From the Guidelines
I strongly recommend a comprehensive nonpharmacologic approach for this 71-year-old male with recurrent lower back pain due to severe multilevel degenerative disc disease, particularly at L5-S1 with likely significant stenosis, focusing on intensive interdisciplinary rehabilitation and exercise therapy as suggested by the American College of Physicians and the American Pain Society 1. Given the patient's history of temporary relief from trigger point injections and the presence of severe degenerative disc disease, it is crucial to address both the pain and the underlying functional limitations.
- The patient should be considered for intensive interdisciplinary rehabilitation, which has been shown to be moderately effective for subacute low back pain, and may also be beneficial for chronic low back pain 1.
- Exercise therapy should be initiated, focusing on core strengthening, flexibility, and proper body mechanics, as it is a proven nonpharmacologic therapy with benefits for chronic or subacute low back pain 1.
- Additional nonpharmacologic treatments such as acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation may also be considered, as they have shown benefits for chronic or subacute low back pain 1.
- Medications such as gabapentin may be considered for patients with sciatica or spinal stenosis, but the evidence is limited, and extended courses of medications should be reserved for patients clearly showing continued benefits from therapy without major adverse events 1.
- A lumbar epidural steroid injection targeting the L5-S1 level may be considered for additional pain relief, but the patient should be closely monitored for potential benefits and risks.
- The patient should use proper lumbar support when sitting and avoid prolonged standing or activities that exacerbate pain.
- If symptoms persist despite these interventions, referral to a spine specialist for surgical evaluation may be warranted given the severe degenerative changes and stenosis.
From the Research
Patient's Condition
The patient is a 71-year-old male with complaints of lower back pain, diagnosed with severe multilevel degenerative disc disease, most prominent at L5-S1, likely resulting in significant stenosis.
Treatment Options
- The patient has already undergone trigger point injection, which provided temporary relief for a couple of days, but the pain returned 2.
- Epidural steroid injections (ESIs) may be beneficial for a small number of patients with advanced degenerative disc disease and chronic low back pain, but long-term benefits have not been demonstrated 2, 3, 4.
- Surgery, such as decompressive laminectomy, may be effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management 5, 3.
- Lumbar fusion may be considered for patients with multilevel spinal stenosis and degenerative spondylolisthesis, but the precise indications for concomitant lumbar fusion remain unclear 5, 3.
Conservative Management
- Comprehensive medical management, including spinal steroid injections, physical therapy, muscle relaxants, anti-inflammatory medication, and narcotic oral agents, did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation 6.
- Activity modification, analgesia, and physical therapy are recommended as first-line therapy for lumbar spinal stenosis 3.
Diagnostic Criteria
- The diagnosis of lumbar spinal stenosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 3.
- The Delphi consensus is the most current recommendation to assist clinicians with making the diagnosis of neurogenic claudication 4.