Discharge Instructions - Sciatica

As discussed in the Emergency Department prior to discharge, you have been diagnosed with sciatica.  Sciatica is a pain that comes from the spine.  The spine is made up of a column of small bones (called “vertebrae”) that have spongey cushions stacked between them, called “discs.”  These discs are cushions that act as shock absorbers for our spine.  Sometimes these discs are injured and protrude outwards.  When discs protrude outwards, they can push on nerves and cause pain.  This pain moves along the pathway of the nerve, and can be excruciating.  If sciatica is happening in your lower back, it is typical for the pain to shoot down the back of your leg, along the path of the nerve.

For most people, sciatica gets better within 4-6 weeks.

If you were prescribed pain medication, take it as directed.  If you are under the age of 70 and have no kidney problems, this usually means starting with Ibuprofen (which is the same thing as Advil or Motrin) or Acetaminophen (same thing as Tylenol, which is safe in all age groups).  You may have been given a stronger pain medication, such as Hydrocodone (also known as Norco) or Oxycodone (also known as Percocet).  These stronger medications can make you drowsy, so DO NOT DRIVE OR OPERATE HEAVY MACHINERY OR EQUIPMENT WITHIN 8 HOURS OF TAKING THESE MEDICATIONS.  These medications usually also cause constipation, so take an over-the-counter medicine for constipation, such as Metamucil or Docusate, at the same time as taking these medications.

You may also have been prescribed a muscle relaxant medication, such as Cyclobenzaprine (also known as Flexeril) or Valium (also known as Diazepam).  These medications work by decreasing muscle spasm that often accompanies injury to a muscle in the back.  It is important that you NOT DRIVE OR OPERATE HEAVY MACHINERY OR EQUIPMENT WITHIN 8 HOURS OF TAKING THESE MEDICATIONS.

Complete bedrest is no longer recommended.  However, do take it easy for a few days, and avoid all heavy lifting (which includes lifting children).  Don’t sit for prolonged periods, because this actually increases the strain on your back.  When you are lying in bed, a firm mattress is best.  See if putting pillows underneath your knees helps.

If the pain persists for longer than a few weeks, talk to your primary care provider about physical therapy and other adjunctive therapies.

Spine surgery becomes an option if the pain continues for months.  Given the high risks associated with operating on the spine, most spine surgeons do not want to see patients until they have experienced six months or more of daily pain.

Return to the Emergency Department if you develop difficulties with urination (no urine for over 6 hours despite attempts to use the bathroom), incontinence of stool (pooping without meaning to), weakness in both of your legs, numbness in the top part of your inner thigh on both sides, fever (≥38.0 °C or 100.4 °F), or any new or concerning symptoms.

https://www.acep.org/patient-care/smart-phrases/mri-for-low-back-pain/

https://orthoinfo.aaos.org/en/about-orthoinfo/OrthoInfo-Basics/basics-handouts/

https://orthoinfo.aaos.org/globalassets/pdfs/low-back-pain.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/about-your-back.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/herniated-disk.pdf

https://orthoinfo.org/globalassets/pdfs/2017-rehab_spine.pdf

Please note, it is no longer my personal practice to prescribe opioid pain medications in the treatment of back pain from musculoskeletal and atraumatic etiologies.  I have included safety precautions in the discharge instructions for your review.  As with all templates on this site, it is important that you review what is documented, and adapt it so as to keep in line with all appropriate practice recommendations relevant to the site where you work.

Discharge Instructions - Back Pain

Return to the Emergency Department for persistent or worsening pain, development of fever, weakness or numbness in the lower extremities, incontinence of urine or stool, or any new or concerning symptoms.

A pulled or strained muscle in the back can be extremely painful, but in most cases will resolve completely within 2 weeks.  Pain can be managed by taking anti-inflammatory medications like Ibuprofen (also known as Motrin or Advil) or Naproxen (also known as Aleve).  You can also take Acetaminophen (also known as Tylenol).  These medications work by reducing the inflammation around injured muscles in the back.  You may also have been prescribed a muscle relaxant medication, such as Cyclobenzaprine (also known as Flexeril) or Valium (also known as Diazepam).  These medications work by decreasing muscle spasm that often accompanies injury to a muscle in the back.  It is important that you NOT DRIVE OR OPERATE HEAVY MACHINERY OR EQUIPMENT WITHIN 8 HOURS OF TAKING THESE MEDICATIONS.

You may also have been prescribed a stronger opioid pain medication, such as Hydrocodone (also known as Norco) or Oxycodone (also known as Percocet) for more severe pain.  It is important that you only use these medications for pain that is not responding to anti-inflammatory medications, such as Ibuprofen or Naproxen.  You should wait at least 1 hour after taking anti-inflammatory medications to see if they are effective before taking these stronger opioid medications.  These opioid medications contain Acetaminophen, so DO NOT TAKE ACETAMINOPHEN (TYLENOL) IF YOU WERE PRESCRIBED OPIOID MEDICATIONS.  It is important that you NOT DRIVE OR OPERATE HEAVY MACHINERY OR EQUIPMENT WITHIN 8 HOURS OF TAKING THESE MEDICATIONS.  These medications may also cause constipation, so be sure to drink plenty of fluids and consider using over-the-counter laxatives, such as Metamucil or Docusate, if you develop constipation.

Remember to continue using simple measures like applying an ice pack to painful areas.  The cold can help decrease swelling associated with inflammation.  Swelling is common in the initial days after an injury to the back, but over time muscle stiffness can develop.  Heat can help with muscle stiffness, so applying a heating pad can be beneficial.  Be sure to not leave a heating pad on overnight, as this can result in burns.

Complete bedrest is no longer recommended in the setting of back pain, but you should avoid all heavy lifting.  Don’t sit or lie down for prolonged periods, because this actually increases the strain on your back.  Long term you may benefit from physical therapy and stretching programs including yoga.  Many back pain patients benefit from a diet and exercise regimen including weight loss.

Please note that if your condition worsens or changes significantly, we would like to see you again. You may return at any time if you have further concerns.  Following up with your primary care provider and/or specialist as indicated is important for your overall health and wellness.

https://www.acep.org/patient-care/smart-phrases/mri-for-low-back-pain/

https://orthoinfo.aaos.org/en/about-orthoinfo/OrthoInfo-Basics/basics-handouts/

https://orthoinfo.aaos.org/globalassets/pdfs/low-back-pain.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/about-your-back.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/herniated-disk.pdf

https://orthoinfo.org/globalassets/pdfs/2017-rehab_spine.pdf

Please note, it is no longer my personal practice to prescribe opioid pain medications in the treatment of back pain from musculoskeletal and atraumatic etiologies.  I have included safety precautions in the discharge instructions for your review.  As with all templates on this site, it is important that you review what is documented, and adapt it so as to keep in line with all appropriate practice recommendations relevant to the site where you work.

Discharge Instructions - Rhabdomyolysis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with rhabdomyolysis.  Rhabdomyolysis is when muscle tissue gets severely damaged and substances from inside the muscle cells leak out into the blood.  This can lead to more serious problems including kidney damage and electrolyte disturbances that can result in deadly irregular heart rhythms.

Different things can cause the muscle damage associated with rhabdomyolysis including muscle injury or surgery, very intense exercise, lying in the same position for a very long time, certain infections, medications and poisons, and certain hereditary muscle disorders.

Rhabdomyolysis can cause muscle pain, red or brown discoloration of the urine, and muscle weakness.  Treatment depends on the cause and severity of rhabdomyolysis.  You may have received fluids through an IV in the Emergency Department, which can help your body flush out the harmful substances released from muscle cells.  It is important that you drink plenty of fluids in the next 24-48 hours to continue to flush out harmful substances in the blood.

You may have been directed to follow up with your primary care provider or in the Emergency Department for repeat labs.  It is important that you follow up with these labs to ensure that your kidneys are recovering from rhabdomyolysis.

Return to the Emergency Department for worsening pain, fever (≥38.0 °C or 100.4 °F) after 2 days of antibiotics, inability to pass urine for 6 hours after multiple attempts, or any new or concerning symptoms.

MDM - Musculoskeletal Back Pain

[##]-year-old [male/female] with back pain with history and exam consistent with likely musculoskeletal back pain.

Initial consideration in this patient included herniated intervertebral disc, acute ligamentous injury, acute muscle strain, spondylolisthesis and other musculoskeletal etiologies, cauda equina, spinal fracture, spinal stenosis, epidural abscess and hematoma, cancer metastases, and kidney stone among others.

Patient presented with lower back pain, and was noted to have [no/one of the] red flag signs or symptoms on presentation [describe].  Patient [reported/denied] preceding trauma.  Patient noted to have a normal neurologic examination in the ED to include deep tendon reflexes in the lower extremities.  Patient felt to have [no indication for imaging at this time/indication for imaging with plain films/MRI of the spine obtained in the ED, and noted to be unremarkable /notable for injury].  Doubt cauda equina or central herniation at this time based on [history and exam/imaging].  No history of recent surgery or injections in the back, fever, or other findings to suggest risk for epidural hematoma or abscess.  Doubt kidney stone or urinary tract infection given absence of urinary symptoms, significant costovertebral angle (CVA) tenderness, [abnormal findings on urinalysis,] or other suggestive findings.  Patient [reported/denied] history of similar episodes [with prior treatments].  Patient reported significant improvement in pain with [treatment] in the ED prior to discharge.

Prior to discharge, we discussed modified activity with emphasis on avoiding prolonged bedrest.  We discussed return precautions, specifically for worsening pain or focal neurologic deficits, treatment with [NSAIDs/muscle relaxants/etc.], and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed follow up with primary care doctor for referral to physical therapy and consideration of outpatient imaging.

https://www.acep.org/patient-care/smart-phrases/mri-for-low-back-pain/

https://orthoinfo.aaos.org/en/about-orthoinfo/OrthoInfo-Basics/basics-handouts/

https://orthoinfo.aaos.org/globalassets/pdfs/low-back-pain.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/about-your-back.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/herniated-disk.pdf

https://orthoinfo.org/globalassets/pdfs/2017-rehab_spine.pdf