol for acute mechanical back pain—they show no superiority over NSAIDs and significantly increase risk of long-term disability when used early 1, 2
• No benzodiazepines for sleep—they compound fall risk with NSAIDs and provide no benefit for back pain itself 1, 10
• No systemic corticosteroids—three high-quality trials show they provide no benefit over placebo for acute low back pain 5, 2
• No bed rest—this is iatrogenic and leads to worse outcomes in elderly patients 1, 9