What is the best course of treatment for a 46-year-old male patient with chronic low back pain radiating to the left leg?

From the Guidelines

The best course of treatment for a 46-year-old male with chronic low back pain radiating to the left leg should begin with conservative management, focusing on nonpharmacologic therapy with proven benefits, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation, as recommended by the American College of Physicians 1.

Initially, I recommend a combination of physical therapy focusing on core strengthening and lumbar stabilization exercises, twice weekly for 6-8 weeks.

• Medication therapy should include an NSAID such as naproxen 500mg twice daily with food (or ibuprofen 600mg three times daily) for inflammation.
• Potentially, gabapentin starting at 300mg at bedtime and gradually increasing to 300mg three times daily for neuropathic pain.
• The patient should maintain activity as tolerated rather than bed rest, and may benefit from applying heat for 15-20 minutes several times daily. If symptoms persist after 4-6 weeks of conservative treatment, further evaluation with MRI should be considered to rule out disc herniation or spinal stenosis.
• For moderate to severe pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime for 1-2 weeks may help, though these can cause drowsiness. This approach addresses both the mechanical aspects of back pain and the potential nerve compression suggested by the radiation to the left leg, which may indicate sciatica from a lumbar disc issue affecting the L4-L5 or L5-S1 nerve roots.

In terms of pharmacologic treatment, nonsteroidal anti-inflammatory drugs should be considered as first-line therapy, or tramadol or duloxetine as second-line therapy, as recommended by the American College of Physicians 1.

• Opioids should only be considered in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. It's also important to note that interventional procedures such as epidural injections, trigger point injections, and sacroiliac joint injection may be considered for short-term relief from chronic low back pain, as recommended by recent guidelines 1.

However, the patient's current request for Methocarbamol should be approached with caution, as muscle relaxants are generally recommended for short-term use and may have adverse effects such as drowsiness.

• A more comprehensive approach to managing chronic low back pain should prioritize nonpharmacologic therapies and lifestyle modifications, with medication and interventional procedures used as adjunctive treatments when necessary.

From the Research

Treatment Options for Chronic Low Back Pain

The patient's complaint of chronic low back pain radiating to the left leg can be addressed through a combination of nonpharmacologic and pharmacologic interventions.

• Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 2.
• The patient's history of seeing a pain specialist and being prescribed gabapentin, lyrica, oxycodone, and methocarbamol suggests that pharmacologic interventions have already been considered.

Use of Methocarbamol

Methocarbamol is a muscle relaxant that has been shown to be effective in treating acute low back pain associated with myofascial components 3.

• A study published in 2015 found that methocarbamol was well-tolerated and effective in reducing pain and improving mobility in patients with acute low back pain 3.
• Another study published in 2017 found that methocarbamol was effective in reducing pain intensity, pain-related disability, and improving quality of life in patients with refractory muscle-related low/back pain 4.

Imaging and Further Evaluation

Routine imaging is not recommended for chronic low back pain, but it may be indicated if there are red flags or if pain does not resolve with conservative therapy 2.

• The patient's complaint of chronic low back pain radiating to the left leg may warrant further evaluation, including an x-ray of the lumbar spine, to rule out any underlying conditions that may be contributing to the pain.

Conservative Management

Conservative management of lumbar radiculopathy, which may be contributing to the patient's symptoms, should focus on providing patients with information about the condition, individualized physical activity, and directional preference exercises, supported with NSAIDs 5.

• The patient's treatment plan, which includes physical therapy and methocarbamol, is consistent with conservative management principles.

Opioid Use

The patient's history of being prescribed oxycodone, an opioid, suggests that opioid use has already been considered.

• However, the evidence suggests that opioids should be used with caution and only when other treatment options have been exhausted, due to the risks of addiction and other adverse effects 6.