How to manage a 67-year-old female with complaints (c/o) of low back pain radiating to the back of the thigh towards the right leg, with magnetic resonance imaging (MRI) revealing bilateral facet joint degeneration with bone spurs compressing the nerve roots and a negative straight leg raise test?

From the Guidelines

For a 67-year-old female with low back pain radiating to the right posterior thigh, with MRI showing bilateral facet joint degeneration and nerve root compression from bone spurs, I recommend a multimodal approach. Initially, prescribe NSAIDs such as naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 1-2 weeks to reduce inflammation, as suggested by the American College of Physicians and the American Pain Society 1. Add acetaminophen 1000mg three times daily for additional pain relief. Physical therapy focusing on core strengthening, flexibility, and proper body mechanics should be started twice weekly for 6-8 weeks. For muscle spasms, consider cyclobenzaprine 5mg at bedtime for 1-2 weeks. If pain persists, a referral for interventional pain management for facet joint injections with corticosteroids may provide targeted relief, as recommended for patients with persistent symptoms associated with spinal stenosis 1. The negative straight leg raise suggests the pain is likely facet joint-mediated rather than due to disc herniation. Encourage weight management if needed, as excess weight increases stress on facet joints. Heat therapy for 15-20 minutes several times daily can help relax muscles, while avoiding prolonged bed rest which can worsen symptoms, as advised by the British Pain Society 1. If conservative measures fail after 6-8 weeks, consider referral to a spine specialist to discuss surgical options such as minimally invasive decompression.

Some key points to consider in the management of this patient include:

• The importance of remaining active and avoiding prolonged bed rest, as this can worsen symptoms 1.
• The use of self-care education books and other self-care options to supplement clinician-provided advice and promote effective self-management of low back pain 1.
• The potential benefits of interventional pain management, such as facet joint injections with corticosteroids, for patients with persistent symptoms despite conservative management 1.
• The importance of considering the patient's age, general health, and physical demands of required job tasks when providing advice about activity limitations and return to work 1.

From the FDA Drug Label

Animal studies indicate that cyclobenzaprine does not act at the neuromuscular junction or directly on skeletal muscle. Such studies show that cyclobenzaprine acts primarily within the central nervous system at brain stem as opposed to spinal cord levels, although its action on the latter may contribute to its overall skeletal muscle relaxant activity Evidence suggests that the net effect of cyclobenzaprine is a reduction of tonic somatic motor activity, influencing both gamma (γ) and alpha (α) motor systems In a pharmacokinetic study in elderly individuals (≥65 yrs old), mean (n=10) steady state cyclobenzaprine AUC values were approximately 1.7-fold (171.0 ng•hr/mL, range 96.1-255. 3) higher than those seen in a group of eighteen younger adults (101.4 ng•hr/mL, range 36.1-182.9) from another study. Elderly male subjects had the highest observed mean increase, approximately 2.4-fold (198.3 ng•hr/mL, range 155.6-255.3 versus 83.2 ng•hr/mL, range 41.1-142.5 for younger males) while levels in elderly females were increased to a much lesser extent, approximately 1.2-fold (143. 8 ng•hr/mL, range 96.1-196.3 versus 115.9 ng•hr/mL, range 36.1-182. 9 for younger females). In light of these findings, therapy with cyclobenzaprine hydrochloride tablets in the elderly should be initiated with a 5 mg dose and titrated slowly upward

The management of a 67-year-old female with complaints of low back pain radiating to the back of the thigh towards the right leg, with magnetic resonance imaging (MRI) revealing bilateral facet joint degeneration with bone spurs compressing the nerve roots and a negative straight leg raise test, may involve the use of cyclobenzaprine.

• Key considerations for the use of cyclobenzaprine in this patient include:
  • Age: The patient is elderly, and pharmacokinetic studies have shown that cyclobenzaprine levels are higher in elderly individuals, particularly males 2.
  • Dosing: Given the patient's age, it is recommended to initiate therapy with a 5 mg dose and titrate slowly upward.
  • Monitoring: The patient should be monitored for adverse effects, such as drowsiness and dry mouth, which are common with cyclobenzaprine use.
• Clinical studies have demonstrated the efficacy of cyclobenzaprine in the treatment of muscle spasm and pain, although the evidence is not specific to this patient's condition 2. Given the lack of direct evidence, a conservative approach would be to consider cyclobenzaprine as a potential treatment option, while also exploring other therapeutic alternatives and monitoring the patient's response closely.

From the Research

Management of Low Back Pain

The patient is a 67-year-old female with complaints of low back pain radiating to the back of the thigh towards the right leg. The MRI reveals bilateral facet joint degeneration with bone spurs compressing the nerve roots, and the straight leg raise test is negative.

Diagnosis and Treatment

• The patient's condition can be categorized as back pain associated with radiculopathy or spinal stenosis, as the MRI shows compression of the nerve roots 3.
• First-line medications for chronic low back pain include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4.
• For patients who do not respond to NSAIDs, tramadol, opioids, and other adjunctive medications may be beneficial 3, 4.
• Epidural steroid injections may be considered for patients with radicular symptoms, as they have been shown to be effective in certain clinical situations 3, 5.

Conservative Treatments

• Conservative treatments, including pharmacological therapy, procedures, and exercise, can be used to control chronic pain 6.
• Procedures such as injection of steroids and local anesthetics, pulsed radiofrequency (PRF), and repetitive transcranial magnetic stimulation (rTMS) may be effective in managing chronic pain 6.
• Exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are also effective in certain clinical situations 3, 6.

Specific Treatment Options

• The patient may benefit from epidural steroid injections, as they have been shown to be effective in managing low back pain with lumbosacral radicular pain 5.
• The lateral parasagittal approach may be a better option than the midline interlaminar approach for epidural steroid injections, as it has been shown to have better ventral epidural spread and higher success rates 5.
• Serial injections may be required to achieve adequate and prolonged symptom control, as seen in the case report of a patient with post-herpetic neuralgia who received serial thoracic transforaminal epidural steroid injections 7.