Max is a 75-year-old retired engineer with very slowly progressive metastatic renal cancer that was diagnosed three years ago.
His primary tumour and lung metastases have always been asymptomatic but osteolytic bone metastases have caused pain at multiple sites. Some of these have been previously irradiated with good relief.
Max's pain control had been satisfactory on paracetamol 1000mg/codeine 60mg and ibuprofen 400mg three times daily until he attended a family wedding interstate and needed to see another doctor for pain.
His medication was revised to oxycodone controlled release 20mg and naproxen 500mg twice daily, with oxycodone immediate release 5mg for breakthrough pain.
Max developed severe pain in the L3-L4 region, a previously irradiated site, after a fall at the airport when returning home.
There were no focal neurologic signs and he was admitted for bed rest