What is the recommended NSAID (Non-Steroidal Anti-Inflammatory Drug) regimen for cervical radiculopathy?

NSAID Regimen for Cervical Radiculopathy

NSAIDs are recommended as first-line pharmacological treatment for cervical radiculopathy, though evidence specifically for cervical radiculopathy is limited with small and inconsistent effects on pain reported in studies. 1

Recommended NSAID Approach

1. Initial Treatment:

   • Start with a traditional NSAID (e.g., ibuprofen, naproxen) for acute symptoms
   • Ibuprofen: 400-600mg three times daily
   • Naproxen: 500mg twice daily
   • Duration: Short-term course (1-2 weeks) to minimize adverse effects

2. For patients with GI risk factors:

   • Consider COX-2 selective NSAIDs (e.g., celecoxib)
   • Celecoxib: 200mg once or twice daily
   • Evidence shows COX-2 selective NSAIDs have lower risk of adverse effects than nonselective NSAIDs (RR, 0.83 [CI, 0.70 to 0.99]) 1

3. Monitoring and Adjustment:

   • Assess response after 1-2 weeks
   • If inadequate response, consider adding or switching to other modalities

Evidence Quality and Considerations

The evidence for NSAID use specifically in cervical radiculopathy is limited. Most studies have focused on low back pain with or without radiculopathy:

• For radiculopathy (primarily lumbar), studies show small and inconsistent effects on pain 1
• No clear differences in pain relief have been found between different NSAIDs 1
• NSAIDs are associated with more adverse effects than placebo (RR, 1.35 [CI, 1.09 to 1.68]), though serious harms are rare 1

Multimodal Approach

NSAIDs should be part of a comprehensive treatment plan:

1. Non-pharmacological treatments (first-line):

   • Heat therapy
   • Massage
   • Physical therapy including range of motion exercises and strengthening of cervical muscles
   • Postural training 2

2. Additional pharmacological options if NSAIDs provide inadequate relief:

   • Muscle relaxants for associated muscle spasm 2
   • Gabapentin for radicular symptoms (small, short-term benefits) 1
   • Avoid long-term opioid use 2

3. Interventional procedures if conservative management fails:

   • Epidural corticosteroid injections (preferably interlaminar approach) may be beneficial for acute and subacute cervical radicular pain 3
   • Pulsed radiofrequency treatment for chronic cervical radicular pain 3

Important Caveats

• Most cases of cervical radiculopathy resolve spontaneously or with non-surgical interventions 2
• Surgical intervention should be considered only after failed conservative management (typically 6+ weeks) or with progressive/disabling motor deficits 4
• Extended courses of medications should be reserved for patients showing clear continued benefits without major adverse events 1
• There is scant evidence for neuropathic pain medications such as gabapentin, pregabalin, and tricyclic antidepressants specifically for cervical radicular pain 3

Red Flags Requiring Urgent Assessment

• Progressive neurological deficits
• Signs of myelopathy (loss of dexterity, hyperreflexia, Hoffmann sign, gait abnormality)
• Severe, unremitting pain unresponsive to conservative measures

Remember that while NSAIDs can help manage symptoms, they address inflammation rather than the underlying mechanical compression, which may require additional interventions if symptoms persist.