What is the cause of persistent lumbar and cervical pain in a 51-year-old male with a history of disc degeneration and bone growths, despite partial improvement in right knee symptoms after corticosteroid injection?

From the Guidelines

I strongly recommend a comprehensive approach to manage this patient's cervical and lumbar pain, as well as his right knee issues, prioritizing conservative measures and considering advanced imaging and interventions only if necessary, as supported by the most recent guidelines from the American College of Physicians and the American Pain Society 1. The patient's history of only 35% improvement in his right knee after corticosteroid injection, along with the "popping" sensation that provided some relief, suggests the need for further evaluation.

• A follow-up MRI to evaluate for possible meniscal or ligamentous injury is warranted, particularly given the "popping" sensation that provided some relief.
• For pain management, prescribe naproxen 500mg twice daily with food for two weeks, then as needed, along with physical therapy focusing on knee and spine stabilization exercises twice weekly for 6-8 weeks.
• Additionally, consider a muscle relaxant such as cyclobenzaprine 5mg at bedtime for muscle spasms.
• The patient should apply ice to the knee for 15-20 minutes three times daily and use heat therapy for the cervical and lumbar spine. The x-ray findings indicating degenerative disc disease and osteophyte formation in both cervical and lumbar regions explain his persistent pain.
• If conservative measures fail after 4-6 weeks, consider referral to pain management for possible facet joint injections or medial branch blocks, as recommended by the American College of Radiology 1. This multimodal approach addresses both the inflammatory and mechanical components of his pain while providing functional improvement through targeted physical therapy, and is supported by the use of opioids in chronic pain management as a second-line treatment, as recommended by the International Association for the Study of Pain 1.

From the Research

Patient Complaints and History

• The patient is a 51-year-old male with multiple complaints of lumbar and cervical pain.
• He reported only a 35% improvement in his right knee after the corticosteroid injection last month.
• The patient felt good for a few days after the injection, but now feels a little better after something popped.
• He is also complaining of back pain.

Previous Diagnostic Tests

• Cervical x-ray and lumbar x-ray from last year show signs of wear and tear in the discs and bone growths in the lower neck area, as well as similar issues in the discs and joints.

Treatment Options for Spinal Pain

• According to 2, non-steroidal anti-inflammatory drugs (NSAIDs) are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important.
• 3 suggests that a multitude of treatment options are available for radicular pain, including rest, physical therapy, medications, epidurals, and surgery.
• 4 states that NSAIDs may be superior to placebo for reducing pain in acute and chronic low back pain, but the effects of opioids, antibiotics, and antidepressants are unknown or have an established profile of harms.

Efficacy of NSAIDs for Acute Low Back Pain

• 5 found that NSAIDs are slightly more effective than placebo for short-term reduction of pain intensity and disability, but the magnitude of the effects is small and probably not clinically relevant.
• The quality of the evidence ranged from high to very low, and further research is likely to have an important impact on the estimates of effect.

Integrated Approach to Examination and Treatment

• 6 describes an episode of care utilizing elements of the mechanical diagnosis and therapy (MDT), movement system impairment (MSI), and treatment-based classification (TBC) systems for a patient with chronic low back pain.
• The patient was treated with a combination of sitting postural corrections, functional movement corrections, lumbar mobilization, and extension-based exercise, resulting in a decrease in pain intensity and improvement in overall function.