What is the treatment for an 87-year-old man with right lower back pain radiating to the right hip?

From the Guidelines

For an 87-year-old man with right lower back pain radiating to the hip, I recommend starting with conservative treatments, prioritizing acetaminophen and non-pharmacologic therapies due to the potential risks associated with NSAIDs and opioids in elderly patients. Begin with acetaminophen (Tylenol) at 500-1000mg every 6 hours, not exceeding 3000mg daily, as it is safer for elderly patients than NSAIDs 1. Apply heat therapy using a heating pad for 15-20 minutes several times daily to relax muscles and improve blood flow. Gentle stretching exercises like knee-to-chest pulls and pelvic tilts can help, performed 2-3 times daily with 5-10 repetitions each.

Some key considerations for treatment include:

• The use of opioids should be carefully weighed due to the risks of aberrant drug-related behaviors and potential for abuse or addiction, especially in vulnerable populations 1.
• Non-pharmacologic therapies such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation may be beneficial for chronic or subacute low back pain 1.
• Topical analgesics like menthol creams can provide temporary relief when applied to the painful area 3-4 times daily.
• Maintaining good posture, avoiding prolonged sitting, and using supportive shoes and chairs are also important aspects of conservative management.

This pain pattern could indicate sciatica, spinal stenosis, or arthritis, which are common in older adults. If pain persists beyond 2-3 weeks, worsens, or is accompanied by weakness, numbness, or bladder/bowel changes, medical evaluation is essential as these symptoms may require different treatment approaches or indicate more serious conditions. Given the most recent and highest quality evidence, a conservative approach with acetaminophen and non-pharmacologic therapies is the recommended initial treatment strategy 1.

From the FDA Drug Label

In three of these studies there was a significantly greater improvement with cyclobenzaprine than with diazepam, while in the other studies the improvement following both treatments was comparable The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

The treatment for right lower back pain that radiates down to the right hip for an 87-year-old man may include cyclobenzaprine hydrochloride tablets.

• The recommended dose is 5 mg, and it should be used with caution due to the patient's age.
• Cyclobenzaprine has been shown to be effective in treating muscle spasm and backache in clinical trials 2.
• However, the patient's age and potential hepatic impairment should be considered when prescribing this medication.

From the Research

Treatment Options for Right Lower Back Pain

The treatment for right lower back pain that radiates down to the right hip in an 87-year-old man can be approached in several ways, considering the potential causes of the pain.

• For patients with back pain associated with radiculopathy, as might be the case with pain radiating down to the hip, magnetic resonance imaging or computed tomography may be used to establish the diagnosis and guide management 3.
• First-line medications for chronic low back pain include acetaminophen and nonsteroidal anti-inflammatory drugs. Tramadol, opioids, and other adjunctive medications may benefit some patients who do not respond to nonsteroidal anti-inflammatory drugs 3.
• Alternative therapies such as acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are effective in certain clinical situations and may be considered for patients with chronic low back pain 3, 4.
• Epidural steroid injections may be beneficial for patients with radicular symptoms, although studies have produced mixed results 3, 4.

Considerations for Osteoporosis

Given the age of the patient, osteoporosis could be a contributing factor to the back pain, especially if there are concerns about bone density or history of fractures.

• Bisphosphonates are widely used in the treatment of osteoporosis to reduce fracture risk and may be considered for patients at high risk of fracture 5, 6, 7.
• However, the use of bisphosphonates should be carefully considered, taking into account potential side effects and the optimal duration of therapy 5, 7.

Evaluation and Management

A thorough history and physical examination are crucial to categorize the patient's condition and guide further management.

• Patients should be evaluated for red flags such as cauda equina syndrome, recent trauma, or risk of infection, which may require immediate attention 4.
• Imaging studies should be reserved for patients with specific indications, such as red flags or when warranted before treatment 3, 4.