Multimodal Analgesia for Acute on Chronic Pain in a Postoperative Patient with Complex Spinal History and Traumatic Fracture: A Case Report

Case Diagnosis: 45 yo male with acute-on-chronic pain following open reduction internal fixation and intramedullary nailing of the right tibia.

Case Description or Program Description: 45 yo male with a complex musculoskeletal history including degenerative disc disease, multiple spine surgeries, and chronic pain management presents with acute pain following open reduction internal fixation and intramedullary nailing of the right tibia. Patient is referred to Pain Management for uncontrolled pain. History of opioid dependence, high-dose opioid use, and PTSD complicated pain management.

Setting: Tertiary Care Hospital

Assessment/Results: Following surgery, the patient’s RLE pain was not controlled on a Fentanyl PCA pump in addition to the outpatient pain regimen of Oxycontin, Oxycodone, and Cymbalta. The patient experienced improvement of symptoms after adding a slow IV push of Ketamine, starting Lamictal for neuropathic pain, increasing Cymbalta, using Baclofen for muscle spasms, and receiving the Jain Auricular Acupuncture for Pain Protocol.

Discussion (relevance): The patient’s high-dose opioid use history that included home usage of Oxycontin 60mg BID and 80mg q8h led to warranted concern about potential side effects and limited efficacy of increasing opioid usage. Ketamine successfully reduced pain intensity and improved sleep, adding to the literature on its efficacy in reducing opioid-induced hyperalgesia. Though Cymbalta and Baclofen have shown to be effective for pain management, studies on lamictal have not been conclusive. Cymbalta, Lamictal, and Baclofen proved supportive in pain management. Lastly, several case studies have found the Jain Auricular Acupuncture for Pain Protocol to reduce pain through strategically placed needles at auricular zones that correspond to pain-processing regions of the brain. The combination of these therapies significantly helped our patient.

Conclusions: This case illustrates a multimodal approach to acute-on-chronic pain through integrating ketamine, opioid stewardship, and adjunctive therapies to optimize pain control while mitigating opioid-related risks. Individualized pain management remains critical in complex postoperative pain management.