Management

Upon diagnosis, all patients are referred to a physical therapist for a personalized treatment and rehabilitation program. Commonly used modalities are the McKenzie exercise approach, spine stabilization exercises, and strengthening of the abdominal and gluteal muscle groups. Vertebral axial decompression (traction) may be considered; however, currently there is no consensus regarding its efficacy and long-term effects (47).

Surgical consultation may be needed, and the patient is often presented with choices of simple diskectomy, diskectomy plus fusion, and, less commonly, chemonucleolysis, as well as the more modern developments such as percutaneous diskectomy and microdiskectomy. It is not uncommon to see that patients remain in pain despite successful surgery. In these patients a comprehensive battery of imaging and electrodiagnostic studies may be needed, including a diagnostic selective neural blockade, which may help determine the involvement of specific nerve root(s), particularly when EMG alone is hard to interpret (47).

A growing and extremely promising modality is that of therapeutic injections. It is, in our opinion, a valid and often surgery-sparing option that may be of limited availability in the rural setting due to scarcity of trained specialists; it should be strongly considered in all cases when the patient does not have medical contraindications and is willing to travel to the location of a specialized treatment center or specialist's practice (48).

A variety of medications including analgesics (opioid and nonopioid), anticonvulsants, steroidal and nonsteroidal antiinflammatory agents, locally injected agents (e.g., anesthetics, steroids), topical agents (e.g., lidocaine patches, fentanyl patches), stimulants, antidepressants and antiparkinsonian agents have been all tried and have showed various degrees of efficacy. Table 17.4 lists some of the most commonly prescribed medications for LPB. As always, a thorough and creative approach to pain management is mandatory. The authors assert that the mere fact of inclusion of a drug in this table does not imply any endorsement or that the drug is officially approved in the United States for the purpose of treatment of LBP-associated neurological conditions.

Table 17.4. Selected medications commonly prescribed for pain management.

Medication

Adult dose

Contraindications

Nonsteroidal antiinflammatory drugs (NSAIDs) Celecoxib (Celebrex) 200 mg/d PO qd;

alternatively, 100 mg PO b.i.d.

Documented hypersensitivity to ibuprofen or other NSAIDs; aspirin/ NSAID-induced asthma

Ibuprofen (Motrin)

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding, NSAIDs-induced asthma

Interactions

Precautions

NSAIDs may increase retention of sodium and fluid and may raise blood pressure with ACE inhibitors and diuretics; may especially increase the risk of bleeding (e.g., GI) among individuals already taking alcohol, aspirin, corticosteroids, heparin, and warfarin; to minimize risks of adverse effects, patients should avoid taking multiple NSAIDs concurrently

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants; phenytoin levels may be increased when administered concurrently

Caution with any history of GI bleeding, hypertension, or CHF; caution in elderly patients; most NSAIDs are considered class-D (unsafe) during the third trimester of pregnancy; avoid use during the third trimester of pregnancy due to potential risk of effecting closure of the ductus arteriosus

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Steroids

Prednisone Dosage varies and needs to Documented be personalized; hypersensitivity; viral, commonly, 5-60 mg/d fungal, or tubercular

PO in 1-2 divided doses skin infections initially, followed by tapering off the medication over 8-10 d

Ketoprofen (Orudis, 25-50 mg PO q6-8h prn; Documented hypersensitivity

Oruvail, Actron) not to exceed 300 mg/d

Opioids and related compounds

Oxycodone (OxyContin) 10 mg PO b.i.d. initially Patients with a significant history of respiratory depression whose respiratory functions are not being closely monitored; severe bronchial asthma; patients with hypocarbia; paralytic ileus

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phénobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Similar to ibuprofen (see above)

Pregnancy category C; hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible

Category D in third trimester of pregnancy; caution in CHF, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity

Pregnancy category B (D if used for prolonged periods or in high doses); caution in COPD, emphysema, and renal insufficiency

Table 17.4. Selected medications commonly prescribed for pain management. (continued)

Medication

Adult dose

Contraindications

Interactions

Precautions

Tramadol (Ultram)

50-100 mg q4-6h; not to exceed 400 mg/d

Cyclobenzaprine (Flexeril) 10 mg PO t.i.d. initially;

not to exceed 60 mg/d

Metaxalone (Skelaxin) 800 mg (2 tab)

Tricyclic antidepressants

Amitriptyline (Elavil) 30-100 mg PO hs

Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOIs or use within 14 days; use of SSRIs, TCAs, or opioids; acute alcohol intoxication

Acute recovery phase of MI; history of arrhythmia; heart block; conduction disturbances; hyperthyroidism

Documented hypersensitivity; known tendency to drug-induced hemolytic or other anemias; significantly impaired renal or hepatic function

Documented hypersensitivity; do not

Decreases carbamazepine effects significantly; cimetidine increases toxicity; risk of serotonin syndrome with coadministration of antidepressants

Possible interaction with MAOIs, alcohol, barbiturates, and CNS depressants

None reported

Can cause dizziness, nausea, constipation, sweating, and/ or pruritus; additive sedation with alcohol and TCAs; adjust dose in liver disease, myxedema, hypothyroidism, or hypoadrenalism; caution in those with seizures

Caution in angle-closure glaucoma and urinary hesitance

Unsafe in pregnancy (category D); caution in hepatic impairment

Metabolized by the P450 2D6 system; therefore,

Pregnancy category D (unsafe in pregnancy); caution in cardiac administer to patients who have taken MAOIs in the past 14 d; use with caution in patients with seizures, cardiac arrhythmias, glaucoma, and urinary retention history drugs that inhibit this enzyme system (i.e., cimetidine, quinidine) may increase the tricyclic levels; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram conduction disturbances and those with a history of hypothyroidism, renal impairment, or hepatic impairment; due to pronounced effects in the cardiovascular system, best to avoid in elderly persons

Anticonvulsants (Note that most of these drugs are not approved by the U.S. FDA for the purposes of pain control and that there is no consensus on appropriate dosing strategies. All listed medications and anticonvulsants in general should be withdrawn slowly to reduce potential for increased seizure frequency.)

Carbamazepine (Tegretol)

200 mg PO b.i.d. and up; generally not to exceed 1600 mg/d

Documented hypersensitivity; history of bone marrow depression

Valproic acid and its derivatives (Depakote, Depakene, Depacon, Divalproex)

5-15 mg/kg/d in 1-3 divided doses, may increase by 5-10 mg/kg/wk; do not exceed 60 mg/kg/d

Documented hypersensitivity; hepatic disease/dysfunction

Do not use concomitantly with MAOIs; cimetidine may increase plasma levels and toxicity; avoid concomitant administration with Danazol, if possible

Cimetidine may cause decrease in clearance and increase in half-life; erythromycin may increase serum concentrations; rifampin may increase oral clearance by 40%; may increase diazepam toxicity; may affect warfarin levels and may decrease zidovudine clearance

Unsafe in pregnancy (category D); not a simple analgesic—do not use for relief of minor aches or pains; use with caution in patients with increased intraocular pressure; obtain and monitor blood counts; may produce drowsiness, dizziness, or blurred vision

Unsafe in pregnancy (category D); thrombocytopenia possible, obtain and monitor blood counts; hepatotoxic; may cause pancreatitis; use caution while driving or operating agricultural machinery

Table 17.4. Selected medications commonly prescribed for pain management. (continued)

Medication

Adult dose

Contraindications

Interactions

Precautions

Gabapentin (Neurontin)

Lamotrigine (Lamictal)

Topiramate (Topamax)

Start at 100 mg b.i.d. or t.i.d.; increase by 100-300 mg slowly; not to exceed 3600 mg total daily dose; alternatively, start at 300 mg before bed and shift to divided doses only after patient's levels of drowsiness are ascertained

No consensus; may follow the standard approach in seizure disorders: weeks 1-2: 50 mg/d weeks 3-4: 100 mg/d in 2 divided doses; maintenance: 300-500 mg/d (in 2 divided doses)

Introduce very slowly to minimize the risk of cognitive adverse effects; commonly, begin at 25- 50 mg/d PO; titrate by 25-50 mg/d at 1-wk intervals to target dose of 200 mg b.i.d.; not to exceed 1600 mg/day

Documented hypersensitivity

Documented hypersensitivity

Documented hypersensitivity

Antacids may reduce bioavailability by about 20% and should be administered at least 2 h before gabapentin; cimetidine may reduce clearance but may not be of clinical significance; conversely, may increase norethindrone levels by 13%

Acetaminophen increases renal clearance, decreasing effects; phenobarbital and phenytoin increase metabolism, causing decrease in levels; valproic acid increases half-life

Reduces digoxin and norethindrone levels; carbonic anhydrase inhibitors may increase risk of renal stone formation and should be avoided; may have additive effect with CNS depressants in CNS depression and other cognitive or

Safety for use during pregnancy has not been established (category C); use caution in patients with severe renal disease

Safety for use during pregnancy has not been established (category C); use caution in patients with impaired renal or hepatic function; associated with a rash in 5% of patients

Safety for use during pregnancy has not been established (category C); may cause cognitive slowing; increases risk of developing kidney stone by 2-4 times that of untreated population (i.e., from 1.5% to 3.0-6.0%); this risk may be reduced by increasing fluid intake; use cautiously in

Tiagabine (Gabitril)

4 divided doses; increase by 4-8 mg/wk until clinical response is achieved; do not exceed daily dose of 56 mg/d administered neuropsychiatry adverse effects

Documented hypersensitivity Cleared more rapidly in patients who have been treated with carbamazepine, phenytoin, primidone, or phenobarbital than in patients who have not received these drugs patients with renal or hepatic impairment

Safety for use during pregnancy has not been established (category C); moderately severe to incapacitating generalized weakness has been reported in as many as 1% of patients

ACE, angiotensin-converting enzyme; CHF, congestive heart failure; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; FDA, Food and Drug Administration; MAOI, monoamine oxidase inhibitor; MI, myocardial infarction; PT. prothrombin time; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

Source: Data from Physicians Desk Reference (49).

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