Neurogenic Back Pain

Author: V. Dimov, M.D.
Reviewer: R. Christie, M.D.

A 35-year-old Caucasian female (CF) was admitted to the hospital with severe back pain which started after she lifted a heavy object at work 2 months ago. She had been having this pain constantly for the last 2 months without a significant improvement. The pain was in the lower back, 10/10, like "electricity shooting down the right buttock". Her back also felt very stiff and the patient was tearful, admitting to feeling depressed.

The MRI of the back showed a disc prolapse at the L5-S1 level. She was treated at home with NSAIDs, Vicodin (hydrocodone and acetaminophen) and tramadol (Ultram) PRN without a significant relief.

What medications would you choose now?

The patient had a "spinal block" (transforaminal epidural block) at level S1, bilaterally, after which the pain increased temporarily. The operator used C-arm instrumentation and Kocher clamp, the needles were put in the appropriate space, and 40 mg of Depo-Medrol (methylprednisolone) with 2 ml of 0.5% Xylocaine (lidocaine) was injected in each area.

She was treated with morphine IV PRN for the pain, Tylenol (acetaminophen) and cyclobenzaprine (Flexeril) for the back spasm. Neurontin (gabapentin) and an antidepressant were started.


Medications used for back pain treatment in this patient (click to enlarge the image).

The patient's condition improved, the pain decreased to 3/10 and she was discharged home with Physical & Occupational Therapy (PT/OT).

Final diagnosis

Neurogenic pain due to a disk prolapse.

What did we learn from this case?

The continuous neurogenic pain is commonly referred to as neuropathic pain.

Neurontin can be helpful in neuropathic pain. Flexeril (cyclobenzaprine) can be used to treat muscle spasms in lower back pain. Many patients receiving opioids will need a concurrent therapy with a stimulant laxative such as Senna 2 tabs po qhs to relieve the opioid-induced constipation.

References

Cyclobenzaprine and Back Pain. Arch Intern Med, 2001.

Back pain in Mini Oxford handbook of clinical medicine By Murray Longmore, Ian Wilkinson, Supraj R. Rajagopalan:



Published: 3/12/2005
Updated: 08/19/2009

17 comments:

  1. I find this case very interesting in that different providers would approach this case with very different approaches.

    As a physical therapist, I would attempt to find a directional preference treatment category(fritz et al), check the clinical prediction rule for acute low back pain (childs et al), and treat using a combination of exercise and manual therapy(drawing a blank). Most importantly I would attempt physical therapy first with meds and imaging only in the event physical therapy proved unsuccessful. This model is beginning to catch on at the County Hospital in which I work.

    Thanks for the interesting study.

    Brian

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  2. I second Brian's opinion. Also a PT, I wonder why this poor woman was in pain so long when it seems as if she may have had many successful prognostic factors for a simply spinal manipulative procedure (Childs et al) that might have significantly reduced her pain without a fluoroscopically assisted ESI.
    Good case, great site.

    Would love to see more Ortho type stuff, especially given the significant research showing the need for education in this area.

    J

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  3. Seems an AWFUL lot of medications indeed.

    It sounds to me like the superimposed/secondary mood disorder was perhaps the main issue. Especially the pain history, what little is given - was there a diurnal pain pattern ? Was there secondary gain with the work situation reinforcing ?
    Was the L5/S1 protrusion impinging on theca/roots etc? You'll never fix pain if someones depressed!

    There is good evidence of a multidisciplinary approach in such situations...but manipulative treatment is DANGEROUS with disc lesions, and the only evidence of benefit is in thoracic manipulation anyway. But maybe a core stabilisation program once pain had settled ?

    I'd like to know what happened down the track...bet you penny to a pound recurrence within 12 months with this treatment plan.

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  4. Extreme pain, without cessation as is often in neuropathies, can cause depression. Injury led to the pain, then the depression. Found it odd that someone felt the depression began first and needed tx. Also found it odd to delay pain mgmt "only in the event PT proved unsuccessful" - would YOU go without pain mgmt if you hurt quite badly? PT would have certainly been helpful, but definitely not manipulation. To delay or disregard pain mgmt would not be in pt's best interest; puritanical thinking creates pt dissatisfaction overall and can lead rightly to legal action. Suffering is unnecessary.

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  5. Manipulative treatment really is NOT dangerous in the case of a disc prolapse, and is often used as a treatment for disc prolapse. Furthermore, there is certainly evidence of benefit for manipulation in other regions of the body than the thoracic spine.

    ----[You SAID: ]-----------------
    There is good evidence of a multidisciplinary approach in such situations...but manipulative treatment is DANGEROUS with disc lesions, and the only evidence of benefit is in thoracic manipulation anyway.

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  6. As an Osteopath, Medical Acupuncturist and former Pain Program Director at a multidisciplinary pain mangement center I can see the potential benefit of all the aforementioned therapeutic approaches. But first I have a question.
    Why was this womens obvious radicular pain into her buttock described as having neuropathic pain. Her description of the pain as like electricity sounds more like an emotional description rather that evidence of neuropathis pain. I would call her pain nerve impingement which is a type of neurogenic pain, not neuropathic. The difference being that in nerve impingement the nerve is still intact and relatively undamaged, where as in neuropathic pain the substance of the nerve itself is damaged.As the Lancet states in "Neuropathic pain results from
    chronic injury to sensory neurons, leading to axonal sprouting and
    neuroma formation. After such an injury, marked changes occur in
    the expression of genes encoding both Na+ and Ca2+ channels, resulting in changes in their distribution and composition....Changes in the expression of Na+ channels lead
    to alterations in their biophysical properties and their abnormal accumulation in nociceptors and sensory nerves. This plasticity in Na+ channel expression is accompanied by electrophysiological changes that poise these cells to fire spontaneously or at inappropriately high frequencies, often from ectopic sites...The spontaneous electrogenesis in neuropathic pain has obvious
    similarities to that in epilepsy."
    From Nature Medicine 10, 685 - 692 (2004)
    Also, neuropathic pain is often acompanied by hyperalgesia of the skin surface and the pain is described as burning with occasional ancinating, stabbing, or shooting pain. Nerve impingment pain is best treated by taking the pressure off the nerve. This can occur with a tincture of time, surgery, manipulation? or chemically.
    Therefore I think this patient had neurogenic pain from impingment of the S1 nerve.

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  7. I have just recently had a spinal fusion done to correct a previous fusion that went bad.(Broke screw) I am 2 weeks post op taking roxicodone 30mg when I started, once again, to have shooting pain down my left leg. My doctor added neurontin 300mg at bed time. After 2 weeks my left leg has stopped hurting. Thank God for neurontin!

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  8. Jude:
    Today 8/20/09 marks anniversary for spinal/fusion laminectomy
    L2-L4-5 in '07. April '08 2nd surgery to replace broken screw. 6
    screws total. Still in a lot pain with neuropathy after recent
    nerve conduction study. On Oxycodone, Cymbalta, Neurontin and
    Tylenol. No positive future in sight for me. Also still have
    stress fracture and possible labrum tear.

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  9. 32y/o active female. Serious stenosis (lumbar & cerv), disc disease, 8 spurs & siatica. Taken everything from tylenol to morpheine and the real problem is that everything wears off. I've been taking neurontin, up to 600mg a day, some help but not the miracle that I hoped so far. How much is someone supposed to take? How long of a span would I have to take it? Will my body get used to it like narcotics & I keep increasing dosage? I ultimately would like to take the least amount of any type of synthetic drugs as possible due to other conditions I already take. I feel that with all the drugs dr.s have given me over the years are going to hurt my kidneys eventually. I'm one of the rare cases that was born with ddd & had arthritis developing by 17. I was a very active dancer & continued to remain in good shape as it gets more difficult every year. They want to fuse the s1,l4,l5 & I'm petrified. So many what if's. How can I save my kidneys?

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  10. You need to see a doctor. No blog or website can provide reliable answers to your questions as a patient.

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  11. Step 3 concept: The imaging results from subjects with regular back pain can be the same imaging results from sick subjects with herniated disk. Imaging results are unespecific for back pain. MRI is only indicated if the subject has neurological syntoms. I did not see any neurological syntoms in the case. So the treatment for anyone with back pain without neurological syntoms with or without findings in the imaging results would be the same (acethaminophen and bed rest for few days).

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  12. "Her back also felt very stiff" is her symptom along with the pain - limited range of motion. It's spelled "symptom" rather than "synton". A pain for 2 months, 10/10 is an indication for imaging.

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  13. I was sent to physical therapy by my neuroligist while awaiting an mri on my lower back. I have pain shooting down my left leg along with burning and numbness in my lower/upper back since slipping and going into a split and twisting to stop my fall. The therapist said that my hip was not inline and when doing a back exam said something about feeling a lesion. What exactly is she talking about? She is starting me on the bicycle next week and I am in alot of pain. Is this safe since i haven't had an mri yet.

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  14. You have to see a physician right away. No medical advice is provided here or on any other website. You must see a doctor in person for history and physical examination.

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  15. What is a lesion or mass in the lower back?

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  16. There is disc prolapse. I don't see any mention of a mass.

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  17. Well, it is true a website cannot diagnose a problem it always best to see you doctor, especially if it is severe chronic pain.

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