CLINICIAN’S CORNER CLINICAL CROSSROADS CONFERENCES WITH PATIENTS AND DOCTORS A 50-Year-Old Man With Chronic Low Back Pain

DR LIBMAN: Mr S is a 50-year-old man with chronic low back pain. In the mid-1970s he developed persistent right leg pain and was diagnosed by myelogram as having a herniated disk. L5-S1diskectomywasperformedin1977withmodestimprovement in his leg pain. He developed low back pain, which was treatedwithphysical therapyandnonopioidandopioiddrugs. Over the next decade, his intermittent back and right leg pain caused him to modify his daily activities. It worsened in 1994 after he fell out of a bathtub. He was evaluated in a local pain unit andreceived local injectionswith limitedbenefit. In1996, Mr S underwent repeat diskectomy, which improved his right legpainbutnothisbackpain.Followingsurgery,hehadacrush injuryofhisrightfoot,whichslowedhisrecovery.Between1996 and 2002, he had facet blocks, epidural injections, and physical therapy, all of which were ineffective. Since 2003, he has been followed up at a pain unit. He takes methadone with oxycodone-acetaminophen for breakthrough pain with modest relief, but he wants better treatment options. His back pain is a constant dull ache, sometimes throbbing and radiating to both legs. It worsens with sitting and standing. There are no other musculoskeletal or neurologic symptoms. Mr S also has hypertension, gastroesophageal reflux disease, seasonal allergies, depression, anemia, and hyperlipidemia. In the 1990s, he underwent tonsillectomy and adenoidectomy for obstructive sleep apnea. He takes clonazepam, 1 mg 3 times per day; cyclobenzaprine, 10 mg by mouth 3 times per day; methadone, 40 mg every morning, 30 mg at noon, and 40 mg at bedtime; naproxen, 500 mg twice per day; and oxycodoneacetaminophen, 5 mg/325 mg (one tablet) 4 times per day as needed. He also takes atorvastatin, fenofibrate, lisinopril/ hydrochlorothiazide, omeprazole, ranitidine, sertraline, and verapamil. Mr S, a former restaurant worker, is now receiving disability benefits and lives with his longtime female partner. He does not smoke cigarettes or use alcohol but occasionally uses marijuana for pain control. There is no other history of drug use. He is 5 ft, 7 in tall, weighs 209 lb [94 kg], and has a blood pressure of 108/80 mm Hg and a heart rate of 72/min. Pertinent physical findings include mild paravertebral tenderness in the lumbar region, 4/5 motor strength in his right lower extremity, and 1 /4 right ankle jerk. He has pain on straight leg raising on the right side at 60°. Magnetic resonance imaging of the lumbosacral spine with andwithoutcontrast(performedin2005) isshowninFIGURE1. Degenerative disk changes are noted at multiple lumbar levels, which are similar to those seen on a magnetic resonance imaging study obtained several years earlier.