What is the best course of treatment for a patient with left lower back pain that is tender to palpation?

Treatment of Left Lower Back Pain with Tenderness to Palpation

For a patient with left lower back pain that is tender to palpation, start with acetaminophen or NSAIDs (such as ibuprofen 400 mg every 4-6 hours) combined with patient education to remain active, and avoid routine imaging unless red flags are present or symptoms persist beyond 6 weeks. 1, 2

Initial Clinical Assessment

Before initiating treatment, you must first categorize this patient's presentation:

• Assess for red flags that would indicate serious underlying pathology requiring immediate imaging: unexplained weight loss (positive likelihood ratio 2.7 for cancer), history of cancer (positive likelihood ratio 14.7 for spinal malignancy), fever with IV drug use or recent infection, rapidly progressive neurologic deficits, fecal incontinence, or bladder dysfunction beyond simple frequency 3, 2

• Evaluate for radiculopathy or spinal stenosis through neurological examination: check for dermatomal sensory changes, motor weakness at specific nerve root levels, and reflexes 1

• Exclude non-spinal causes: If urinary symptoms like dysuria and frequency are present, this fundamentally changes the diagnostic approach and requires primary investigation for genitourinary etiology such as nephrolithiasis rather than treating as musculoskeletal pain 3

• Assess psychosocial risk factors (yellow flags) that predict risk for chronic disabling back pain, as these influence prognosis and treatment planning 1

First-Line Treatment Algorithm

Patient Education (Critical First Step)

• Provide evidence-based reassurance about the expected favorable natural course and explicitly advise the patient to remain active rather than resting in bed, as prolonged bed rest leads to deconditioning and worsens disability 1, 2

• Emphasize that staying active is therapeutic, not harmful, and that most nonspecific low back pain resolves with conservative management 1, 2

• Provide written educational materials about self-care options and activity modification 2

Pharmacologic Management

• Start with acetaminophen (up to 4g/day) or NSAIDs as first-line medication options for most patients after assessing severity of baseline pain and functional deficits 1, 2

• Acetaminophen has a more favorable safety profile and lower cost but is a slightly weaker analgesic than NSAIDs 2

• For NSAIDs, ibuprofen 400 mg every 4-6 hours is the recommended dose for mild to moderate pain (do not exceed 3200 mg total daily dose), and should be taken with meals or milk if gastrointestinal complaints occur 4

• NSAIDs provide superior pain relief but carry gastrointestinal, renovascular, and cardiovascular risks, so assess these risks before initiating therapy 1, 2

Imaging Decisions

• Do not routinely obtain imaging in patients with nonspecific low back pain without red flags, as routine imaging provides no clinical benefit and leads to increased healthcare utilization without improving outcomes 1, 2

• Perform imaging only if: (1) severe or progressive neurologic deficits are present, (2) serious underlying conditions are suspected based on history and physical examination, or (3) symptoms persist or progress despite 6 weeks of optimal conservative management 1, 2

• MRI lumbar spine without contrast is the preferred imaging modality when imaging becomes indicated 1, 2

Second-Line Treatment for Persistent Symptoms

If the patient does not improve with self-care and first-line medications:

Non-Pharmacologic Therapies

• For acute low back pain, consider spinal manipulation by appropriately trained providers 1, 2

• For chronic or subacute low back pain, consider: intensive interdisciplinary rehabilitation, exercise therapy (with individual tailoring, supervision, stretching, and strengthening components), acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation 1, 2

Additional Pharmacologic Options

• Skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) can be used for short-term relief if muscle spasm contributes to pain 2

• Tramadol or opioids may benefit some patients who do not respond to NSAIDs, but assess potential benefits versus risks and the relative lack of long-term efficacy and safety data before initiating 1, 5

Critical Pitfalls to Avoid

• Do not order imaging in the absence of red flags or failure of 6 weeks of conservative therapy, as this leads to unnecessary interventions, does not improve outcomes, and increases healthcare costs 1, 2

• Do not prescribe prolonged bed rest, as this causes deconditioning and potentially worsens symptoms 1, 2

• Do not empirically treat as musculoskeletal low back pain when urinary symptoms are present, as this delays appropriate diagnosis and treatment of conditions like nephrolithiasis 3

• Do not attribute symptoms to "normal aging" without proper clinical assessment, as this can delay recognition of serious pathology such as cancer, which can present with evening/night pain and atypical patterns 6

• Monitor for lack of improvement: If the patient's condition gradually worsens despite conservative treatment over 4-5 weeks, communicate with the patient's physician for further medical evaluation, as serious underlying diseases can initially present with features mimicking mechanical pain 6