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).
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.
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: