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Medication

Medication Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of the initial treatment for LBP. With the use of all NSAIDs, elderly patients should be monitored for gastrointestinal (GI) and renal toxicity. Pain control with acetaminophen or a suitable narcotic may be more appropriate for elderly patients.

Muscle relaxant drugs are not first-line agents, but they may be considered for patients who are experiencing significant spasms. No studies have documented that these medications change the natural history of the disease. Because muscle relaxant drugs may cause drowsiness and dry mouth, the clinician may find it useful to recommend that these medications be taken at least 2 hours before bedtime.

Class Summary

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Diclofenac (Voltaren, Cataflam)

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Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which in turn decreases the formation of prostaglandin precursors.

Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)

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For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Class Summary

Muscle relaxant medications are used for radiculopathy that has a significant component of muscle spasm.

Cyclobenzaprine (Flexeril)

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Skeletal-muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins that influence both alpha- and gamma-motor neurons. Structurally related to TCAs and, thus, carries some of the same risks.

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who are in pain.

Oxycodone (OxyContin)

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Indicated for the relief of moderate to severe pain.

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)

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Drug combination indicated for the relief of moderate to severe pain.

Tramadol (Ultram)

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Inhibits the ascending pain pathways, altering perception of and response to pain. Also inhibits the reuptake of norepinephrine and serotonin.

Class Summary

Some agents in this category are used to manage pain.

Gabapentin (Neurontin)

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Membrane stabilizer, a structural analogue of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), which paradoxically is thought not to exert effects on GABA receptors. Appears to exert action via the alpha(2)-delta1 and alpha(2)-delta2 auxiliary subunits of voltage-gaited calcium channels.

Used to manage pain and provide sedation in neuropathic pain.

Follow-up

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Media Gallery

Sagittal magnetic resonance image showing loss of intervertebral disc height at L5/S1. Herniations of the nucleus pulposus are noted at L4/5 and L5/S1. Courtesy of Barton Branstetter, MD.
Discogram showing examples of an intact disc and a disrupted disc at the lumbar level.
Magnetic resonance image demonstrating extension of the nucleus pulposus to the right paracentral region of the spinal cord. The disc is adjacent to the inflamed right L5 nerve root. Courtesy of Barton Branstetter, MD.

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Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Coauthor(s)

Charles J Buttaci, DO, PT Pain Management, Northeast Orthopedics

Charles J Buttaci, DO, PT is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Mariam Rubbani, MD Staff Physician, Department of Medicine--Physical Medicine and Rehabilitation Division, Trinitas Regional Medical Center

Mariam Rubbani, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lumbosacral Radiculopathy Medication

Medication Summary

Nonsteroidal Anti-inflammatory Agents (NSAIDs)