A Patient With Low Back Pain: Part 1
by Daniel I. Silvershein, MD
JL is a 40 y.o. male without significant past medical history who presents to his primary care physician complaining of low back pain. He describes the pain as soreness in the lumbar region on the midline, without radiation. He did not report any inciting event for the pain, which gradually increased in intensity over the past 2 weeks. Upon further questioning he noted he led a sedentary lifestyle, sitting for several hours consecutively at work with poor ergonomics. He denied any recent lifting or strenuous exercise.
Low back pain is the second most common pain syndrome, after headache. It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary lifestyles with too little—interspersed with too much—exercise. The risk of low back pain from disc disease or spinal degeneration increases with age. The most common causes of low back pain include bulging or ruptured intervertebral discs, sciatica , spinal degeneration , spinal stenosis, osteoporosis, skeletal irregularities, fibromyalgia, and spondyloarthropathies.
The patient’s physical exam was significant for a diminished range of motion at the lumbar spine, a loss of 20 degrees of range in both flexion and extension. His neurological exam was within normal limits. He was started on a regimen of twice daily naproxen and carisoprodol with a program of core strengthening and flexibility.
Most low back pain can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength to the back, and preventing recurrence of the injury. Most patients with back pain recover without residual functional loss. Bedrest is usually contraindicated in low back pain and exercise may be the most effective way to speed recovery. Strengthening back and abdominal muscles will both speed relief and help prevent further injury. Exercise is particularly important for persons with skeletal irregularities. Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of medications. Nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain.
Four weeks after his initial presentation, the patient returned to his primary care physician. He stated his symptoms initially improved but subsequently worsened and he reported onset of numbness in his right foot. Upon physical exam he was noted to have a new sensory deficit in the L5 dermatome with normal motor strength and normal reflexes. His range of motion at the lumbar spine was improved, with a 10 degree loss in both flexion and extension. The patient was started on a short course of methylprednisolone, continued on the carisoprodol, and sent for MRI of the lumbar spine. He was also referred for evaluation by a physiatrist.
Physiatrists possess training in both the neurologic and orthopedic treatment of back pain. They specialize in the “hands-on” approach that is necessary for diagnosis and treatment of back pain and are instrumental in creating a multi-modal treatment strategy. Muscle relaxants are a group of medications that have differing mechanisms of action but all ultimately serve to diminish the muscle spasm often associated with low back pain. By “loosening” the muscle, there is less damage done to the muscle with movement, diminishing pain and inflammation.
At the evaluation, the patient reported no improvement in the sensory deficit, but worsening of the lumbar pain, now with radiation through the right buttock, down the posterior thigh to the knee. MRI of the Lumbar spine was unremarkable, but electromyelogram revealed denervation of the L5 nerve root. At this time, the physiatrist initiated a medical regimen of meloxicam and cyclobenzaprine, with oxycodone 5mg every 6 hours for breakthrough pain.
Doctors may use certain opioid analgesics to treat low back pain. There is a general reluctance for physicians to use opiates as a long-term treatment due to side effects and concerns about dependence. The most common side effects that limit their use include nausea and constipation, which can be severe. In addition, other common but less known important side effects include dizziness and sedation.
Two weeks later, the patient reported to the Emergency Room with complaints of left chest pain, described as “tightness” with radiation to the left arm and intensity of 6/10. Cardiac workup was unremarkable and the patient was discharged back to his primary care physician. One week after evaluation, he was seen again by his primary care physician. At this time, his medication regimen was changed to celecoxib 200mg daily, gabapentin 300mg at bedtime, and oxycodone/apap 5/325 every four hours as needed for pain. The patient was referred to a neurologist/pain management specialist at this time.
The progression of symptoms in the face of treatment and evidence of denervation warrant referral to neurology. Neurologists are best equipped to interpret the progression of symptoms. However, When more specific measures are needed, such as surgery or pain management—both medical and interventional—there is more utility in evaluation by a neurologist with a subspecialty in pain management as they can both diagnose and treat appropriately.
Antidepressant medications may be helpful in the treatment of low back pain. Generally, for low back pain, theses medications are taken in lower doses than would be used to treat depression. Antidepressants may be mediated by increase in serotonin levels one of the neurotransmitters associated with pain control. Antidepressants may also reduce anxiety and muscle tension. TCAs and SNRIs seem to have better effect than SSRIs. Anticonvulsants can also be used to treat neuropathic pain and are favored over TCAs because they are generally less sedating; but anti-epileptics are generally more useful for the leg pain associated with radiculopathy, as opposed to the low back pain itself.
The patient was seen by neurology /pain one week after his referral. He reported continuous chest pain with radiation to the left arm and back, and worsened lumbar stiffness. The discomfort was significantly worsened with prolonged sitting and the patient was having significant pain at work with difficulty accomplishing work tasks. In addition, he also was intolerant of the opiates during work hours, noting that they were causing significant cognitive impairment. Neurologic exam revealed radiculopathy of the T5 and L5 nerve roots, with continued loss of sensation in the distal L5 dermatome. At this time his gabapentin was increased to 300mg tid and referred the patient for MRI of the entire spine.
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