What is the next step in managing a 42-year-old woman's severe left back pain, refractory to ketorolac (Toradol) and opioids, 2 days after a left laparoscopic radical nephrectomy for a 10cm renal mass, with stable vital signs and normal hemoglobin?

From the Guidelines

The next step in managing this patient's severe left back pain is to obtain an urgent CT scan of the abdomen and pelvis with contrast to evaluate for potential complications such as a retroperitoneal hematoma, urinoma, or abscess. Given that her pain is refractory to both ketorolac and opioids two days after laparoscopic radical nephrectomy, this suggests a possible post-surgical complication rather than expected post-operative pain. While her stable vital signs and normal hemoglobin are reassuring against major hemorrhage, localized bleeding or other fluid collections can cause significant pain without affecting these parameters. After imaging, consultation with the surgical team is essential for interpretation of findings and management planning. If imaging reveals no complications, pain management should be optimized with a multimodal approach including scheduled acetaminophen (1000mg every 6 hours) as recommended by 1, continuation of appropriate opioid dosing, possibly gabapentin (300mg three times daily) for neuropathic pain components, and consideration of local anesthetic techniques such as a transversus abdominis plane (TAP) block. Early mobilization and physical therapy should also be incorporated as the patient's condition allows, as emphasized by the importance of patient-centered care and pain management in 1 and 1. This comprehensive approach addresses both the diagnostic concerns for a surgical complication while ensuring adequate pain control during the recovery period, aligning with the guidelines for postoperative pain management 1 and cancer pain management 1.

Some key points to consider in managing this patient's pain include:

• The use of validated pain scales for assessment as mentioned in 1 and 1
• The importance of a multimodal approach to pain management, including non-opioid and opioid analgesics, as well as adjuvant therapies like gabapentin for neuropathic pain
• The role of imaging in diagnosing potential post-surgical complications that could be contributing to the patient's pain
• The need for consultation with the surgical team for interpretation of imaging findings and management planning
• The incorporation of early mobilization and physical therapy to enhance recovery and reduce the risk of complications, as supported by the principles outlined in 1 and 1.

By prioritizing the patient's pain management and addressing potential complications, we can improve her quality of life and outcomes, which is the primary goal in managing postoperative pain, as highlighted in 1, 1, and 1.

From the Research

Severe Left Back Pain after Laparoscopic Radical Nephrectomy

• The patient is experiencing severe left back pain refractory to ketorolac and opioids 2 days after a left laparoscopic radical nephrectomy for a 10cm renal mass.
• Vital signs are stable and hemoglobin is normal.

Possible Causes of Back Pain

• Back pain after laparoscopic radical nephrectomy can be caused by various factors, including surgical trauma, nerve damage, or bleeding 2.
• However, the provided studies do not specifically address the management of severe back pain after laparoscopic radical nephrectomy.

Diagnostic Tests

• Liver function tests (A) are not directly relevant to the management of back pain after laparoscopic radical nephrectomy.
• Creatine kinase (B) may be elevated in cases of muscle damage, but it is not a specific test for back pain.
• Serum amylase and lipase (C) are enzymes that can be elevated in cases of pancreatic damage, but they are not directly relevant to the management of back pain after laparoscopic radical nephrectomy.
• Duplex ultrasonography of the abdomen (D) may be useful in detecting bleeding or other complications, but it is not a specific test for back pain.
• MRI scan of the spine (E) may be useful in detecting nerve damage or other spinal complications, but it is not a first-line test for back pain after laparoscopic radical nephrectomy.

Next Step

• Based on the provided studies, there is no clear consensus on the next step in managing severe left back pain after laparoscopic radical nephrectomy 3, 4, 5, 2, 6.
• However, it is essential to rule out any complications, such as bleeding or nerve damage, that may be causing the back pain.
• A thorough physical examination and review of the patient's medical history are necessary to determine the cause of the back pain and guide further management.