What is the diagnosis and treatment plan for a 48-year-old male patient with celiac disease, history of right knee surgery, and lower right back pain, requesting a steroid injection in his right hip?

From the Guidelines

I strongly recommend proceeding with the lumbar spine x-ray before administering a steroid injection to the patient's right hip, as this will help establish a clear diagnosis and identify potential causes of the patient's symptoms, such as degenerative disc disease, arthritis, or other structural abnormalities. The 48-year-old male with lower right back pain should take ibuprofen 400 mg as prescribed for pain management in the interim. While the patient attributes his back pain to previous knee issues, it's essential to consider the possibility of other underlying conditions that may be contributing to his symptoms.

According to the guidelines from the American College of Physicians and the American Pain Society 1, a thorough evaluation, including a focused history and physical examination, is necessary to determine the underlying cause of the patient's symptoms. The patient's controlled celiac disease is unlikely to impact this treatment plan, but his history of knee problems may indeed be contributing to altered biomechanics affecting his back.

The British Pain Society's pathway for low back and radicular pain also emphasizes the importance of a multidisciplinary approach to managing chronic pain, including the use of psychological therapies and interventions such as radiofrequency denervation 1. However, in this case, the primary concern is to establish a clear diagnosis through imaging before proceeding with any invasive treatments.

• Key points to consider:
  • The patient's symptoms and medical history, including his previous knee issues and controlled celiac disease
  • The importance of establishing a clear diagnosis through imaging before proceeding with steroid treatment
  • The potential benefits and risks of steroid injections and other interventions
  • The need for a multidisciplinary approach to managing chronic pain, including the use of psychological therapies and physical therapy. The x-ray will provide valuable information to guide further treatment and ensure that any interventions are targeted to the correct underlying condition, rather than simply providing symptomatic relief without addressing the root cause of the patient's symptoms.

From the Research

Patient Assessment and Treatment

• The patient is a 48-year-old male with complaints of pain in the lower right side of the back, and has a history of celiac disease and right knee surgery.
• The patient is requesting a steroid injection in his right hip, and the doctor plans to prescribe an x-ray of the lumbar spine and ibuprofen 400 mg.
• The patient declined physical therapy (PT) and a follow-up appointment is scheduled to review the x-ray and administer the steroid injection.

Steroid Injections for Back Pain

• Studies have shown that epidural corticosteroid injections can provide short-term relief for lumbosacral radicular pain, with moderate-quality evidence supporting their use 2.
• However, the treatment effects are small and may not be considered clinically important by patients and clinicians, with a mean difference of less than 10% 2.
• Other studies have compared oral opioid analgesics to spinal steroid injections for low back pain, finding that spinal steroid injections are beneficial in the short-term, but with limited high-quality evidence to support their use 3.

Safety and Side Effects of Steroid Injections

• Local corticosteroid injections can have systemic effects, including Cushing syndrome, loss of bone density, infection, and hyperglycemia, with significant individual variability in the amount of systemic absorption and clinical effects 4.
• The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used are all important considerations in estimating risks 4.
• Caution should be exercised when using local glucocosteroid injections in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term 4.

Imaging and Procedure

• Image-guided spinal injection is commonly performed to decrease pain severity, confirm the pain generator, and delay or avoid surgery, with radiologists playing a critical role in procedural selection and planning 5.
• Fluoroscopic anatomy and patterns of contrast material flow guide the planning and execution of safe and effective needle placement 5.