What is the cause of severe left back pain in a 42-year-old woman, two days post-laparoscopic radical nephrectomy for a 10 cm renal mass, refractory to Toradol (Ketorolac) and opioids, with normal vital signs and hemoglobin levels?

From the Guidelines

For a 42-year-old woman experiencing severe left back pain refractory to Toradol and opioids two days after laparoscopic radical nephrectomy, I strongly recommend urgent CT imaging of the abdomen and pelvis with contrast to evaluate for postoperative complications, as this approach is crucial for early detection of potential life-threatening conditions such as bleeding, urinoma, or abscess formation, despite normal vital signs and hemoglobin 1.

Clinical Considerations

The patient's severe left back pain, unresponsive to standard analgesics, is concerning for a potential surgical complication. Normal vital signs and hemoglobin do not rule out significant complications, as clinical deterioration can occur rapidly in the postoperative period.

Pain Management

While awaiting imaging, pain management should be continued with multimodal analgesia, including acetaminophen and gabapentin, to help mitigate the patient's discomfort. Opioids may be considered for severe pain unresponsive to other medications, with careful titration and monitoring for side effects, as recommended by recent guidelines on postoperative pain management 1.

Evaluation for Complications

The patient should undergo a thorough physical examination to evaluate for pneumothorax, pulmonary embolism, and wound complications. Early detection of complications such as retroperitoneal hematoma, urine leak, or infection is crucial, even when laboratory values remain normal.

Guideline Recommendations

Recent guidelines emphasize the importance of careful patient selection and surgical approach for radical nephrectomy, considering the increased risk of surgical complications and chronic kidney disease in patients with substantial comorbidities 1. However, in the context of postoperative care, the focus shifts to prompt identification and management of complications, with imaging playing a critical role in this process.

Conclusion is not needed as per the guidelines, so the answer will be ended here.

From the FDA Drug Label

ADVERSE REACTIONS Adverse reaction rates increase with higher doses of ketorolac tromethamine Practitioners should be alert for the severe complications of treatment with ketorolac tromethamine, such as GI ulceration, bleeding and perforation, postoperative bleeding, acute renal failure, anaphylactic and anaphylactoid reactions and liver failure Urogenital: flank pain with or without hematuria and/or azotemia, hemolytic uremic syndrome

The patient's severe left back pain refractory to Toradol (ketorolac tromethamine) could be related to the flank pain listed as an adverse reaction in the drug label 2. However, given the recent laparoscopic radical nephrectomy and the normal vital signs and hemoglobin, it is also possible that the pain is related to the surgical procedure rather than the medication. Acute renal failure and hematuria are also potential adverse reactions to consider, but without further information, it is unclear if these are contributing to the patient's symptoms.

From the Research

Severe Left Back Pain after Laparoscopic Radical Nephrectomy

• The patient is experiencing severe left back pain refractory to Toradol and opioids two days after laparoscopic radical nephrectomy for a 10 cm renal mass 3, 4, 5, 6, 7.
• Vital signs and hemoglobin are normal, indicating no immediate signs of complications such as bleeding or infection.

Management of Back Pain

• The management of back pain, especially in the context of recent surgery, requires careful consideration of the underlying cause and the potential risks and benefits of different treatments 3, 5, 6.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac have been shown to be effective in managing pain after surgery, including partial nephrectomy 4.
• Opioids may be effective for chronic low back pain, but their use is associated with risks such as addiction, overdose, and side effects like constipation, nausea, and sedation 3, 6, 7.

Treatment Options

• Considering the patient's severe back pain refractory to Toradol and opioids, alternative treatment options such as NSAIDs, muscle relaxants, or other analgesics may be considered 4, 5, 6.
• The use of opioids for chronic low back pain management has been analyzed in several studies, with some showing efficacy for certain types of opioids like oxymorphone, tapentadol, and fentanyl 6, 7.
• However, the choice of treatment should be individualized based on the patient's specific needs, medical history, and potential risks and benefits of different treatments 3, 5, 6, 7.