From the Guidelines
For a patient with L5/S1 disc bulge who continues to experience significant pain and muscle tension despite initial management, my next step would be to prioritize nonpharmacologic interventions, given the recent evidence from the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1. This approach is based on the understanding that noninvasive nonpharmacologic therapies can improve pain and function without the risk of serious harms associated with pharmacologic treatments. Given the patient's ongoing pain and muscle tension, I would recommend:
- More targeted physical therapy interventions, such as core strengthening and McKenzie extension exercises, which have been shown to be effective for low back pain 1.
- Consideration of other nonpharmacologic therapies with proven benefits, including cognitive-behavioral therapy, yoga, or acupuncture, as suggested by the guideline 1.
- Encouraging the patient to maintain modified activities rather than complete bed rest, as prolonged immobility can worsen muscle tension and delay recovery.
- Addressing sleep quality, possibly with short-term low-dose amitriptyline 10-25mg at night, which can help with both sleep and pain modulation.
- Referral to a pain management specialist for further evaluation and consideration of other treatment options, such as epidural steroid injections, which can provide more direct anti-inflammatory effects at the disc level. It's essential to note that the use of systemic corticosteroids, such as prednisone, is not recommended for the treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1. Therefore, the focus should be on nonpharmacologic interventions and other evidence-based treatments that can provide relief and improve function for the patient.
From the FDA Drug Label
These studies enrolled patients with neuralgia persisting for at least 3 months following healing of herpes zoster rash and a minimum baseline score of greater than or equal to 4 on an 11-point numerical pain rating scale ranging from 0 (no pain) to 10 (worst possible pain). Treatment with pregabalin statistically significantly improved the endpoint mean pain score and increased the proportion of patients with at least a 50% reduction in pain score from baseline
The patient's MRI findings show minor disc disease at L5/S1 with a shallow broad-based posterior disc bulge, and they are still experiencing a lot of pain and muscle tension despite previous suggestions.
- Pregabalin could be considered as an option for managing the patient's pain, as it has been shown to be effective in reducing pain scores in patients with neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia 2.
- However, it's essential to carefully evaluate the patient's medical history, current medications, and potential side effects of pregabalin, such as dizziness, somnolence, and weight gain, before initiating treatment 2.
- The patient's renal function should also be assessed, as pregabalin is excreted primarily by the kidneys, and dose adjustments may be necessary in patients with impaired renal function 2.
- A conservative approach would be to start with a low dose of pregabalin and gradually increase as needed and tolerated, while closely monitoring the patient's response to treatment and adjusting the dose accordingly.
From the Research
Assessment of Current Treatment
The patient's MRI findings show minor disc disease at L5/S1 with a shallow broad-based posterior disc bulge, and they are still experiencing a lot of pain and muscle tension despite the current treatment plan. The current medications include Pristiq, Catapres, Panadeine Forte, Panadol Osteo, and Nurofen.
Potential Next Steps
Considering the patient's ongoing pain and muscle tension, the following options could be explored:
- Pregabalin: Studies have shown that pregabalin can be effective in managing neuropathic pain, including postherpetic neuralgia, painful diabetic neuropathy, and mixed or unclassified post-traumatic neuropathic pain 3, 4, 5, 6. However, it's essential to carefully consider the dosing and titration to minimize side effects and optimize tolerability 4.
- Dose adjustment: If the patient is already taking medications for pain management, adjusting the doses or switching to alternative medications may be necessary to achieve better pain control.
- Multidisciplinary approach: Continuing physiotherapy, myotherapy, and other non-pharmacological interventions may help alleviate the patient's symptoms.
- Re-evaluation of work-related activities: The patient's work schedule and activities may need to be reassessed to prevent further exacerbation of the condition.
Considerations
When considering pregabalin as a treatment option, it's crucial to discuss the potential benefits and risks with the patient, including the possibility of side effects such as somnolence, dizziness, and peripheral edema 3, 7. The patient's medical history, current medications, and lifestyle should also be taken into account when making treatment decisions.
Additional Interventions
Other interventions that may be considered include:
- Cognitive-behavioral therapy: To help the patient manage pain and stress.
- Relaxation techniques: Such as meditation, deep breathing, or yoga to reduce muscle tension and promote relaxation.
- Lifestyle modifications: Encouraging the patient to maintain a healthy weight, engage in regular exercise, and improve their sleep habits to help manage pain and overall well-being.