What could be causing a 65-year-old patient with chronic kidney disease (CKD) and impaired renal function (eGFR of 60) to experience neck pain localized to the left trapezius muscle, which worsens when turning their head to the right or nodding, and what are the potential management options?

Neck Pain Management in 65-Year-Old with CKD Stage 3a

This is most likely myofascial pain or cervical muscle strain affecting the left trapezius, and acetaminophen up to 3000 mg/day is the safest first-line treatment given the patient's eGFR of 60 mL/min/1.73m². 1

Understanding the Clinical Picture

The pattern described—left trapezius pain worsening with right head turning and nodding, but relatively spared with left turning—is classic for unilateral myofascial pain or muscle strain rather than serious pathology. The pain pattern suggests mechanical strain of the left trapezius muscle, which is stretched when turning the head to the opposite (right) side and contracted during nodding movements.

First-Line Treatment Approach

Acetaminophen is the preferred initial agent due to its superior safety profile in CKD patients, with no significant gastrointestinal bleeding, adverse renal effects, or cardiovascular toxicity. 1

• Maximum safe dose: 3000 mg/day (lower than the general population's 4000 mg/day limit due to CKD). 1
• Prescribe on a regular schedule (e.g., 1000 mg three times daily) rather than "as needed" to maintain consistent pain control. 1
• Continue for at least 7-10 days to assess efficacy.

Second-Line Options if Acetaminophen Insufficient

Topical analgesics are excellent alternatives for localized neck/trapezius pain without systemic absorption or renal impact:

• Lidocaine 5% patch applied to the painful trapezius area for up to 12 hours daily. 1
• Diclofenac gel applied topically to the affected area 2-4 times daily. 1

Local heat application provides significant relief for musculoskeletal pain without affecting renal function—recommend moist heat for 15-20 minutes, 3-4 times daily. 1

Non-Pharmacological Interventions (Essential)

Physical activity and exercise programs should be considered as initial treatment for musculoskeletal pain and can be implemented alongside medications. 1

• Gentle neck range-of-motion exercises performed 2-3 times daily.
• Stretching of the trapezius muscle: gentle left lateral neck flexion (ear toward left shoulder) to stretch the affected left trapezius.
• Avoid prolonged static positions that strain the neck.

Critical Medications to AVOID

NSAIDs (including ibuprofen, naproxen, and COX-2 inhibitors) should generally be avoided in CKD patients due to nephrotoxicity, risk of acute kidney injury, progressive GFR loss, electrolyte derangements, and worsening heart failure/hypertension. 1 While short-term use with careful monitoring has been suggested in some contexts 2, the risk-benefit ratio strongly favors avoiding them entirely at eGFR 60 mL/min/1.73m².

When to Consider Additional Evaluation

Refer for further evaluation if:

• Pain persists beyond 4-6 weeks despite conservative management.
• Development of red flag symptoms: fever, unexplained weight loss, progressive neurological deficits (weakness, numbness radiating down the arm), severe night pain, or history of cancer.
• Pain significantly worsens or changes character.

Special Considerations for CKD Stage 3a

With an eGFR of 60 mL/min/1.73m², this patient has CKD Stage 3a. 3 This level of kidney function requires:

• Dose adjustment for renally cleared medications (acetaminophen maximum 3000 mg/day). 1
• Avoidance of nephrotoxic agents (NSAIDs). 1
• Monitoring for CKD complications including anemia, bone disease, and cardiovascular risk factors. 3

If Pain Becomes Chronic or Severe

Should the pain persist beyond 6-8 weeks or become severe:

• Gabapentin starting at 100-300 mg at night with careful titration is recommended for neuropathic components, though significant dose adjustment is required in CKD. 1
• Fentanyl or buprenorphine are the safest opioid options for CKD patients if pain becomes severe and refractory to other treatments, but these should be reserved as last-line options with risk mitigation strategies and informed consent. 1, 2

Practical Summary for This Patient

1. Start acetaminophen 1000 mg three times daily (total 3000 mg/day). 1
2. Apply moist heat to left trapezius 15-20 minutes, 3-4 times daily. 1
3. Begin gentle neck stretching exercises focusing on left lateral flexion. 1
4. Add lidocaine 5% patch or diclofenac gel if inadequate response after 5-7 days. 1
5. Avoid all NSAIDs given CKD. 1
6. Reassess in 2 weeks; if no improvement, consider physical therapy referral or further evaluation.