Case: Musculoskeletal pain from multiple causes
With Dr Liam G Conroy | 3 Mar 2015 | Print
Dr Liam Conroy is director, Department of Pain Medicine, Mercy University Hospital, Cork, Ireland.
This is a case of severe musculoskeletal pain with multiple causes. It was complicated by an episode of life-threatening sepsis with bilateral hip joint and possibly cervical facet joint infection. The patient had renal impairment and hypertension, and NSAIDs were contraindicated. His opioid therapy had been complicated by severe opioid-induced constipation and associated hemorrhoids.
In August 2009, a 62-year-old pub landlord was referred to our department for management of excruciating bilateral hip pain, neck pain and left shoulder pain.
His medical history included:
• Severe bilateral hip dysplasia with end-stage osteoarthritic change
• Severe scoliosis of the thoracic spine
• Renal impairment
• Hypertension and IHD
• Sleep apnea.
The patient had been hospitalized in February 2009 with a diagnosis of septicemia secondary to septic arthritis of both hips. This was confirmed on an MRI scan and a blood culture isolated Escherichia coli. His CRP was 230 mg/L. This admission lasted for three months and required long-term IV antibiotic therapy.
Pain was a constant problem for him and he admitted to having abused alcohol and cannabis in the past in an effort to achieve relief. The patient had been reviewed by three pain specialists since 2000 and had been commenced on long-term opioid therapy. This had included transdermal fentanyl, which caused severe nausea and vomiting, requiring admission to hospital and IV rehydration.
At the time of initial review, the patient was taking sustained release oral hydromorphone 8 mg twice daily, transdermal buprenorphine 15 microgram per hour, pregabalin 150 mg twice daily and diclofenac 100 mg a day.
The patient rated his pain as 8/10 on a visual analogue scale and described his pain as ‘sharp’. He could only walk with the aid of crutches and his sleep was seriously disturbed. He commented that he ‘could never remember waking up without pain’. He had made a conscious decision not to proceed with hip replacement surgery.
A particular problem at first review was the presence of severe constipation and prolapsed hemorrhoids.
MRI of the cervical spine showed the presence of scoliosis, foraminal compromise at multiple levels and worryingly, a significant amount of fluid/effusion in multiple facet joints. Thankfully, his CRP was only 7 mg/L and his WCC was normal. The fluid/effusion in the cervical facet joints was found to have improved on subsequent MRI of the cervical spine.
Hydromorphone, buprenorphine and diclofenac were discontinued and the patient was commenced on prolonged release oral oxycodone 50 mg/naloxone 25 mg twice daily, in addition to local treatment for his hemorrhoids.
On review one month later, the patient claimed to have had a ‘huge improvement’ in his pain score, his constipation and his hemorrhoids. Over the next three months the prolonged release oxycodone/naloxone dosage was reduced gradually to 30 mg/15 mg twice daily without detriment to his pain score or bowel function. At his last review the patient was quite mobile and was using only a walking stick to get about.
By taking prolonged release oxycodone/naloxone, the patient’s pain was effectively controlled and his constipation ceased to be a problem. His mobility and quality of life improved dramatically.
Regretfully, because of funding issues with Ireland’s health service, the patient was unable to afford prolonged release oxycodone/naloxone and he is currently being treated with oxycodone 30 mg twice daily, lactulose 15 mL twice daily and bisacodyl 10 mg at night.
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