Gabapentin for Spinal Stenosis Pain and Radiculopathy

Gabapentin shows small to moderate short-term benefits for radicular pain but has limited evidence for spinal stenosis specifically. 1, 2

Efficacy in Radiculopathy

Gabapentin is associated with small, short-term benefits in patients with radiculopathy and has not been directly compared with other medications or treatments 1
For chronic radicular back pain, studies report inconsistent findings for gabapentin (doses titrated up to 1200-3600 mg/day) versus placebo, with effects on pain intensity ranging from 0.3 to 1.9 points on a 0-10 point scale 1
The American Academy of Neurology suggests that gabapentin may provide benefits in terms of pain alleviation and improved quality of life in patients with chronic radiculopathy, though the strength of evidence is moderate 2
An open pilot study found significant reduction in pain and restricted mobility after 8 weeks of gabapentin treatment (up to 3600 mg/day) in patients with discogenic lumbosacral radiculopathy, with better results when treatment was initiated earlier 3

For spinal stenosis specifically, a recent meta-analysis found no significant differences in pain scores at 2,4, and 8 weeks between gabapentinoids (pregabalin/gabapentin) and control groups 4
However, at 3 months, significant differences were found in favor of pregabalin with respect to pain scores, though no significant differences were observed in functional disability scores 4
Adverse events were significantly higher in the gabapentinoid group compared to controls 4

For neuropathic pain conditions, the American Academy of Neurology recommends that gabapentinoids, serotonin-norepinephrine reuptake inhibitors (SNRIs), sodium channel blockers, and tricyclic antidepressants (TCAs) could all be considered 1
A recent head-to-head trial suggested therapeutic equivalency for TCAs, SNRIs, and gabapentinoids in the treatment of neuropathic pain, and supported the role of combination therapy over monotherapy 1
Lumbosacral radiculopathy appears to be relatively refractory to existing first- and second-line medications, with limited high-quality evidence on the best nonoperative therapy 2

Adverse effects of gabapentinoids may be more severe in older individuals and may be attenuated by lower starting doses and more gradual titration 1
Gabapentin is not FDA-approved for treatment of low back pain (with or without radiculopathy), and if used, a time-limited course of therapy is recommended 1

For radiculopathy, a multimodal approach is often recommended, with NSAIDs as first-line treatment to target the inflammatory component, and gabapentin added to address the neuropathic component of pain 2
The initial approach to managing cervical and lumbar radiculopathy involves starting with NSAIDs such as naproxen, adding gabapentin for the neuropathic component, and using muscle relaxants for short-term relief of muscle spasm 2

Evidence suggests that medications with established efficacy in other neuropathic pain conditions might not have the same efficacy in radiculopathy 2
Most medication trials evaluated patients with nonspecific low back pain or mixed populations with and without sciatica, with limited evidence specifically for patients with spinal stenosis or radiculopathy 1
Extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events 1