What is the best course of action for a female patient with spondylosis at L4-L5 and intervertebral disc prolapse (IVDP) whose pain is worsening after physical therapy sessions and not improving with ketorolac?

Management of Refractory Pain in L4-L5 Spondylosis with IVDP After Failed Physiotherapy and Ketorolac

Stop physiotherapy immediately and transition to flexion-based activities only, as extension-based exercises are worsening her neurogenic claudication from spinal stenosis. 1

Immediate Action: Discontinue Harmful Interventions

• Cease all physiotherapy sessions that involve spinal extension or manipulation, as these worsen pain in patients with lumbar stenosis and disc prolapse by narrowing the spinal canal and compressing neural structures 1
• The American College of Rheumatology strongly recommends against spinal manipulation with high-velocity thrusts in patients with advanced spinal pathology due to risk of fractures, spinal cord injury, and paraplegia 2
• Pain aggravation after physiotherapy indicates the wrong type of exercises are being prescribed—extension-based activities are contraindicated in this clinical scenario 1

Optimize Pharmacologic Management

Replace Ketorolac with Alternative NSAIDs

• Discontinue ketorolac and switch to scheduled oral NSAIDs (ibuprofen 600mg every 6 hours or naproxen 500mg twice daily), as ketorolac has limited utility for chronic pain management with a maximum treatment duration of 5 days 3
• Ketorolac demonstrates a prolonged onset to analgesic action (30-60 minutes) and more than 25% of patients exhibit little or no response, making it suboptimal for ongoing pain control 4
• The American Academy of Family Physicians restricts ketorolac use to a maximum of 5 days due to increased risk of gastrointestinal bleeding, renal dysfunction, and operative site bleeding, especially in females and those with compromised fluid status 3

Add Neuropathic Pain Agents

• Initiate gabapentin (starting 300mg at bedtime, titrating to 300-900mg three times daily) for radicular symptoms, as it provides small to moderate short-term benefits for radiculopathy 1
• Consider adding a tricyclic antidepressant (amitriptyline 10-25mg at bedtime, titrating as tolerated) if neuropathic pain components are present 1

Consider Muscle Relaxants

• Add a skeletal muscle relaxant such as cyclobenzaprine (5-10mg at bedtime), tizanidine (2-4mg every 6-8 hours), or metaxalone (800mg three times daily) for short-term relief if muscle spasm is contributing to pain 1

Prescribe Appropriate Activity Modification

• Advise flexion-based activities exclusively: sitting, leaning forward while walking, and avoiding prolonged standing or walking without forward flexion 1
• Forward flexion increases spinal canal diameter and decompresses neural structures, providing symptomatic relief in neurogenic claudication 1
• The American College of Physicians recommends remaining active with appropriate modifications rather than bed rest, as prolonged bed rest causes deconditioning and worsens disability 1

Obtain Imaging Now

• Order MRI lumbar spine immediately, as pain worsening despite conservative management for what appears to be more than 6 weeks warrants imaging to assess the degree of stenosis, disc herniation, and nerve root compression 1
• The American College of Physicians recommends MRI (preferred over CT) when symptoms persist or progress despite optimal conservative management, or if severe or progressive neurologic deficits develop 1
• Do not delay imaging in this case—the failure of initial conservative measures and pain aggravation from physiotherapy indicates the need for diagnostic clarification before proceeding with further treatment 1

Restructure Physical Therapy Approach

• Refer to a physical therapist experienced in lumbar stenosis who will prescribe flexion-based exercises and core strengthening exclusively 1
• Supervised physical therapy programs with individual tailoring, stretching, and strengthening components show the best outcomes in meta-regression analyses 1
• Avoid any extension-based exercises, spinal manipulation, or activities that increase lordosis 2, 1

Plan for Escalation if Conservative Measures Fail

• Consider epidural steroid injections only after failure of optimized conservative management (appropriate NSAIDs, neuropathic agents, flexion-based therapy) and after MRI confirms nerve root compression 1
• Reserve surgical consultation for patients with persistent functional disabilities and pain despite comprehensive conservative therapy, or progressive neurologic deficits 1
• The evidence from randomized trials shows that both surgical and intensive conservative therapy can improve outcomes in degenerative lumbar disease, but surgery provides statistically significantly better pain relief, disability reduction, and return-to-work status when conservative measures have failed 2

Critical Pitfalls to Avoid

• Do not continue physiotherapy that worsens symptoms—this is the most common error in managing lumbar stenosis, as many therapists prescribe extension exercises that are contraindicated 1
• Do not use ketorolac beyond 5 days, as this increases risk of serious adverse events including gastrointestinal bleeding and renal failure, particularly in females 3, 5
• Do not prescribe bed rest, as this causes deconditioning and potentially worsens symptoms 1
• Do not attribute symptoms to "normal aging" or "arthritis" without proper imaging, as this can delay recognition of progressive neurologic compromise requiring intervention 1
• Do not use systemic corticosteroids, as they are not more effective than placebo for spinal stenosis 1