Case of the Month #27: Lower back and buttock pain by Dr Kerry Bosworth

Mrs C is a 47-year-old lady who was referred to the chronic pain service by her GP. She has recently moved house to be closer to her daughter who is expecting her first child. She was seen by the chronic pain service in her previous home town for persistent lower back pain with pain radiating into her right leg.

The pain began approximately five years ago with no obvious precipitant and has gradually got worse. Other than her pain, her only medical issue is obesity (BMI 31) which she felt she could not address as her pain limits her mobility. She does not drink alcohol, smoke or take recreational drugs. She used to work in an office but lost her job a few months before moving house after needing to take time off due to her pain as she could not sit at her desk for long periods. 

She has tried paracetamol, ibuprofen and naproxen (no benefit), codeine and tramadol (nausea, dizziness and hallucinations), gabapentin and pregabalin (fatigue and brain fog), amitriptyline (dizziness) and duloxetine (gastrointestinal upset).

She was offered an MRI scan by her previous chronic pain service but was unable to tolerate it due to severe claustrophobia. She had a L5 nerve root block which she found very painful and gave her no benefit. She has attended physiotherapy appointments but could not do the exercises because she found them too painful. She declined an offer to attend a pain management programme as she felt she would not be able to cope with the requirements.

She feels that she has missed out on too much of her life due to pain and attends the clinic asking if there are any new medications that she can have to take away the pain so she can play an active role in her grandchild’s life.

• If you were the pain clinician for this first consultation, what questions would you like to ask?
• What might you look for on examination of the patient?
• Would you ask for any further investigations?