What is the plan of care for a 70-year-old male with severe left spine pain, radiating to both legs, and decreased range of motion (ROM) of right hip external rotation, who has been taking meloxicam (Mobic) (meloxicam) with some relief?

Management Plan for 70-Year-Old Male with Left Spine Pain and Radicular Symptoms

For this 70-year-old male with severe left spine pain radiating to both legs and decreased right hip external rotation, the initial treatment should include continued meloxicam at the maximum tolerated dose along with activity modification, physical therapy, and consideration of imaging if symptoms persist beyond 4 weeks. 1

Initial Assessment and Classification

Pain Characteristics

• Severe left spine pain (9/10 at worst)
• Sharp pain shooting down right leg occasionally and sometimes left leg
• Tenderness in the groin
• Decreased ROM of right hip external rotation
• Symptoms began with physical activity (cutting and moving wood)
• Meloxicam has been helpful

Recommended Approach

1. Continue Pharmacological Management:

   • Continue meloxicam at maximum tolerated dose (typically 7.5-15mg daily) 2, 3
   • Monitor for gastrointestinal, renal, and hepatic adverse effects 2
   • Avoid long-term use of additional corticosteroids 1
   • Consider acetaminophen as an adjunct if additional pain control is needed 1

2. Activity Modification:

   • Remain active rather than resting in bed 1
   • Modify activities that exacerbate pain (e.g., heavy lifting, prolonged sitting)
   • Apply heat for short-term relief 1

3. Physical Therapy:

   • Initiate physical therapy focusing on:
     • Core strengthening exercises
     • Hip mobility exercises
     • Proper body mechanics for activities like wood cutting
     • Gradual return to normal activities 1

4. Patient Education:

   • Explain the generally favorable prognosis of acute back pain with radicular symptoms
   • Provide information about self-care options
   • Discuss the natural history of disc herniation with radiculopathy (improvement typically within 4 weeks with noninvasive management) 1

Imaging Considerations

• Initial imaging is not recommended unless there are signs of severe or progressive neurologic deficits 1
• If symptoms persist beyond 4 weeks despite conservative management:
  • Consider MRI (preferred) or CT to evaluate for disc herniation or spinal stenosis 1
  • Plain radiography cannot adequately visualize discs or evaluate spinal stenosis 1

Follow-up and Treatment Progression

2-4 Week Follow-up:

• Reassess pain levels and functional status
• If insufficient response to meloxicam:
  • Consider changing to another NSAID 1
  • Evaluate for radicular symptoms that may require further intervention 1

4-12 Week Follow-up:

• For persistent radicular symptoms despite conservative management:
  • Consider referral for specialist evaluation 1
  • Potential interventions may include epidural steroid injections for radiculopathy 1
  • MRI should be obtained before considering interventional procedures 1

Special Considerations

• Hip Pathology: Given the decreased ROM of right hip external rotation and groin tenderness, consider concurrent hip pathology that may require specific evaluation 1
• Age-Related Concerns: At 70 years old, the patient has higher risk for:
  • Degenerative spinal conditions
  • Osteoporosis
  • Reduced tolerance for certain medications 1

Common Pitfalls to Avoid

1. Overreliance on imaging: Early imaging without red flags can lead to unnecessary interventions 1
2. Prolonged bed rest: This can worsen outcomes and delay recovery 1
3. Inadequate pain control: Undertreated pain can lead to deconditioning and chronic pain 1
4. Failure to recognize hip pathology: Hip conditions can mimic or coexist with spine pathology 1
5. Prolonged NSAID use: Monitor for GI, renal, and cardiovascular adverse effects, especially in older adults 2, 3

By following this structured approach, focusing on continued appropriate medication use, activity modification, and physical therapy, most patients with this presentation will experience significant improvement within 4-6 weeks 1.