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Clinical Crossroads | Clinician's Corner

A 50-Year-Old Man With Chronic Low Back Pain

James P. Rathmell, MD, Discussant
JAMA. 2008;299(17):2066-2077. doi:10.1001/jama.299.13.jrr80002.
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Mr S, a 50-year-old man, has long-standing low back pain. His pain began more than 20 years earlier with a lumbar disk herniation and has persisted despite diskectomy. He has undergone numerous treatments, but he remains disabled with ongoing pain. His treatment course is used to frame the epidemiology and pathophysiology underlying acute and chronic lumbosacral and radicular pain. The roles of neuropathic pain medications, chronic opioid therapy, physical therapy, spinal manipulation, and multidisciplinary pain treatment programs are reviewed. The indications for and outcomes associated with interventional pain treatments, including epidural steroid injection, facet blocks and radiofrequency treatment for facet-related pain, intradiskal electrothermal therapy, spinal cord stimulation, and intrathecal drug delivery, are discussed. Clinicians are given an evidence-based approach to using available treatment options for low back pain.

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Figure 1. Most Recent Magnetic Resonance Imaging (MRI) Study of Mr S's Lumbosacral Spine (April 2005)
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A, Sagittal T2-weighted image near midline demonstrating advanced degenerative disk disease at the L3-4, L4-5, and L5-S1 levels. Note presence of a Schmorl node (black arrowhead). White lines indicate levels of axial images. B, Axial T2-weighted image at the L3-4 level demonstrating degenerative disk changes and a diffuse disk bulge (yellow arrowheads) resulting in mild stenosis of the central spinal canal. C, Axial T2-weighted image at the L4-5 level demonstrating degenerative disk changes and right-sided postoperative changes with indentation of the thecal sac (white arrowhead). D, Axial T2-weighted image at the L5-S1 level demonstrating degenerative disk changes and prior right hemilaminotomy (blue arrowhead). Overall, there were no significant changes in this MRI study compared with an earlier study performed in September 2003.

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Figure 2. Distribution of Lumbosacral and Radicular Pain
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A, “Low back pain” is more precisely termed lumbosacral spinal pain, which encompasses both lumbar spinal pain (L) and sacral spinal pain (S). Lumbosacral spinal pain is pain in either or both regions and constitutes “low back pain.” B, Radicular pain is caused by stimulation of a spinal nerve and describes pain that is referred to the lower extremity along the corresponding dermatome.

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Figure 3. Normal Anatomy of the Functional Spinal Unit (L4-5) and Associated Neural Structures
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The basic unit of the spine, the functional spinal unit, is composed of 2 adjacent vertebral bodies with 2 posterior facet joints, an intervertebral disk, and surrounding ligamentous structures. See online interactive supplement.

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Figure 4. Progressive Degenerative Changes of the Functional Spinal Unit (L4-5) Associated With Repetitive Mechanical Stress and Aging
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Patterns of pain associated with specific degenerative changes are shown in red. A, Early degenerative changes of the functional spinal unit include loss of hydration of the nucleus pulposus accompanied by mild loss of height of the intervertebral disk. Internal disk disruption (left) begins with radial and/or concentric fissures that extend from the periphery of the nucleus pulposus into the annulus fibrosus. Extension of these fissures or of material from the nucleus pulposus to the peripheral portion of the annulus fibrosis can produce lumbosacral pain mediated by the sinuvertebral nerve. Extension of material from the nucleous pulposus posterolaterally outside the annulus fibrosis (herniated nucleus pulposus, right) can produce an intense inflammatory reaction surrounding the spinal nerve leading to radicular pain. B, Advanced degenerative changes include complete loss of hydration of the nucleus pulposus, marked loss of height of the intervertebral disk, osteophyte formation, and thickening of ligaments. Central canal stenosis results from the combined effects of facet hypertrophy and thickening of the ligamentum flavum and posterior longitudinal ligaments. These degenerative changes can produce neurogenic claudication. Progressive degeneration of the disk or facets can produce chronic lumbosacral pain. Facet hypertrophy can produce stenosis of the lateral recess of the spinal canal and the intervertebral foramen, which may result in radicular pain.

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Relief of Chronic Pain From Failed Back Syndrome
Posted on April 18, 2008
Mark D. Brown, MD, PhD
U Miami Miller School Medicine
Conflict of Interest: None Declared
This patient suffers from "Failed Back Syndrome," (1) has a body mass index greater than 30, hypertension, and depression. The MRI from 2005, following his second surgery, shows an adequate decompression at L5-S1 and significant spinal stenosis at the L4-5 level. The latter correlates with the patient's back and leg pain. Surgical decompression of spinal stenosis can relieve pain. However, it is difficult to obtain a satisfactory outcome from this type of surgery in a patient who is on large doses of opioids.
The patient's medications include significant doses of two potent opioids as well as muscle relaxants, yet he is still suffering with disabling chronic pain. If he can be weaned off of these medications his depressed pain threshold will be restored to a more normal level and he will suffer less.(2) Detoxification from these medications will allow for safer surgical intervention; less anesthetic required and effective relief of post-operative pain. These are the incentives that should be presented to the patient to convince him to withdraw from the medication. However, uncontrolled withdrawal from this combination of medications may result in psychotic attacks and/or seizures with fatal consequences; therefore, the safest method of weaning him is in an inpatient drug rehabilitation center. The patient should be warned of the risks of withdrawal on his own.(3)
Medication withdrawal should be coordinated with weight loss as well as physical rehabilitation to improve his stamina and strength. Exercise will relieve chronic back pain, help with weight reduction, and control depression. All of these measures will contribute to the relief of his chronic back pain syndrome(2,4,5).
If this patient will allow himself to be safely detoxified, lose weight, and exercise, he will have a marked improvement in his quality of life. Following these measures, if his disabling pain persists, a surgical decompression of his spinal stenosis will be safer, followed by more rapid recovery, and would have a higher probability of giving him long-lasting relief.
1. Long DM. "Failed back surgery syndrome." Neurosurgical Clinics North America 2: 899-919, 1991.
2. Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back pain. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004959. DOI: 10.1002/14651858.CD004959.pub3
3. See drug inserts for methadone, oxycodone, clonazapam, and cyclobenzaprine
4. Melissas J, Kontakis G, Volakakis E, Tsepetis T, Alegakis A, Hadjipavlou A. The effect of surgical weight reduction on functional status in morbidly obese patients with low back pain. Obesity Research. 15:378-381, 2005.
5. Rainville J, Hartigan C, Martinez E, Limke J, Jouve J, Finno M. Exercise as a treatment for low back pain. The Spine Journal 4: 106-115, 2004.
The point of view of rehabilitation medicine
Posted on April 8, 2008
Andrea D. Furlan, MD PhD
Toronto Rehabilitation Institute / Institute for Work & Health
Conflict of Interest: None Declared
This unfortunate gentleman's presentation is very typical for the group of patients referred as chronic low-back pain. These people suffer not only from the painful disorder, but also from the side effects of strong medications, depression, low self-esteem, lack of hope and lack of money. After 30 years in pain, it is unlikely that an intervention will miraculously improve 100% of his pain. It is known that the pain pathways in the spinal cord and brain are modified after a period of chronic stimulation and these changes are irreversible.(1)
His perception that short-acting strong opioids, acupuncture, and massage offer some relief for his pain and suffering are in accordance with some recent systematic reviews of the literature.(2,3,4) However, the beneficial effects don't last too long. Nobody should expect that taking an oxycodone tablet will relief his condition for life. The same principle applies to a session of massage or acupuncture. But they do help for a short period. The evidence to support the use of methadone for chronic pain is poor,(5) and it would be advised to convert it to a long-acting strong opioid such as morphine or fentanyl, unless he also has problems with opioid addictions.
In my opinion, what could help at this stage of his life and disease, is to devise achievable and objective short and long-term goals. He needs an interdisciplinary team to assist him in setting and achieving these goals. Below are some examples: I) improve his endurance and fitness (physiotherapist); II) improve his mood (psychologist, family doctor, psychiatrist); III) improve his relationship with his partner and friends (psychologist, social worker); IV) learn how to relax his muscles (physiotherapist, psychologist); V) be aware of devices that he can use to prevent future falls (occupational therapist); VI) learn about special seats, cushions, or chairs that might improve his seating position (occupational therapist, ergonomist); VII) improve his sex life; this might be affected by his mood, medications, or difficulty for positioning, etc (physician, psychologist, physiotherapists); VII) reduce the amount of medications, especially narcotics, because long term use of narcotics might be involved in hypogonadism.(6)(physician); IX) try some gainful occupational activity or volunteer work (social worker, occupational therapist, return-to-work coordinator); X) have more social interactions, help other people, and have a feeling that he is useful to society and not a burden (psychologist, recreational therapist, occupational therapy, social worker); An useful tool to measure his achievements is the goal attainment scale, where there is a process by which important outcomes are selected for individual subjects, and the changes in those outcomes are measured over time.(7)
References
(1) Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000 Jun 9;288(5472):1765-9.
(2) Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006 May 23;174(11):1589-94.
(3) Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine. 2005 Apr 15;30(8):944-63.
(4) Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2002 Sep 1;27(17):1896-910.
(5) Sandoval JA, Furlan AD, Mailis-Gagnon A. Oral methadone for chronic noncancer pain: a systematic literature review of reasons for administration, prescription patterns, effectiveness, and side effects. Clin J Pain. 2005 Nov-Dec;21(6):503-12.
(6) Daniell HW. Hypogonadism in men consuming sustained-action oral opioids. J Pain 2002;3:377-84.
(7) Farrar JT. Goal Attainment Scaling: A New Tool for Pain Medicine. Medscape Neurology & Neurosurgery. 2006;8(2)
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