Melissa is a 45-year-old female whose primary complaint is chronic neck and shoulder pain related to cervical spondylosis with radiculopathy. Melissa first received this diagnosis a few years ago after being injured while at work. When the provider asked Melissa to describe her pain, she described it as burning and radiating down her left arm with occasional numbness and tingling in her fingers. Her current pain level is 8/10, and her pain gets worse anytime she is on her computer or sits for prolonged periods of time.
Melissa currently works as a medical billing specialist, but misses several days of work each month because of her pain. She denies changes to her bowel or bladder function, fever, or recent infection. Sleep is poor, and she complains of feeling more fatigued.
Melissa's past medical history consists of anxiety disorder and gastroesophageal reflux disease (GERD). She takes pantoprazole 40 mg daily for reflux and buspirone 10 mg twice daily for anxiety. She has no history of substance abuse and drinks alcohol only occasionally. She quit smoking five years ago.
Melissa has tried multiple treatments, including physical therapy, acupuncture, heat therapy, TENS, and medications such as acetaminophen, naproxen, and muscle relaxants, but still lives in chronic pain. Melissa had tried gabapentin 300 mg three times daily, but it caused excessive drowsiness. She has also used topical diclofenac with minimal benefit.
When conducting a neurological exam, the provider notes some weakness in her left triceps, diminished sensation in the left thumb, and a positive Spurling's test. Reflexes are symmetric, and there is no muscle atrophy. A recent MRI confirmed moderate degenerative changes at C5–C6 with mild foraminal narrowing.
According to the ORT, Melissa scored low risk for misuse. Per the guidelines, she signed an opioid treatment agreement and was counseled about safe use, secure storage, and potential side effects.
Melissa's provider prescribed tramadol 50 mg every six hours as needed (maximum four per day) for one week. After five days, she called the office complaining of continued pain, along with nausea and a headache. The provider discontinued the tramadol and prescribed duloxetine 30 mg daily, with instructions to increase to 60 mg after two weeks.
A few weeks later, Melissa had her one-month follow-up and reported some improvement in her pain and mood, and that she had missed fewer days of work. The provider opted to add a topical lidocaine patch for breakthrough pain and referred Melissa to a pain management specialist for a possible cervical epidural injection.
Since Melissa was not on any opioids, the provider skipped over the discussion on a bowel regimen. She was also educated on posture, ergonomics in the workplace, and exercises to prevent further degeneration. Three months later, Melissa reports her pain level averaging 4–5/10, her sleep improving, and an improved quality of life overall. She continues duloxetine 60 mg daily and uses lidocaine patches occasionally.
