Back pain, wants muscle relaxer.
That was the chief complaint entered by the nurse. I glanced at that and reviewed the vitals as I entered the room. A middle-aged man was standing holding his back with one hand and leaning supporting himself against the wall with the other hand, obviously in pain.
He informed me that his chiropractor told him to see an MD to get a muscle relaxer. I asked for his story. He said he had been walking beside and moving his heavy motorcycle in the garage when it had fallen over. He was able, with great effort, to lift the bike upright but experienced such a severe low back pain that he feel backwards to the floor, landing on his butt. He had just laid there for a few minutes in excruciating pain, then eventually was able to get up.
That had been two weeks previously. He had been seeing his chiropractor twice a week, but was still having significant pain. That is why he was told to get some muscle relaxers and could I just write the prescription so he could be on his way and get some relief. On a busy night with a full ER, it is sorely tempting just to write a prescription and get out of the room, but my conscience won’t let me do that.
After asking a few more questions to fill in the history and rule out some red flag issues like infection, tumors, or neurologic impairment, I asked him if I could examine him. He reluctantly agreed. His exam was positive for bony spinal tenderness at L1 and decreased range of motion but no neurologic deficits. With the finding of bony tenderness and a history of falling, I was concerned for the possibility of a spinal fracture.
I ordered an x-ray. He was very reluctant to do this. After all, he said, his chiropractor had already x-rayed him four times. If something was broken, he would have seen it. Indeed! Every time he was seen, he got another x-ray!
I told him I have to see the x-ray myself or no prescription. Did he have a copy with him? No. Well then we need to do one. He expressed his displeasure with this but agreed. He headed to the x-ray department, muttering under his breath about why he never goes to doctors.
A few minutes later, I was reviewing his x-ray. There was an obvious severe compression fracture of L1. I asked the patient to view the x-ray with me. “See this,” I said, pointing to the fractured vertebrae. “Notice how this one doesn’t look like the others?” (Sesame Street approach to reading x-rays, but effective.)
“Is it broken?” he asked.
“Yes,” I replied. He asked why his chiropractor didn’t see this. I said I didn’t know. “Maybe his x-rays are different.” I didn’t feel it appropriate to render an opinion. Much of what chiropractors see on x-rays is a mystery to me anyway. However, this x-ray explained why the adjustments actually made him feel worse.
I gave the patient a prescription for his pain. I thought he would likely need something stronger than a muscle relaxer. He offered no further resistance and agreed to follow up with a spine specialist the following day, who would likely prescribe a back brace.
Marven Ewen, MD, Medical Director