What are the next steps in managing radicular pain that does not respond to simple analgesics?

From the Guidelines

For radicular pain that doesn't respond to simple analgesics, the next steps should prioritize a stepped care approach, starting with neuropathic pain medications, and considering early referral to specialist services for assessment and management, as recommended by the British Pain Society pathway 1. The management of radicular pain that does not respond to simple analgesics requires a comprehensive approach, taking into account the patient's overall condition, the severity of symptoms, and the presence of any neurological deficits.

Key Considerations

• The British Pain Society pathway emphasizes the importance of early assessment and stratification of patients using tools like the STarT Back Tool to allocate resources effectively 1.
• Neuropathic pain medications such as gabapentin or pregabalin are recommended as initial treatments for radicular pain, given their efficacy in modulating calcium channels to reduce nerve hyperexcitability 1.
• For patients who do not respond to these medications, consideration should be given to adding tricyclic antidepressants like amitriptyline or duloxetine, which can modify pain perception by affecting serotonin and norepinephrine reuptake 1.
• Short-term use of muscle relaxants like cyclobenzaprine may be beneficial if muscle spasm is present, but their use should be cautious due to potential central nervous system adverse effects 1.
• In more severe cases, a short course of oral corticosteroids like prednisone can help reduce inflammation around the affected nerve root, and epidural steroid injections may be considered if pain persists despite other measures 1.

Treatment Approach

• A stepped care approach is recommended, with a logical progression from less invasive to more invasive treatments, based on the severity of symptoms and the patient's response to initial therapies 1.
• Early referral to specialist services for assessment and management is crucial, especially for patients with severe radicular pain or neurological deficits, with the consensus being that referral should occur within 2 weeks of presentation for severe cases and not later than 3 months for less severe cases 1.
• Throughout the treatment process, physical therapy focusing on spine stabilization exercises and proper body mechanics should be continued to address the underlying mechanical issues contributing to nerve compression.
• The patient's condition should be regularly reassessed, and treatment plans adjusted as necessary to ensure optimal outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Management of Radicular Pain

• Radicular pain that does not respond to simple analgesics can be challenging to manage, and treatment options may include adjuvant analgesics, such as membrane stabilizing agents and drugs that enhance dorsal horn inhibition 2.
• Adjuvant analgesics can be classified into groups according to the type of pain to be treated, including continuous neuropathic pain, lancinating neuropathic pain, sympathetically maintained pain, and bone pain 3.
• For continuous neuropathic pain, adjuvant drugs such as local anesthetics, clonidine, capsaicin, and antidepressants can be used, with tricyclic antidepressants being the most well-investigated and considered the drugs of choice 3.
• The overall efficacy of tricyclic antidepressants for neuropathic pain is modest, and they may produce intolerable side effects, while gabapentin is a reasonable alternative to antidepressants, as initial monotherapy or add-on treatment 2.
• For lancinating neuropathic pain, anticonvulsant drugs such as carbamazepine, clonazepam, valproate, and phenytoin can be used, while baclofen, a GABA agonist, is effective in the treatment of trigeminal neuralgia and is often used in the management of lancinating pain of unspecific origin 3.

Treatment Options for Radicular Pain

• Exercise with or without other treatments can be beneficial for cervical radicular pain, while there is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants 4.
• Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach, while for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited 4.
• Pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered for chronic cervical radicular pain, and there is currently no gold standard for the diagnosis of cervical radicular pain 4.
• Conventional analgesics have limited efficacy in the management of neuropathic pain, and adjuvant analgesics such as antidepressants, anticonvulsants, and topical agents can be used as part of a multimodal therapeutic program 5, 6.