From the Guidelines
For this 59-year-old male with severe lower back pain who is on Xarelto and has a history of lumbar disc rupture and back surgery, a multimodal approach is recommended since he hasn't responded to over-the-counter medications or muscle relaxers. The best pain management approach would include prescription-strength pain medication such as tramadol 50mg every 6 hours as needed, which provides moderate pain relief while having less interaction with Xarelto than other opioids 1. This should be combined with physical therapy focusing on core strengthening and flexibility exercises, 2-3 times weekly for at least 6-8 weeks. Topical analgesics like lidocaine 5% patches applied to the painful area for 12 hours daily can provide localized relief without systemic effects. Given his anticoagulation therapy with Xarelto, NSAIDs should be avoided due to increased bleeding risk 1. For breakthrough pain, acetaminophen can be continued but should not exceed 3000mg daily. A referral to a pain specialist for consideration of interventional procedures like epidural steroid injections may be appropriate, though these require careful planning due to his anticoagulation status 1. This multimodal approach addresses pain through different mechanisms while minimizing risks associated with his anticoagulation therapy and previous surgical history. Some key points to consider in the ER include:
- Avoiding NSAIDs due to the risk of bleeding with Xarelto
- Considering alternative pain management options such as tramadol or topical analgesics
- Referring the patient to a pain specialist for further evaluation and management
- Ensuring the patient's anticoagulation status is carefully managed if interventional procedures are planned.
From the Research
Pain Management Approach
The patient's severe lower back pain, with a history of lumbar disc rupture and back surgery, requires a comprehensive pain management approach. Considering the patient's current medication, Xarelto (rivaroxaban), and lack of response to over-the-counter ibuprofen, acetaminophen, or prescribed muscle relaxers (methocarbamol), alternative options should be explored.
Pharmacological Interventions
- Non-steroidal anti-inflammatory drugs (NSAIDs) may not be suitable due to the patient's blood thinner medication, Xarelto 2.
- Multimodal therapy, combining opioids, non-opioid analgesics, and regional anesthesia, may be effective in managing the patient's pain 3, 4.
- Tricyclic antidepressants, phenothiazines, and new non-steroidal anti-inflammatory drugs may also be considered to tailor specific drugs to the patient's needs 2.
Non-Pharmacological Interventions
- Comprehensive pain recovery programs, including physical therapy, emotional and spiritual support, cognitive behavioral therapy, and non-opioid pharmacotherapies, may be beneficial in addressing the patient's chronic pain 5.
- Alternative therapies, such as heat, cold, physical supports, and surgery, should also be considered 2.
ER Orders
- A thorough evaluation of the patient's pain, including its cause, severity, type, location, duration, quality, and response to therapies, is essential 2.
- Orders for imaging studies, such as MRI or CT scans, may be necessary to determine the underlying cause of the patient's pain.
- Consultation with orthopedics and pain management specialists may be required to develop a comprehensive treatment plan.
- Patient-controlled analgesia (PCA) or epidural opioid analgesia (EOA) may be considered for pain management, but with caution due to the patient's history of opioid use and current medication regimen 6.