What is the best medication for acute lower back pain due to muscle spasm in a 91-year-old patient with compression fractures, currently on acetaminophen (Tylenol)/hydromorphone (Dilaudid)/diclofenac (Voltaren)/calcitonin?

From the Guidelines

For occasional sharp lower back pain due to spasms in a 91-year-old patient with compression fractures, low-dose cyclobenzaprine 5mg as needed is recommended. This medication works as a muscle relaxant, helping to break the pain-spasm cycle effectively in elderly patients. Given the patient's advanced age, start with the lowest effective dose and use only for short periods (3-5 days maximum) to minimize side effects like sedation, confusion, and fall risk. Cyclobenzaprine should be taken at bedtime when possible to reduce daytime sedation. Monitor closely for adverse events, especially if combined with other medications like hydromorphone 1. Alternatives include tizanidine, but it may cause more hepatotoxicity, and methocarbamol 500mg, but it may cause more anticholinergic side effects in the elderly. Non-pharmacological approaches should be continued alongside medication, including gentle heat therapy, physical therapy focusing on gentle stretching, and proper body mechanics when moving.

Some key points to consider when prescribing muscle relaxants for elderly patients with low back pain include:

• The use of skeletal muscle relaxants is associated with central nervous system adverse effects, primarily sedation 1
• There is no compelling evidence that skeletal muscle relaxants differ in efficacy or safety, but risk-benefit profiles could vary substantially 1
• Cyclobenzaprine is an option for short-term relief of acute low back pain, but it is associated with anticholinergic side effects 1
• Tizanidine is well-studied for low back pain, but it is associated with hepatotoxicity that is generally reversible and usually not serious 1

It is essential to weigh the potential benefits and harms of muscle relaxants in elderly patients with low back pain, considering their advanced age and potential comorbidities. Close monitoring and regular reassessment are crucial to minimize adverse events and ensure the safe use of these medications 1.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living Cyclobenzaprine hydrochloride tablets should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available and because muscle spasm associated with acute, painful musculoskeletal conditions is generally of short duration and specific therapy for longer periods is seldom warranted

The best back spasm prn medication for occasional sharp lower back pain after a twisting motion, in a very elderly 91 year old patient with compression fractures, is cyclobenzaprine.

• Key considerations:
  • Use with caution due to potential for increased risk of adverse effects in elderly patients.
  • Monitor for signs of sedation, dry mouth, and dizziness.
  • Limit use to short periods (up to two or three weeks) due to lack of evidence for prolonged use 2, 2.

From the Research

Treatment Options for Back Spasm

The patient is already on Tylenol, hydromorphone, voltaren, and calcitonin. Considering the patient's age and medical history, the following treatment options can be explored:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen may be effective in reducing pain and inflammation 3
• Muscle relaxants like cyclobenzaprine may be considered, but their effectiveness in combination with naproxen is unclear 3
• Opioids like oxycodone/acetaminophen may be used, but their benefits and risks should be carefully weighed, especially in elderly patients 3, 4

Considerations for Elderly Patients

When treating elderly patients with compression fractures, it is essential to consider the potential risks and benefits of each medication.

• Calcitonin has been shown to be effective in reducing acute pain associated with recent osteoporotic vertebral compression fractures, but its effectiveness for chronic pain is unclear 5
• NSAIDs may be effective in managing acute and chronic low back pain, but their use should be cautious in patients at risk of adverse events 4
• Opioids should be used with caution in elderly patients due to the risk of adverse effects 4

Current Treatment Strategies

The current treatment strategies for spinal compression fractures include conservative pain management and vertebral augmentation.

• Medical management, including NSAIDs, calcitonin, and bisphosphonates, remains the first-line therapy for patients with compression fractures 6
• Vertebral augmentation, such as balloon-assisted kyphoplasty, may be considered for patients who do not respond to conservative treatment 6