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Andrew is 75-year-old man who has been very active until about a year ago. He used to play golf twice a week. One year ago, he slowly started to get persistent lower back pain which gradually began to worsen. A few months later he noted that he was getting pain in his thigh and to his dismay his neck was becoming painful too. Finally, he had to stop playing golf altogether. He was seen by his PCP who after a careful examination made a diagnosis of non-specific back pain. Andrew was started on acetaminophen and ibuprofen, which reduced his back pain to such an extent that he could play some golf again. However, a few months later during a routine checkup his PCP noticed edema of his ankles. On further investigation, he was found to have elevated blood urea and crea-tinine. Ibuprofen was promptly stopped with resulting recurrence of back and neck pain. Andrew was then prescribed regular codeine phosphate and diazepam before bedtime for insomnia. These medications made him constipated and sleepy during the day. Andrew again consulted his PCP, who suggested that he should see a pain specialist.

Outline your approach to Andrew's problems?

Majority of back pain cases have a benign etiology. Regardless, a detailed history and complete physical examination are necessary. The ankle edema could be directly linked to the NSAID use as it can cause water retention and heart failure as well as rise in creatinine. It is essential to rule out the existence of red flags which could be a warning of existing serious health problems.

During evaluation, Andrew describes his pain as a dull ache in the lower part of his back. It is present most of the time and radiates to his both thighs but not below the knees. On exam, he exhibits tenderness over the paravertebral area in the lumbar region and pain on flexion and rotation of lumbar spine. On examining the neck, he has trigger points in the trapezius muscles and the gluteus muscles. There are no sensory or motor deficits and nothing suggestive in his past medical history. Reports from the laboratory show mild renal impairment, and the provisional diagnosis of mechanical back pain is made. You order an MRI scan and the report states that Andrew has lumbar facet joint arthropathy and generalized degenerative disk disease.

Can you correlate neck pain and back pain?

We can consider the vertebral column as a complex, integrated unit made of bones, muscles, and ligaments. Damage to one component or misalignment between the individual components can lead to instability of posture and balance leading to the symptoms of pain spreading to other parts. Alternatively, the two could have totally unrelated pathologies.

What are your management options?

In general terms, it depends on the age, desired range of activities, and the attitude of the patient. In the case of Andrew, he wants to be able to play golf at least once a week. He cannot take NSAIDs. Regular physiotherapy and regular exercise could be helpful, but persistent pain could hinder this mode of treatment. TENS therapy might be helpful and this has the advantage of being simple, side effect free and could be used practically anytime during the day or night. An analgesic such as tramadol is another option. Interventions such as facet joint injections combined with physiotherapy could give short-term pain relief. A successful facet joint injection could be followed-up with RF ablation, which if successful, can provide long-term pain relief.

Andrew does not want to take any more pills because of their side effects. He would like you to do the facet joint injection.

What are the pros for Andrews's choice? What are the cons?

One advantage is that the facet joint injection can be used as a diagnostic test. If pain relief is achieved, the cause of the back pain could be attributed to facet joint arthropathy. If it gives immediate pain relief, steroid could be administered through the needle before it is withdrawn. A successful block can later be followed with RF ablation.

However, RF ablation is an invasive procedure with a success rate of about 50-70%. Though considered a safe procedure, the risks of infection, bleeding, intrathecal injection, and nerve damage are real. Following a good response to the injection, Andrew should be encouraged to mobilize actively.

How do you treat trigger points?

These could be dealt with at the time of facet joint injections. You can either inject them with bupivacaine or in combination with steroid. Back pain can arise from various structures at the same time. Treating one source can unmask pain from adjacent sources, which will need to be treated at a later time. Andrew has degenerative changes due to the natural aging process; the options to treat this are unfortunately limited. Hence, at a later stage he could be a potential candidate for a pain management program

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