What is the best course of treatment for an adult patient with a history of chest and back pain, possibly related to musculoskeletal or neuropathic pain, and a previous normal Low-Dose Computed Tomography (LDCT) scan 20 months ago, who is concerned about X-ray exposure and has been prescribed gabapentin and a sleep study?

Treatment Approach for Chest and Back Pain with Prior Normal LDCT

Your pulmonologist made the correct clinical decision to prescribe gabapentin and order a sleep study without repeating the LDCT scan, given your normal imaging 20 months ago, absence of red flags, and concern about radiation exposure. 1

Why Repeat LDCT Was Not Necessary

Imaging is not indicated for thoracic back pain without red flags, myelopathy, or radiculopathy. 1 The American College of Radiology explicitly states there is no relevant literature supporting the use of CT imaging in the initial evaluation of thoracic back pain without red flags or neurologic deficits 1. Your clinical presentation—musculoskeletal chest and back pain without alarm symptoms—does not warrant repeat imaging at this time 1.

Lung Cancer Screening Context

For lung cancer screening specifically, annual LDCT is recommended only for adults ages 55-74 years with at least a 30 pack-year smoking history who currently smoke or quit within the past 15 years 1. Your normal LDCT 20 months ago provides reassurance, and routine screening intervals (if you meet criteria) would be annual—not at 20 months 1. The pulmonologist appropriately reconsidered after clinical examination revealed no concerning pulmonary findings 1.

Gabapentin for Musculoskeletal/Neuropathic Pain

Gabapentin is appropriate first-line therapy for neuropathic pain components of your chest and back pain. 1

Dosing Protocol

• Start at 300 mg three times daily (900 mg/day total) 2, 3
• Titrate to 1800 mg/day over approximately 3 days (300 mg day 1,600 mg day 2,900 mg day 3, then increase by 300-600 mg every few days) 2, 3
• Target maintenance dose: 1800-3600 mg/day in three divided doses 2, 3
• Maximum time between doses should not exceed 12 hours 2

Expected Efficacy

Gabapentin at 1800-3600 mg/day provides at least 50% pain reduction in approximately 32-38% of patients with neuropathic pain, compared to 17-21% with placebo 4, 5, 6. This means 3-4 out of 10 patients achieve meaningful pain relief 5. For neuropathic pain descriptors like burning, shooting pain, and allodynia, gabapentin demonstrates significant benefit 7, 3.

Common Side Effects to Anticipate

• Dizziness (19% of patients) 4, 5
• Somnolence/drowsiness (14%) 4, 5
• Peripheral edema (7%) 4, 5
• Gait disturbance (9-14%) 4, 5, 7

Most adverse effects are mild to moderate and typically subside within approximately 10 days from initiation 3. About 11% of patients discontinue due to adverse events 4, 5.

Sleep Study Rationale

The sleep study addresses a critical component of your pain syndrome. 1 Sleep disturbance is both a consequence and exacerbating factor for chronic pain 1. Achieving at least 50% pain reduction with gabapentin is associated with important improvements in sleep interference, fatigue, and depression 4, 5. Identifying and treating sleep disorders (such as sleep apnea) can significantly improve pain outcomes and quality of life 1.

Critical Monitoring Points

When to Seek Immediate Re-evaluation

• Development of myelopathy signs (spasticity, hyperreflexia, gait disturbance, bladder dysfunction) 1, 8
• Progressive motor weakness in a specific nerve distribution 8
• Severe, intractable pain unresponsive to gabapentin 8
• New respiratory symptoms (hemoptysis, unexplained weight loss, persistent cough) 1

Medication Management Cautions

• Do not stop gabapentin suddenly—taper over minimum 1 week to avoid withdrawal seizures 2
• Avoid alcohol and sedating medications while on gabapentin due to additive CNS depression 2
• Take antacids at least 2 hours apart from gabapentin to avoid absorption interference 2
• Dose adjustment required for kidney disease—inform your physician if you have renal impairment 2

Expected Timeline

Most patients with musculoskeletal/neuropathic pain improve within 4-12 weeks with conservative management including gabapentin 8. Pain reduction with gabapentin is typically seen by week 1 and maintained through treatment 2. If you do not achieve adequate pain relief after 6 weeks at optimal gabapentin dosing (1800-3600 mg/day), consider discussing additional interventions such as physical therapy focused on core strengthening, or evaluation for other adjuvant analgesics 1, 8.