Read the Case-Based Curriculum for Neurology Residents.

An onhopedic surgeon. Dr. Jackson, asks you to evaluate and take over the pain
management of Mr. Jones, a 48 year old unmarried man followed unril recenrly by Dr. Williams,
a retired senior panner. Dr. Williams had been prescribing hydrocodone. Last Saturday night,
Mr. Jones ran out of medication and came to the hospiral emergency room (ER) seeking a refill.
Dr. Blake, cross-covering onhopedics, refused to authorize narcotics over the phone for a patient
whom he did not personally know. Dr. Harris, the ER attending, told Mr. Jones that the besr she
could do was to provide 20 acetaminophen with codeine ro "tide him over" until Monday. Mr.
Jones refused that offer with obscenities, angrily protesting that he needed hydrocodone
"up to 4
times a day ro get by," and dismissing codeine as "totally wonhless" for his chronic pain.
Unsettled by repons from the ER, Dr. Jackson felt uncomfonable about writing scripts for srrong
narcotics for a patient he believed he hardly knew himself. He wanted the patient
"good
to be seen by a
neurologist who might pick up something that's been missed,
'wonder
or maybe know of a new
drug'."
Mr. Jones' back problems began at age 27, soon after he staned work as a long distance
lruck driver. While loading his truck, he experienced sudden excruciating low back and bilareral
leg pain caused by a severely herniared L4-L5 disc. Surgery by Dr. williams had relieved mosr of
the back pain and all ofthe leg pain, leaving him for several years with mild interminent low
back pain panicularly with "long hauls" cross-country. Subsequently. this pain became more
intense and continuous with less provocadon. Six years ago, he had a life-rhreatening upper GI
bleed requiring multiple transfusions, attributed to overuse of aspirin and nonsteroidals, and ro
alcohol abuse. He joined Alcoholics Anonymous and has been abstinent from alcohol ever since.
His weight and smoking have increased. Past medical history is norewonhy for hypenension,
moderate obesity and a 2 pack-per-day (50 pack-year) cigarctte habir. He denies ever havins used
rnFavenous drugs.
Three years ago, while helping to unload a truck, Mr. Jones lost his balance and rwisred
his trunk, triggering immediate incapacitating lumbar pain, paroxysmal
"elecric shocks"
superimposed upon new numbness and tingling within the left Sl dermatome, and weakness,
particularly when standing on his left toes. Pain was unrelieved by 2 weeks of strict bed rcst,
oxycodone, and muscle relaxants. An EMG study showed a severe, acule, and chronic lefr sl
radiculopathy, superimposed upon mild bilateral chronic L5-Sl radiculoparhies. Lumbosacral
MRI showed herniation of'the lJ-S I disc with a large fragrnent comprcssing the left S I root
Three weeks after the injury, Dr. Williams performed L5-Sl discectomy and fusion withour
apparent complication. Despite postoperative physical therapy, Mr. Jones rcponed gradually
increasing lumbar pain and burning dysesthetic pain in a left Sl distribution.
Over the ensuing year, his left foot became cooler and duskier in color, with the soread of
burning pain over his entirc foot up his calf to the knee. The touch of sheers and socks on hir f*t
became unbearably painful. He consulted several local onhopedic surgeons and neurosurgeons
who found no funher surgical indications, underwent several courses ofphysical therapy that he
believed made the pain worse, and briefly attended a pain clinic but found that symparhetic and
regional nerve blocks provided no or transient pain relief. A numbcr of adjuvant analgesics failed
to relieve his "reflex sympathetic dystrophy," including amitriptyline, fluoxetine, carbamazeDine