What is the next management plan for an elderly patient with rheumatic eye disease on chronic prednisone, with unbearable neck pain, normal cervical spine imaging, and inability to take NSAIDs, who has tried lidocaine patch, Tylenol, baclofen, and gabapentin?

Management of Refractory Neck Pain in an Elderly Patient with Polymyalgia Rheumatica on Chronic Prednisone

Given the patient's polymyalgia rheumatica (PMR) on chronic prednisone with unbearable neck pain despite multiple failed therapies and normal imaging, the next step is to consider a short-term increase in prednisone dose (0.5 mg/kg/day) combined with colchicine 0.5 mg twice daily, while evaluating for crowned dens syndrome or other inflammatory causes of cervical pain. 1

Immediate Diagnostic Considerations

Rule Out Crowned Dens Syndrome

• Obtain CT of the craniocervical junction to evaluate for calcifications around the odontoid process, as crowned dens syndrome presents with acute severe neck pain and stiffness with elevated inflammatory markers and can occur in patients with various rheumatic diseases, not just CPPD 1
• This condition responds dramatically to glucocorticoids (0.5 mg/kg prednisone) plus colchicine 0.5 mg twice daily 1
• Crowned dens syndrome should be suspected in any patient with acute cervical or occipital pain with extreme neck stiffness and elevated inflammatory markers, particularly in those with pre-existing rheumatic disease 1

Evaluate for Cervical Spine Involvement of PMR

• While cervical spine involvement in rheumatic disease typically occurs after 10 years, it can present as an early feature with severe neck pain and myelopathy 2
• Order MRI cervical spine without contrast if not already performed, as MRI has higher sensitivity than plain radiographs for detecting early inflammatory changes, bone erosions, and pannus formation 2
• Check inflammatory markers (ESR, CRP) to assess disease activity 3

Pharmacologic Management Algorithm

Step 1: Optimize Glucocorticoid Therapy

• Temporarily increase prednisone to 0.5 mg/kg/day (approximately 25-40 mg for most elderly patients) for acute severe neck pain, as this dose has proven effective for crowned dens syndrome and other inflammatory cervical conditions 1
• The 2015 EULAR/ACR guidelines for PMR recommend initial doses of 12.5-25 mg prednisone equivalent daily, with higher doses within this range for patients at high risk of relapse 3
• Administer prednisone as a single morning dose before 9 am to minimize HPA axis suppression 4

Step 2: Add Colchicine

• Initiate colchicine 0.5 mg twice daily as adjunctive therapy, particularly if crowned dens syndrome is suspected or confirmed 1
• This combination (prednisone + colchicine) produces dramatic improvement in both clinical symptoms and laboratory markers within days 1

Step 3: Consider Opioid Therapy with Age-Adjusted Dosing

• If pain remains unbearable despite optimized anti-inflammatory therapy, initiate low-dose tramadol as scheduled dosing (not as-needed) as part of a multimodal analgesic approach 3
• For elderly patients, reduce opioid dosing by 20-25% per decade after age 55 to minimize exposure without altering pain control 3
• Reserve stronger opioids (oxycodone) for breakthrough pain only 3

Step 4: Multimodal Analgesic Optimization

• Continue scheduled acetaminophen (not as-needed) to maintain steady serum levels and reduce pain fluctuations 3
• Since gabapentin has failed, consider switching to pregabalin as an alternative gabapentinoid, which may have different efficacy 3
• Consider adding a tricyclic antidepressant (e.g., nortriptyline 10-25 mg at bedtime) or SNRI (duloxetine 30-60 mg daily) for neuropathic pain component 3

Step 5: Regional Anesthesia Consultation

• Refer to pain management or anesthesiology for consideration of cervical epidural steroid injection or peripheral nerve blocks targeting the cervical plexus (C2-C3 distribution) 3
• Regional analgesia is a crucial component of multimodal analgesia and can provide targeted relief while reducing systemic opioid requirements 3
• Peripheral nerve blocks have strong evidence for decreasing opioid use and pain in elderly patients with acute pain 3

Steroid Tapering Strategy Once Pain Controlled

• Once adequate pain control is achieved, taper prednisone by 1 mg every 4 weeks back to the maintenance dose 3
• Monitor disease activity, laboratory markers, and adverse events at each taper 3
• If relapse occurs during taper, increase prednisone back to the pre-relapse dose and decrease gradually over 4-8 weeks 3

Consider Steroid-Sparing Agent

• Evaluate for methotrexate 7.5-10 mg weekly as a steroid-sparing agent, particularly given this patient's need for prolonged glucocorticoid therapy and risk of adverse events 3
• Methotrexate should be considered in patients at high risk for relapse, prolonged therapy, or those with risk factors for glucocorticoid-related adverse events 3

Critical Pitfalls to Avoid

• Do not attribute all neck pain to mechanical causes when imaging is normal—inflammatory conditions like crowned dens syndrome require specific imaging (CT craniocervical junction) and respond dramatically to anti-inflammatory therapy 1
• Do not avoid glucocorticoids due to fear of side effects in elderly patients with severe inflammatory pain—low-dose prednisone (≤10 mg/day for maintenance) is safe and effective when combined with calcium 800-1000 mg/day and vitamin D 400-800 units/day 5
• Do not use NSAIDs in PMR patients except for short-term use for pain related to other conditions, as glucocorticoids are the strongly recommended treatment 3
• Do not prescribe opioids as-needed—scheduled dosing of non-opioid analgesics with opioids reserved for breakthrough pain reduces overall opioid exposure and provides better pain control 3
• Do not overlook the need for temporal artery biopsy if giant cell arteritis is suspected, though this patient's normal imaging and lack of visual symptoms make this less likely 1

Follow-Up Timeline

• Reassess in 48-72 hours after initiating increased prednisone and colchicine to evaluate response 1
• If dramatic improvement occurs, this supports an inflammatory etiology and confirms appropriate treatment 1
• Schedule follow-up every 4-8 weeks during the first year of treatment to monitor for relapse and adverse events 3