Chronic Lower Back Pain Without Diagnosis: What Are Your Options?

If you have been experiencing lower back pain for more than three months without a clear diagnosis, what should you do?

Hello, Doctor Wu! I am here to inquire about a family member who is a 47-year-old male, working as a night shift operator for 25 years (his job does not require physical labor and does not involve maintaining the same posture for long periods, as he is just a supervisor).
Around early August this year, he began experiencing severe pain in the lower back, specifically around the lumbar muscles (psoas major), which corresponds to the kidney area (I have verified this through online images).
This was accompanied by loss of appetite, vomiting, chills, and a rapid weight loss of 10 kilograms.
He underwent examinations in the gastroenterology department at a hospital, where an endoscopy was performed, and everything was normal.
After that, he stopped vomiting and his appetite returned to normal, but the pain in his lower back persisted and worsened, extending to severe pain between the toes on the dorsum of his feet.
He subsequently visited the urology department twice, where he underwent blood tests, urinalysis, ultrasound, X-rays, and MRI; all tests returned normal results.
He also consulted a neurologist, and everything was fine there as well.

Later on, he experienced a loss of sleepiness, with pain so severe that he could not sleep, leading him to see a psychiatrist.
He relied on sleeping pills to fall asleep until now, in December, when the issue of loss of sleepiness has resolved, and he no longer takes sleeping pills.
However, he still suffers from persistent lower back pain, resulting in very poor sleep quality.
His palms, fingers, and complexion often appear pale.
This has been ongoing for over three months, with symptoms including severe lower back pain, foot pain, chills, and urinary abnormalities (sometimes urinating every 1-2 hours, sometimes unable to urinate, and sometimes normal).
To add some details:
1.
This family member has a history of hypertension and arrhythmia, and during these three months, he has "not experienced any fever!"
2.
During this uncomfortable period, his sleep quality has been poor, and his blood pressure has been consistently high (which he has been controlling with medication).
He can also feel his heart racing and uncomfortable while sleeping.
3.
The pain in his lower back and feet occurs every 2-3 hours, with the most intense pain lasting up to 4 hours.
The pain is least severe right after waking up, but the worst pain occurs in the early morning after his night shift ends at 4 AM.
4.
The areas of pain in the lower back and feet become swollen! During the peak of the pain, the muscles feel swollen (but not hard lumps), and as the soreness subsides, the swelling disappears, creating a cycle of symptoms.
5.
He has consulted a traditional Chinese medicine practitioner, who indicated that his kidneys are very weak.
Due to concerns about potential kidney issues, he has avoided taking any pain medication or using patches, as he once experienced difficulty urinating after taking painkillers.
According to him, the pain is extremely intense, almost causing him to faint.
Sometimes, he visits a nearby clinic for anti-inflammatory and muscle relaxant injections, which provide immediate relief, but this also leads to urinary difficulties and night sweats.
After a few hours, the pain returns.
I would like to ask the doctor what significant symptoms could lead to this situation.
Which specialty should we consult for the best hope of a resolution? Initially, we wondered if it could be gout, but the urology department has examined him twice and reported everything as normal.
Could this still be a kidney issue? However, since the pain is clearly in the areas that the urology department deemed normal, we have not directly consulted a nephrologist.
They suggested we see a rehabilitation specialist, and X-rays have also shown no issues.
If it is indeed a muscular problem, how could there be urinary abnormalities? Since we have not found a solution at the same hospital, would you recommend that we transfer to another major hospital for a re-evaluation in urology? If it is truly not a kidney issue, where should we go next—urology, infectious disease, or rheumatology?
I appreciate your professional response and thank you for taking the time to read this message.
My family member's condition seems to be increasingly concerning, and I hope to receive your prompt advice and insights.

Miss Lin, 20~29 year old female. Ask Date: 2023/12/17

Dr. Wu Hongjie reply Internal Medicine

It is recommended to see a large hospital's Immunology and Rheumatology department or Orthopedics.
Wishing you well.

Reply Date: 2023/12/17

More Info

Chronic lower back pain can be a complex issue, especially when it is accompanied by other symptoms such as abdominal pain, vomiting, and urinary irregularities. In the case of your family member, a 47-year-old male with a history of night shift work, the symptoms you describe suggest a multifaceted problem that requires careful evaluation.

Understanding the Symptoms
1. Back Pain and Associated Symptoms: The severe pain in the lower back, particularly around the kidney area, along with the pain radiating to the feet, indicates that there may be an underlying issue affecting the lumbar spine or the surrounding structures. The fact that the pain worsens after night shifts could suggest a connection to posture or muscle fatigue.

2. Gastrointestinal Symptoms: The initial symptoms of loss of appetite and vomiting, which later resolved, could have been related to stress or anxiety due to the pain. It's important to note that chronic pain can significantly impact mental health, leading to conditions such as depression or anxiety, which can further exacerbate physical symptoms.

3. Urinary Issues: The urinary irregularities, including frequent urination and difficulty urinating, are concerning. These symptoms could indicate a possible issue with the urinary tract or kidneys, especially given the location of the back pain.
4. Other Health Conditions: The presence of hypertension and arrhythmia complicates the clinical picture. Chronic pain can lead to increased blood pressure and heart rate, which may explain the symptoms of feeling the heart racing during sleep.

Diagnostic Pathway
Given the complexity of the symptoms, a multidisciplinary approach is recommended. Here are some steps to consider:
1. Revisit Urology: Since urinary symptoms are present, it may be beneficial to consult a urologist again. They can perform further tests, such as a renal ultrasound or CT scan, to rule out any kidney issues or obstructions.

2. Consult a Rheumatologist: Given the chronic nature of the pain and the potential for inflammatory conditions, a rheumatologist could evaluate for conditions such as ankylosing spondylitis or other autoimmune disorders that may cause both back pain and urinary symptoms.

3. Physical Therapy: Engaging in physical therapy may help address the muscular component of the pain. A physical therapist can provide exercises to strengthen the back and improve posture, which may alleviate some of the discomfort.

4. Pain Management: Since over-the-counter pain medications have been avoided due to concerns about urinary retention, discussing alternative pain management strategies with a pain specialist may be beneficial. This could include nerve blocks or other interventions that do not involve systemic medications.

5. Psychological Support: Given the impact of chronic pain on mental health, consulting a psychologist or psychiatrist could help manage anxiety or depression that may arise from the ongoing pain and sleep disturbances.

Conclusion
In summary, your family member's situation is complex and may require a combination of medical evaluations and treatments. It is crucial to address both the physical and psychological aspects of chronic pain. If the current healthcare providers are unable to provide answers, seeking a second opinion at a larger medical center or a specialized clinic may yield better results. The goal is to identify the root cause of the symptoms and develop a comprehensive treatment plan that addresses all aspects of health.

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