What is the recommended treatment for a 69-year-old male with persistent neck pain radiating to his right arm, currently on gabapentin, acetaminophen, prednisone, and lidocaine (lidocaine) ointment, with inadequate symptom relief?

Management of Cervical Radiculopathy with Inadequate Pain Relief

For a 69-year-old male with persistent cervical radiculopathy not responding to current therapy (gabapentin, acetaminophen, prednisone, and lidocaine ointment), the recommended treatment is to optimize the current gabapentin dosage to 900-3600 mg daily in divided doses, add a tricyclic antidepressant such as nortriptyline (starting at 10-25 mg nightly), and consider referral to neurology for further management.

Current Treatment Assessment

The patient presents with:

• Severe neck pain (9/10) radiating down right arm
• Sharp pain consistent with neuropathic pain/radiculopathy
• History of cervical spine compression
• Inadequate response to current regimen:
  • Gabapentin (dose not specified)
  • Acetaminophen
  • Prednisone
  • Lidocaine ointment

Optimizing Pharmacological Management

Step 1: Optimize Gabapentin Dosing

• Gabapentin is an appropriate first-line agent for neuropathic pain 1
• Current dose may be inadequate as therapeutic dosing requires:
  • Starting dose: 100-300 mg nightly
  • Target dose: 900-3600 mg daily in divided doses (2-3 times daily) 2
  • Dose increments of 50-100% every few days 2
  • Note: An adequate trial of gabapentin can require 2 months or more 2

Step 2: Add a Tricyclic Antidepressant

• Add nortriptyline or desipramine:
  • Starting dose: 10-25 mg nightly
  • Target dose: 50-150 mg nightly 2, 1
  • Secondary amines (nortriptyline, desipramine) are better tolerated than tertiary amines (amitriptyline, imipramine), especially in older patients 2

Step 3: Consider Topical Treatment Enhancement

• Optimize topical lidocaine application:
  • Switch from ointment to 5% lidocaine patch
  • Apply directly to painful area daily 2
  • Minimal systemic absorption, well-tolerated in older patients 2

Step 4: For Refractory Pain (if above measures fail)

• Consider tramadol:
  • Starting dose: 50 mg once or twice daily
  • Maximum dose: 400 mg/day (lower in elderly) 2
  • Caution: Tramadol should be reserved for patients who have not responded to first-line medications due to concerns about long-term safety 2, 1

Important Considerations for This Patient

Age-Related Factors

• At 69 years old, slower titration of medications is recommended 2
• Monitor for side effects more closely
• Lower maximum doses may be appropriate

Monitoring Plan

• Schedule follow-up within 2-4 weeks to assess response 1
• Target at least 30-50% pain reduction as a realistic goal 1
• Monitor for common side effects:
  • Gabapentin: dizziness, somnolence, peripheral edema 3
  • Tricyclic antidepressants: sedation, dry mouth, urinary hesitancy 2

Patient Education

• Set realistic expectations: complete pain relief may not be achievable; aim for 30-50% reduction 1
• Explain that gabapentin may take several weeks to reach full effectiveness 2, 3
• Discuss importance of taking medications as prescribed and not stopping abruptly

Referral Recommendations

• Prompt neurology referral is indicated given:
  • Severe pain (9/10) despite multiple medications
  • History of cervical spine compression
  • Previous neurology care 4-6 years ago for same issue
  • Inadequate response to current treatment

Common Pitfalls to Avoid

1. Inadequate gabapentin dosing - many patients receive subtherapeutic doses 3, 4
2. Insufficient trial duration - gabapentin requires at least 2-8 weeks for adequate trial 2
3. Premature escalation to opioids before optimizing first-line agents
4. Failure to address both systemic and topical treatment options
5. Not scheduling timely follow-up to assess treatment response

By following this structured approach, the patient's cervical radiculopathy can be managed more effectively while minimizing risks associated with medication therapy.