Refractory Neuropathic Pain With Escalating Opioid Requirements and Ketamine Use in Advanced Degenerative Spine Disease: A Hospice Case Report

BackgroundHospice patients with advanced degenerative spine disease frequently experience refractory neuropathic pain complicated by opioid tolerance, central sensitization, and functional decline.Case PresentationA 63-year-old male with stage III adhesive arachnoiditis, cauda equina syndrome, prior spinal cord stimulator implantation, and multiple lumbar surgeries was admitted to hospice with uncontrolled multifactorial back pain. Due to refractory pain that could not be adequately managed in the outpatient setting, the patient was enrolled in home hospice care. Methadone rotation, pregabalin, corticosteroids, and escalating hydromorphone dosing provided limited relief. Oral ketamine was introduced for opioid-refractory pain and titrated from 10 mg 3 times daily to 40 mg 4 times daily with gradual improvement in pain severity, sleep, and functional activity.ConclusionMultimodal hospice care incorporating opioid optimization, adjuvant medications, and NMDA antagonists such as ketamine may improve quality of life in advanced degenerative spinal disease.