What is the best care plan for a patient with chronic back pain, degenerative changes in the lumbar spine, sacroiliac (SI) joint issues, a history of depression, and possible verbal spousal abuse?

Comprehensive Care Plan for Chronic Back Pain with Degenerative Changes, Depression, and Possible Spousal Abuse

This patient requires immediate prioritization of depression treatment and psychosocial safety assessment alongside multimodal nonpharmacologic therapy for chronic back pain, as depression is a stronger predictor of poor outcomes than pain severity itself. 1

Immediate Safety and Psychosocial Assessment

• Screen for intimate partner violence using validated tools and establish safety planning if verbal abuse is confirmed, as this represents a critical barrier to pain management and recovery 2
• Document specific patterns of verbal abuse, frequency, and impact on daily functioning and pain perception 2
• Assess for fear-avoidance behaviors, anxiety levels using Hospital Anxiety and Depression Scale, and depression severity using standardized measures 3
• Evaluate the spouse/caregiver's role as either supportive or contributing to disability, as caregiver involvement significantly impacts treatment outcomes 4

First-Line Treatment: Depression Management

Initiate duloxetine 60 mg once daily as first-line pharmacologic treatment, as it addresses both depression and chronic back pain simultaneously with Level II evidence supporting efficacy 1, 5

• Duloxetine demonstrated superiority over placebo for both major depressive disorder (mean HAMD-17 improvement of -4.9 points, 95% CI: -6.8 to -2.9) and chronic low back pain in controlled trials 5
• Alternative first-line option: tricyclic antidepressants if duloxetine is contraindicated or not tolerated 1
• Establish monitoring strategy for side effects before prescribing, including nausea (23% incidence), dry mouth (13%), somnolence (10%), and sexual dysfunction, with routine inquiry at follow-up visits 2, 5
• Consider sertraline as second-line if SNRIs/tricyclics fail, though evidence is weaker for pain populations 1

Concurrent Nonpharmacologic Interventions (Mandatory First-Line)

Begin structured physical therapy focused on core strengthening, flexibility, and pain management techniques for at least 12 weeks, as nonpharmacologic treatment must be prioritized initially for chronic back pain 2, 1, 6

Physical/Restorative Therapy Components:

• Supervised exercise therapy with progressive loading targeting lumbar stabilization 2
• Manual therapy and spinal manipulation as tolerated 1
• Proper ergonomics training and activity modification to reduce mechanical stress 6

Psychological Interventions (Essential Component):

Implement cognitive-behavioral therapy addressing pain beliefs, catastrophizing, and depression concurrently with physical therapy 2, 1

• CBT provides effective relief for back pain with assessment periods ranging from 4 weeks to 2 years (Category A2 evidence) 2
• Include biofeedback and progressive relaxation training as adjuncts 2
• If spousal abuse is confirmed, integrate couple-based therapy or individual supportive psychotherapy to address relationship dynamics, as couple interventions can improve social function, reduce pain intensity, and address neglected needs of both patients and caregivers 4

Additional Nonpharmacologic Options:

• Acupuncture for pain reduction 1
• Mindfulness-based stress reduction 1
• Consider intensive interdisciplinary rehabilitation if initial measures fail after 3 months, including physician consultation, psychological intervention, physical therapy, and cognitive-behavioral components 1

Pharmacologic Pain Management

Use NSAIDs as first-line pharmacologic treatment for back pain 1

• Tramadol as second-line if NSAIDs insufficient or contraindicated 1
• Avoid long-term opioids given depression and psychosocial complexity; if considered, establish strict monitoring protocol for side effects, adverse effects, and compliance before prescribing 2
• Consider skeletal muscle relaxants for acute exacerbations, though evidence is limited 2

Interventional Considerations (Only After Conservative Failure)

Sacroiliac joint diagnostic blocks may be considered if pain localizes to SI joint after 3-6 months of failed conservative management, with one high-quality guideline providing strong recommendation for SI blocks 2

• Epidural steroid injections have contradictory evidence for non-radicular axial back pain: one high-quality guideline recommends lumbar interlaminar or caudal epidurals for axial/discogenic pain 2, while moderate-quality guidelines recommend against ESIs for non-radicular low back pain due to lack of long-term effectiveness 2
• Given this patient's non-radicular presentation with degenerative changes, ESIs are NOT recommended based on the most recent moderate-quality evidence 2
• Facet joint injections may provide diagnostic and therapeutic benefit, as facet-mediated pain causes 9-42% of chronic low back pain 7

Monitoring and Reassessment Protocol

Reassess at 1 month after initiating treatment to evaluate response to duloxetine, adherence to physical therapy, and depression symptoms 1

• Monitor for treatment-emergent suicidality, particularly in first 4-8 weeks of antidepressant therapy 5
• Assess functional improvement using Oswestry Disability Index at 3-month intervals 7
• Document pain intensity using validated scales (0-10 numeric rating) at each visit 2
• If symptoms persist or worsen after 3 months of comprehensive conservative management, consider referral to multidisciplinary pain center for advanced interventional options or intensive rehabilitation 1, 6

Critical Pitfalls to Avoid

• Do not pursue surgical fusion without minimum 3-6 months of comprehensive conservative management including formal physical therapy, as imaging findings of degenerative changes correlate poorly with symptoms and may not be the pain source 7, 6
• Do not use discography as stand-alone test for treatment decisions, as it is not recommended and may accelerate degenerative process 2
• Avoid focusing solely on pain elimination rather than functional restoration, as this perpetuates disability 6
• Do not overlook the psychosocial component—untreated depression and ongoing verbal abuse will sabotage all pain interventions, as depression predicts poor outcomes independent of pain severity 1, 8
• Recognize that patients with chronic pain and depression have temporal association (HR: 8.47,95% CI: 6.84-10.49) requiring integrated treatment approach 8

When Surgical Consultation May Be Appropriate

Consider surgical evaluation only if ALL criteria met: failure of comprehensive conservative management for 6 months minimum, significant functional impairment despite maximal medical management, documented instability or spondylolisthesis on imaging, and pain that directly correlates with specific anatomical abnormalities 7, 6

• Fusion reserved for documented instability, spondylolisthesis, or when extensive decompression might create instability 7
• Decompression alone may suffice if stenosis without instability 7
• Current presentation with degenerative changes and SI joint pain does NOT meet surgical criteria without trial of comprehensive conservative management 6