What is the best approach to manage chronic lower back pain in a 400-pound patient with a history of traumatic back injury, moderate disc herniation, and degenerative changes?

From the Guidelines

The most effective approach to managing chronic lower back pain in a 400-pound patient with a history of traumatic back injury, moderate disc herniation, and degenerative changes is a comprehensive multidisciplinary strategy that includes weight management, physical therapy, medication, and possibly interventional procedures, with a strong recommendation in favour of epidural injections for chronic low back pain due to disc disease, as suggested by the 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain 1.

Initial Management

The patient should start with a supervised weight loss program aiming for 1-2 pounds weekly through dietary changes and gradually increased physical activity. Physical therapy, focusing on core strengthening, flexibility, and proper body mechanics, should be done 2-3 times weekly for 8-12 weeks. Medication management may include:

• Acetaminophen (up to 3000mg daily in divided doses)
• NSAIDs like naproxen (500mg twice daily) if no contraindications exist
• Duloxetine (30mg daily, increasing to 60mg if needed) for neuropathic pain
• Muscle relaxants such as cyclobenzaprine (5-10mg at bedtime) for muscle spasms
• Limited use of tramadol (50-100mg every 6 hours as needed) for severe pain episodes, avoiding long-term opioid therapy

Supportive Measures

Supportive measures should include:

• Ergonomic adjustments
• A medium-firm mattress
• Possibly a bariatric back brace for temporary support during activities

Interventional Options

If conservative management fails after 6-8 weeks, consider interventional options like:

• Epidural steroid injections, which have a strong recommendation for chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome 1
• Medial branch blocks, with radiofrequency denervation considered only after a positive response to a medial branch block, as per the 2020 NICE Guideline on Low back pain and sciatica in over 16s: assessment and management 1

Key Considerations

It's crucial to prioritize a multimodal approach that addresses the mechanical stress from excess weight, inflammatory processes, and neuropathic components while minimizing the risks of surgical intervention in a high-BMI patient, unless neurological deficits develop. The 2021 American College of Occupational and Environmental Medicine Low Back Disorders Guideline and the 2021 Epidural interventions in the management of chronic spinal pain: American society of interventional pain physicians (ASIPP) comprehensive evidence-based guidelines provide additional insights into the management of chronic low back pain, but the most recent and highest quality evidence supports the use of epidural injections and a comprehensive multidisciplinary approach 1.

From the Research

Treatment Approach for Chronic Lower Back Pain

The treatment of chronic lower back pain in a 400-pound patient with a history of traumatic back injury, moderate disc herniation, and degenerative changes requires a comprehensive and multimodal approach.

• A personalized, stepwise, and multimodal approach that includes pharmacotherapy, psychotherapy, integrative treatments, and interventional procedures is recommended 2.
• The biopsychosocial model with a multidisciplinary pain management program is widely accepted as one of the most effective methods to assess and manage chronic pain 2.
• Nonpharmacologic therapies, such as behavioral, cognitive, integrative, and physical therapies, can be used as stand-alone therapies or to augment and complement pharmacologic treatments 3.

Pharmacological Interventions

• Gabapentin, an anticonvulsant, has been shown to be effective in the treatment of neuropathic pain related to spinal cord injury and discogenic lumbosacral radiculopathy 4, 5.
• Gabapentin can reduce the intensity and frequency of pain, relieve neuropathic pain descriptors, and improve quality of life 4.
• The use of gabapentin in patients with discogenic lumbosacral radiculopathy has been shown to result in significant reduction of pain and restricted mobility, with more rapid reduction of symptoms in patients with earlier onset of treatment 5.

Multimodal Treatment

• Multimodal treatment of chronic pain involves a combination of pharmacotherapy, psychotherapy, and interventional procedures 6.
• The practitioner and patient must weigh the benefits of combination pharmacotherapy with the potential side effects, as many medications have modest effects yet carry significant side effects that can be additive 6.
• Structured interdisciplinary programs can be beneficial but are often costly, and further research is needed to validate many common combination treatments 6.