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A Case of Severe Low Back Pain after Spinal Fusion

The patient is a 48-year-old male, with psoriatic arthritis, who underwent L4-S1 spinal fusion in 2000, presents with continuous low back pain and intolerance to sitting. He rates his pain as 8 out of 10. His rheumatologist says he is stable, has no new skin lesions, remains on a disease-modifying agent, and doesn’t need a change in his medications.

This case is the focus of A Case of Severe Low Back Pain after Spinal Fusion. Dr. McCarberg leads the discussion with panel members Steven Stanos, MD and Joseph Ihm, MD.

Differential Diagnosis
Although the rheumatologist indicates the patient is “stable”, the cause of the patient’s severe pain and intolerance to sitting requires re-examination. Especially in light of the following:

  • Since the patient underwent lumbar fusion more than 10 years ago, adjacent segment disease is a valid concern.
  • If he had taken steroids, he may be at risk for vascular necrosis.
  • Intolerance to sitting leads to the question, “What is the patient’s occupation?” For example, if he works at a desk, perhaps his workstation could be modified to accommodate the need to alternate sitting, standing, and walking about.

After further discussion, the panel focuses on three potential areas:

  • Lumbar spine
  • Hip(s)
  • Sacroiliac joints (SIJs); presence of transitional pain (eg, sitting to standing)

It is important to differentiate between involvement of the SIJ and the hip. Where does the patient feel pain; at or near the SIJ? Manual palpation, Faber/Patrick’s test, and/or sacral thrust may be helpful in making a determination.

In addition to treating the patient’s severe pain, it is advantageous to evaluate the quality of sleep, mood and anxiety. Medications can be prescribed to help relieve the latter symptoms and augment an analgesic. Prescribing a short- or long-acting opioid is an option. However, if this is the patient’s first visit, a thorough history with risk stratification using a tool such as the Opioid Risk Tool1 is appropriate.


  1. Webster LR. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine. 2005;6(6):432-442. http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf . Accessed November 5, 2013.
Last updated on: November 6, 2013
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