What analgesics can an orthopedic spine surgeon prescribe for patients undergoing non-operative (non-op) treatment for spinal conditions, including indications and contraindications?

From the Guidelines

As an orthopedic spine surgeon managing non-operative treatment, you can prescribe acetaminophen, NSAIDs, tramadol, and short-term opioids for pain management, considering the severity and type of pain, as well as the patient's medical history and potential risks. When considering pain management options, it is essential to weigh the benefits and risks of each medication class, as noted in the study by 1. For mild to moderate pain,

• acetaminophen (Tylenol) is a good first-line option at 500-1000mg every 6 hours (maximum 3000-4000mg daily), with minimal gastrointestinal side effects but contraindicated in liver disease, as it is a slightly weaker analgesic than NSAIDs but has a more favorable safety profile and low cost 1.
• NSAIDs like ibuprofen (400-800mg every 6-8 hours) or naproxen (250-500mg twice daily) effectively reduce inflammation but should be avoided in patients with renal impairment, gastrointestinal ulcers, or bleeding disorders, due to their association with well-known gastrointestinal and renovascular risks 1. For moderate to severe pain,
• consider tramadol (50-100mg every 4-6 hours) as it has lower addiction potential than traditional opioids but is contraindicated with MAOIs and can cause serotonin syndrome, as an option when used judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled (or is unlikely to be controlled) with acetaminophen and NSAIDs 1.
• short-term opioids like hydrocodone/acetaminophen (5-10mg/325mg every 4-6 hours) or oxycodone (5-10mg every 4-6 hours) may be necessary for severe acute pain but carry addiction risks and should be limited to 3-7 days when possible, as their potential benefits and harms should be carefully weighed before starting therapy 1. Additionally,
• muscle relaxants such as cyclobenzaprine (5-10mg three times daily) can help with muscle spasms but cause sedation and are contraindicated in arrhythmias and MAOIs.
• gabapentinoids like gabapentin (starting at 300mg daily, increasing to 300-600mg three times daily) are useful for neuropathic pain but require dose adjustment in renal impairment and can cause dizziness and sedation. Always consider a multimodal approach combining different medication classes to maximize efficacy while minimizing side effects, as suggested by the study 1.

From the FDA Drug Label

NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout Naproxen may be used safely in combination with gold salts and/or corticosteroids; however, in controlled clinical trials, when added to the regimen of patients receiving corticosteroids, it did not appear to cause greater improvement over that seen with corticosteroids alone. The analgesic effect has been found to last for up to 12 hours NSAID medicines that need a prescription Generic Name Trade Name Naproxen Naprosyn®, Anaprox®, Anaprox® DS, EC-Naproxyn®, Naprelan®, Naprapac® (copackaged with lansoprazole)

Pain Medications for Non-Op Treatment:

• Naproxen (PO): indicated for pain and inflammation associated with various conditions, including arthritis, tendonitis, and bursitis 2
• Contraindications:
  • History of asthma attack, hives, or other allergic reaction with aspirin or any other NSAID medicine
  • Right before or after heart bypass surgery
  • Pregnancy (late term)
  • Breastfeeding (consult doctor)
• Indications:
  • Rheumatoid arthritis
  • Osteoarthritis
  • Juvenile arthritis
  • Ankylosing spondylitis
  • Tendonitis and bursitis
  • Acute gout
  • Mild to moderate pain secondary to postoperative, orthopedic, postpartum episiotomy and uterine contraction pain and dysmenorrhea
• Other NSAID options:
  • Ibuprofen (Motrin®, Tab-Profen®, Vicoprofen®)
  • Ketoprofen (Oruvail®)
  • Mefenamic Acid (Ponstel®)
  • Meloxicam (Mobic®)
  • Nabumetone (Relafen®)
  • Oxaprozin (Daypro®)
  • Piroxicam (Feldene®)
  • Sulindac (Clinoril®)
  • Tolmetin (Tolectin®, Tolectin® DS, Tolectin® 600) 2

From the Research

Pain Management Options for Non-Op Treatment

As an orthopedic spine surgeon, you can prescribe the following pain medications for patients undergoing non-op treatment:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, and naproxen 3, 4, 5, 6
• Acetaminophen, which is suitable for mild to moderate pain and is a good option for children and pregnant women 5

Indications for Pain Medications

• NSAIDs are effective for reducing postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty 3
• NSAIDs can also reduce the risk of symptomatic heterotopic bone formation in hip arthroscopy 4
• Acetaminophen and NSAIDs are recommended as first-line medications for acute migraine attacks, with oral NSAIDs being the first choice for mild to moderate attacks 5

Contraindications for Pain Medications

• NSAIDs may have adverse effects on bone and soft-tissue healing, and their use should be carefully considered in patients with osteoarthritis or those undergoing surgery 3, 4, 6
• NSAIDs can cause gastrointestinal, cardiovascular, and renal toxicity, and their use should be monitored closely in patients with comorbid conditions 6
• Opiates are not recommended for acute migraine treatment due to the risk of serious adverse events 5