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Non-surgical Management of a 72-year-old Patient with Low Back Pain

This case discussion is of a 72-year-old female who presents with progressive low back pain that radiates into her right leg. She has experienced pain for three to four weeks, and it is not responsive to over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) or exercises her daughter recommended.

Bill McCarberg, MD speaks from the primary care physician’s (PCPs) perspective. Many PCPs would view radiating leg pain as a radiculopathy, a pinched nerve—likely disc-related. Steven Stanos, MD and Joseph Ihm, MD broadens the scope of the discussion to include:

  • Spinal stenosis (eg, central canal stenosis)
  • Facet-related pain
  • Hip-related pain
  • Myofascial pain

Differential Diagnosis
The cause of the patient’s pain relies on a thorough physical and neurological examination that considers relevant past medical history and age-related variables (eg, falling).

  • Dr. Ihm stresses the importance of, “Exactly, where does pain radiate?”
  • Consider that osteoarthritis is a common cause of hip pain in this age group.
  • Does the patient experience pain when walking—and is that pain immediate, upon weight bearing, or after walking one or two blocks?
  • Rule out red flags (eg, metastatic cancer, osteoporosis)

Sample Exam Considerations

  • Palpation reproduces pain (eg, trigger point)
  • Muscle stretch reflexes
  • Effect of lumbar flexion or extension on pain
  • Postural changes may influence hip pain
  • Patient states one or both legs feel heavy
  • X-ray; a small subset of older patients have a spondylolisthesis

What treatment would you offer this patient at the first visit? She indicated she had taken OTC NSAIDs without a favorable result.

  • Gabapentin vs methylprednisolone dosepak
  • Gabapentin trial for four or five days
  • Short-term opioid (eg, tramadol)
  • Stabilization exercises
  • Pool-based vs land-based exercise/therapy
  • Trigger point injection(s)

The goal of treatment for this patient is to keep her active.

First published on: November 6, 2013