What is the best course of treatment for a 72-year-old male patient with low back pain and recurring leg numbness, who has right knee problems and is non-compliant with physical therapy?

Management of Low Back Pain with Leg Numbness in a 72-Year-Old Male

For a 72-year-old male with low back pain, recurring leg numbness, and non-compliance with physical therapy, the best approach is to obtain MRI imaging to evaluate for possible spinal stenosis or radiculopathy, while simultaneously reinforcing the importance of conservative management including physical therapy, which remains the first-line treatment. 1, 2

Initial Evaluation

• The patient's symptoms of leg numbness while walking with a walker suggest possible neurological involvement that requires prompt assessment, as these symptoms could indicate spinal stenosis or radiculopathy 1
• The recurring nature of the symptoms and the patient's age (>50 years) increase the risk of serious underlying conditions that warrant diagnostic imaging 1, 2
• Given the presence of neurological symptoms (leg numbness) that could affect mobility and increase fall risk, this case requires more urgent evaluation than typical nonspecific low back pain 1, 2

Diagnostic Approach

• MRI is the preferred imaging modality (over CT) for evaluating persistent back and leg pain with neurological symptoms, as it provides better visualization of soft tissue, vertebral marrow, and the spinal canal 1
• Imaging is justified in this case due to the presence of neurological symptoms (leg numbness) and the patient's age (>70 years), which are risk factors for more serious pathology 1, 2
• The clinician should specifically look for evidence of spinal stenosis, which can cause neurogenic claudication (leg numbness while walking) that improves with rest, a symptom pattern consistent with this patient's presentation 1, 2

Treatment Recommendations

First-Line Approaches

• Despite the patient's non-compliance, physical therapy remains a cornerstone of treatment and should be strongly encouraged, with clear explanation of its benefits and the limited options without it 1, 2
• Patient education about the expected course of symptoms and the importance of remaining active should be provided, emphasizing that conservative management is not optional but essential 1, 2
• For pain management, acetaminophen or NSAIDs should be considered as first-line medications, with acetaminophen preferred if there are concerns about NSAID risks in an elderly patient 1, 2

Second-Line Approaches

• If pain is significant, consider short-term use of skeletal muscle relaxants (e.g., cyclobenzaprine, tizanidine) for acute symptom relief 1, 2
• For neuropathic components of pain, gabapentin may provide small, short-term benefits and should be considered, particularly given the neurological symptoms 1, 2
• Tricyclic antidepressants at low doses can be considered as part of a multimodal strategy for pain management if there are no contraindications 1, 2

Advanced Interventions

• If symptoms persist despite adequate trial of conservative measures (which the patient must attempt), consider referral for epidural steroid injections, particularly if imaging confirms radiculopathy 2
• For patients with confirmed spinal stenosis causing significant functional limitation despite conservative management, surgical consultation may be appropriate 1, 2
• Intensive interdisciplinary rehabilitation should be considered if pain becomes chronic and significantly impacts function 1, 2

Addressing Non-Compliance

• Clearly communicate to the patient that advanced treatments (including interventional procedures or surgery) are only appropriate after failure of conservative management, which must be attempted first 1, 2
• Brief individualized educational interventions that explain the rationale for physical therapy and its role in preventing disability may improve compliance 1, 2
• Consider identifying and addressing specific barriers to physical therapy compliance (transportation issues, pain during exercises, misunderstanding of purpose) 1, 2

Important Considerations and Pitfalls

• Avoid prolonged bed rest, as it can lead to deconditioning and potentially worsen symptoms, particularly in elderly patients 1, 2
• Systemic corticosteroids are not recommended as they have not been shown to be more effective than placebo for low back pain with neurological symptoms 1, 2
• Be cautious about overreliance on imaging findings without clinical correlation, as bulging discs without nerve root impingement are often nonspecific and may not explain symptoms 1, 2
• Consider the patient's age and comorbidities when selecting medications, particularly being cautious with NSAIDs in elderly patients due to increased risk of adverse effects 1, 2