What is the best course of action for managing chronic low back pain in a patient with degenerative disease and facet osteoarthropathy at L4-5 and L5-S1 levels?

From the Guidelines

The patient's treatment plan should prioritize non-pharmacologic therapies and reserve imaging and medications for cases where there are severe or progressive neurologic deficits, or when serious underlying conditions are suspected, as recommended by the American College of Physicians and the American Pain Society 1. The patient is a 59-year-old male with chronic low back pain who has degenerative disease and facet osteoarthropathy at L4-5 and L5-S1 levels as shown on a previous x-ray.

Key Considerations

• The treatment plan includes discontinuing ibuprofen and starting naproxen 500 mg along with methocarbamol 1000 mg twice daily for 7 days.
• A new x-ray will be ordered to compare with the previous one from July 2024.
• According to the American College of Radiology, MRI of the lumbar spine is the initial imaging modality of choice for patients with subacute or chronic low back pain who have failed 6 weeks of conservative therapy 1.

Medication Management

• Naproxen is an NSAID that can provide longer-lasting pain relief than ibuprofen due to its longer half-life, potentially offering better coverage for chronic pain.
• Methocarbamol is a muscle relaxant that will help reduce muscle spasms often associated with low back pain, particularly in cases with degenerative changes.
• The short 7-day course of methocarbamol is appropriate to minimize side effects like drowsiness while providing acute relief, as recommended by the American College of Physicians and the American Pain Society 1.

Imaging and Diagnostic Testing

• The comparative x-ray will help determine if there has been any progression of the degenerative changes at the affected lumbar levels, which is important for ongoing management of this chronic condition.
• However, the American College of Radiology suggests that MRI of the lumbar spine is the preferred imaging modality for patients with chronic low back pain, as it provides excellent soft-tissue contrast and accurately depicts lumbar pathology 1.

Non-Pharmacologic Therapies

• The patient may benefit from non-pharmacologic therapies such as exercise therapy, acupuncture, massage therapy, or cognitive-behavioral therapy, which have been shown to be effective in managing chronic low back pain 1.
• These therapies should be considered in conjunction with pharmacologic treatment to provide comprehensive management of the patient's chronic low back pain.

From the FDA Drug Label

NSAID medicines can cause ulcers and bleeding in the stomach and intestines at any time during treatment Ulcers and bleeding: can happen without warning symptoms may cause death The chance of a person getting an ulcer or bleeding increases with: taking medicines called "corticosteroids" and "anticoagulants" longer use smoking drinking alcohol older age having poor health

The patient is a 59-year-old male with chronic low back pain and degenerative disease. Naproxen is prescribed for this patient. Considering the patient's age and the potential risks associated with NSAID use, such as ulcers and bleeding, it is essential to monitor the patient closely and advise them to report any warning symptoms. The patient should be informed about the potential side effects of naproxen and the importance of taking the medication exactly as prescribed. It is also crucial to assess the patient's overall health and medical history to minimize the risk of adverse events. 2 2

From the Research

Diagnosis and Treatment of Chronic Low Back Pain

• The patient's diagnosis of degenerative disease and facet osteoarthropathy L4-5 and L5-S1 is consistent with common causes of chronic low back pain, as noted in studies 3, 4.
• The decision to order another x-ray to compare with the previous one is reasonable, as routine imaging is not recommended but may be indicated to monitor changes in the condition 3.
• The prescription of methocarbamol 1000 mg BID for 7 days and the switch from ibuprofen to naproxen 500 mg are pharmacologic interventions that may be beneficial for managing chronic low back pain, although evidence for the use of muscle relaxants like methocarbamol is inconclusive 3, 5.

Nonpharmacologic Treatment Options

• Nonpharmacologic treatment is considered first-line management for chronic low back pain and may include therapies such as exercise therapy, spinal manipulation, and physical therapy 3, 6.
• Exercise therapy has been shown to be effective in reducing pain and improving functional limitations in patients with chronic low back pain, with moderate-certainty evidence supporting its use 6.
• Other nonpharmacologic treatments, such as counseling, massage, heat, dry needling, acupuncture, and transcutaneous electrical nerve stimulation, may also be beneficial, although the evidence for these treatments is varied 3.

Facet Joint Osteoarthritis and Chronic Low Back Pain

• The patient's diagnosis of facet osteoarthritis is a common cause of chronic low back pain, and injections such as facet joint injections and medial branch blocks may be effective in managing this condition 7.
• The use of corticosteroids, hyaluronic acid, and local anesthetics in these injections has been shown to reduce pain and improve functional limitations in patients with facet joint osteoarthritis 7.