Struck From Behind: Maintaining Quality of Life With Chronic Low Back Pain

Abstract

A 38-year-old woman was the driver of a stopped car that was struck from behind by another vehicle. She developed sudden flexion and extension of her back, but without head trauma or change in level of consciousness. On the evening of the accident, she presented to the emergency room with severe mid and low back pain, and right knee pain, but was discharged with pain medications. One week following the accident, the pain became increasingly severe. For the past 6 months, she hasbeenunable toworkand is ondisability. Chiropractic treatment, trigger-point injections, epidural injections and physical therapy, nonsteroidal anti–inflammatory drugs, muscle relaxers, and hydrocodone provided no or minimal relief. An MRI of the thoracic spine revealed a subacute appearing left paracentral disc herniation at T11-T12, with effacement of the subarachnoid space, but without spinal-cord or nerve-root compression; an MRI of the lumbar spine revealed a disc bulge at L4-L5 without significant mass effect; and EMG and nerve-conduction studies of the lower extremities were normal. At the time of her initial presentation, she reported severe, constant right-sided mid and low back pain, as well as pain in the right anterior shin. The thoracic disc herniation was not considered a primary anatomic basis of her pain. She was treated in a multidisciplinary manner, including medication management, psychological counseling, physical therapy with a focus on myofascial release, and cognitive behavioral psychotherapy. She did not improve with numerous anticonvulsant and antidepressant medications. She has obtained pain relief with methadone in escalating doses up to 140 mg per day as well as bupropion 300 mg daily and lamotrigine 400 mg daily. She has been able to function reasonably well as a home-