Rebecca is a 34-year-old attorney and a mother of two who presents with an 18-month history of right lower back pain, buttock pain, and right lower extremity pain. The pain began insidiously without any specific identifiable inciting event 18 months ago when her youngest son was 2 years old. At first the pain she reports that the pain was mild. She tried to “just ignore the pain.” She initially attributed t he pain to taking care of her kids, including lifting her 2-year-old son into and out of the car, working long hours, and generally not taking better care of herself. However, over following 3 months her pain gradually worsened to the point that she realized it was affecting her work performance and making it difficult for her to take care of her children. At that point, she went to see her primary care physician who sent her to a pain management doctor.

The pain management doctor that Rebecca initially went to immediately ordered an MRI of her lumbar spine. The MRI revealed a small right L5–S1 disc bulge and she was diagnosed with a right L5 and S1 radiculopathy. She was given an L5–S1 interlaminar epidural steroid injection and sent to physical therapy. Unfortunately, the interlaminar epidural steroid injection did not help at all. She went to physical therapy and that did not help her pain either.

She returned to the first pain management doctor after 3 weeks of physical therapy and had a repeat L5–S1 interlaminar epidural steroid injection. Again, the injection did not help and two more weeks of physical therapy did not help either. When asked what was done during her physical therapy sessions, Rebecca reports frequent treatments of hot packs, massage, and extension-based stretches.

Rebecca became frustrated with the first pain management doctor and also with physical therapy. She then went to a chiropractor on the recommendation of a friend. She saw the chiropractor 3 times per week for 3 weeks but the pain did not improve. She returned to the first pain management doctor at that time who in turn gave her a referral to a spine surgeon. Rebecca went to the spine surgeon who told her that he could not help her and she should return to her pain management doctor.

At that time, Rebecca went to a different pain management doctor. That pain management doctor gave her trigger point injections in her lower back and buttock. After the trigger point injections, Rebecca’s pain got better for about 3 days but then the pain returned to baseline. She had two more rounds of trigger point injections over the next month and each time she experienced only 2–3 days of partial pain relief.

The pain that Rebecca gets is a sharp pain in her right lower back and buttock. She has right leg pain that she feels is referred from her lower back and buttock but she does not describe it as “sharp” or “shooting” or “electric.” Rather, the pain is a vague aching sensation that refers down her leg in the posterior thigh and into the right posterior calf in a predominately S1 dermatomal distribution. Rebecca’s pain is worse with sitting and better with standing. The pain is worse in the morning and worse with transitioning from sit to stand. The pain is 4/10 at best and 9/10 at worst. Rebecca denies any numbness, tingling, or burning sensations in her legs. She does not have left lower back or leg symptoms. She does not note any subjective weakness in her legs. She denies any change in bowel or bladder habits. Other than her pain, Rebecca has always been in very good general medical health.

Over the course of the last several months, Rebecca has been given various pain medications. She has tried Cymbalta, Lyrica, Neurontin, Topamax, Vicodin, Percocet, tramadol, and various NSAIDs. The only medications that she feels really helps her pain are the narcotic medications. Currently, she is taking Percocet 5/325 one tab 3–4 times per day. She says that she hates taking the medication and wants very much to get off of it. She is embarrassed about the medication and feels “like a drug addict.” She says that without the pain medication, she cannot function at her job or with her family.

Her husband, who is also an attorney, is very concerned about her and wants her to go on medical disability. He has continually recommended that she “fly somewhere like to the Mayo Clinic or somewhere like that” where they can figure her problem out. Since the second pain management doctor, Rebecca has been to a second spine surgeon who also told her that he could not help her. That spine surgeon suggested that her pain may be coming from her hip. She went to a hip surgeon who told her that her problem was coming from her spine. Her primary care doctor told her that she was depressed and sent her to a psychiatrist. Rebecca says that she does not feel depressed but is “willing to try anything” to get the pain to go away so she went to the psychiatrist.

The psychiatrist is the one who put Rebecca on Cymbalta but that made her feel “very out of it” and she stopped it after only a week. She also went to a clinical psychologist for a month but she did not feel that was helping. Rebecca admits to feeling very frustrated, stressed, and depressed but believes that her psychological symptoms are a result of her pain and not the cause of her pain.

Rebecca has also been to a neurologist. The neurologist performed an EMG/NCS that he told her was normal. The neurologist gave her Topamax but it made her feel very sleepy and so she had to stop it. She went to a rheumatologist who checked “a bunch of lab work including a Lyme test” that was all normal. The rheumatologist said that she could not help and recommended going back to her pain management doctor.

Rebecca has tried two other chiropractors in the last several months. One of them did not help at all. The other chiropractor seemed to be helping at first but then the pain kept returning. Rebecca says that she is at her “wits end” and feels that the pain is ruining her life. Several times during the history taking, Rebecca pauses to dab her teary eyes with tissue paper. She has come to this office, which is a 2 h drive, because a colleague referred her after he had a very positive experience.