What is the best course of treatment for an adult patient, possibly older, with a history of chronic back pain, presenting with lower back pain suggestive of sciatic nerve pain, and radiographic findings of mild multilevel degenerative changes of the lumbar spine, who has been initially treated with Toradol (Ketorolac) 30mg intramuscular (IM) injection, Prednisone 20mg three times a day for 5 days, Gabapentin (Neurontin) 300mg nightly, and referred to physical therapy (PT)?

Treatment Modification for Lower Back Pain with Sciatica and Degenerative Changes

Discontinue the prednisone immediately, as systemic corticosteroids are not recommended for low back pain with or without sciatica because they have not been shown to be more effective than placebo. 1

Immediate Medication Adjustments

Your initial treatment requires several modifications based on guideline recommendations:

Discontinue Ineffective Therapy

• Stop the prednisone course now - systemic corticosteroids provide no benefit over placebo for low back pain with or without sciatica 1
• The 5-day course at 60mg daily (20mg three times daily) should not be continued or repeated 1

Optimize Current Medications

• Continue gabapentin 300mg nightly - this medication shows small, short-term benefits in patients with radiculopathy, though evidence is limited 1
• Consider titrating gabapentin up to 900mg three times daily if symptoms persist, as this dosing has shown efficacy in sciatica 2, 3
• The single dose of Toradol 30mg IM was appropriate for acute pain management 1

Add Evidence-Based Pharmacotherapy

• Initiate NSAIDs as first-line therapy for ongoing pain management, as they have moderate evidence for short-term treatment of mechanical low back pain 4
• Consider adding a tricyclic antidepressant for chronic pain relief if symptoms persist beyond 4 weeks, as they are an option for pain relief in patients with chronic low back pain 1
• Avoid skeletal muscle relaxants beyond short-term use (maximum 1-2 weeks) due to central nervous system adverse effects, primarily sedation 1

Physical Therapy and Non-Pharmacologic Management

Ensure the patient completes formal physical therapy for at least 6 weeks, as this is the minimum requirement before considering any advanced interventions 5

PT Should Include:

• Spinal manipulation - associated with small to moderate short-term benefits for acute low back pain (duration <4 weeks) 1
• Exercise therapy should begin after 2-6 weeks if symptoms persist into the subacute phase 1
• Individual tailoring, supervision, stretching, and strengthening components are associated with the best outcomes 1

Additional Non-Pharmacologic Options if No Improvement:

• Acupuncture - moderately effective for chronic low back pain 1
• Massage therapy - moderately effective for chronic low back pain 1
• Cognitive-behavioral therapy - moderately effective for chronic low back pain 1

Timeline-Based Treatment Algorithm

Acute Phase (Current - 4 weeks):

• NSAIDs + gabapentin (titrate as needed) 1, 4
• Spinal manipulation through PT 1
• Patient education on self-care and prognosis 4, 6

Subacute Phase (4-8 weeks if symptoms persist):

• Continue medications showing benefit 1
• Initiate structured exercise therapy 1
• Consider intensive interdisciplinary rehabilitation if not improving 1

Chronic Phase (>3 months if symptoms persist):

• Reassess for need to add tricyclic antidepressants 1
• Expand non-pharmacologic therapies: acupuncture, massage, yoga, cognitive-behavioral therapy 1
• Screen for depression, which is common in chronic low back pain patients 1

Critical Pitfalls to Avoid

• Do not prescribe extended courses of any medication unless the patient clearly shows continued benefits without major adverse events 1
• Do not use epidural steroid injections for nonspecific low back pain without radiculopathy, as they provide only short-term relief (<2 weeks) 1, 7
• Do not consider surgical referral until at least 3 months of comprehensive conservative management has failed 1, 5
• Do not use benzodiazepines except for very time-limited courses due to risks for abuse, addiction, and tolerance 1

Imaging Interpretation and Clinical Correlation

The X-ray findings of "mild multilevel degenerative changes" are nonspecific and correlate poorly with symptoms 1

• These degenerative changes are common and do not necessarily indicate the source of pain 1
• The absence of acute fracture, subluxation, or destructive process is reassuring 1
• No surgical intervention is indicated based on these imaging findings alone 5

When to Reassess or Escalate Care

Reassess at 2-4 weeks to determine response to modified treatment:

• If significant improvement: continue current regimen and advance PT 1
• If minimal improvement: add additional non-pharmacologic therapies 1
• If worsening or development of red flags (progressive motor/sensory loss, new urinary retention, saddle anesthesia): obtain MRI and consider urgent specialist referral 4