What are the treatment options for a pinched nerve?

Treatment for Pinched Nerve

For a pinched nerve, begin with conservative management including activity modification and neuropathic pain medications (gabapentin 900-3600 mg/day, pregabalin 300-600 mg/day, or duloxetine 60-120 mg/day), reserving electrodiagnostic testing and imaging only for cases that fail conservative therapy or have atypical features. 1, 2

Initial Conservative Management

Most peripheral nerve entrapments respond well to conservative measures without requiring surgery. 3 The key is identifying and eliminating the aggravating activity:

• Immediately cease or modify the repetitive activity causing compression (e.g., stop overhead activities for suprascapular nerve injury, avoid tight clothing for meralgia paresthetica) 3, 4
• Rest from the offending exercise or movement pattern for 2-4 weeks minimum 5
• Correct poor technique if the injury is activity-related (sports, weight training, occupational) 5
• Recovery is faster and more likely with shorter duration of compression and mild injury 3

First-Line Pharmacological Treatment

When pain is significant, initiate neuropathic pain medication:

• Gabapentin 900-3600 mg/day in divided doses or pregabalin 300-600 mg/day as first-line agents 1, 6
• Duloxetine 60-120 mg/day is equally effective, particularly if the patient has comorbid depression 1, 6
• Tricyclic antidepressants (amitriptyline 25-75 mg at bedtime or nortriptyline 25-75 mg at bedtime) are highly effective but have more side effects 1, 6
  • Avoid TCAs in patients with cardiac disease, glaucoma, or orthostatic hypotension 6
  • Obtain screening ECG for patients over 40 years before starting TCAs 6

Topical Treatments for Localized Nerve Pain

For localized peripheral nerve entrapment with skin hypersensitivity:

• Lidocaine 5% patches applied to the affected area for localized neuropathic pain with allodynia 1, 6
• Capsaicin 0.075% cream applied 3-4 times daily to the painful area (warn patients about initial worsening of symptoms for first few weeks) 1, 6

When to Escalate Treatment

If first-line medication provides inadequate relief after 6-8 weeks at therapeutic doses, add a second agent from a different class rather than switching 6, 1:

• Combine gabapentin/pregabalin with duloxetine or a TCA 6
• Add tramadol 200-400 mg/day as second-line if combination therapy insufficient 1
• Avoid strong opioids due to addiction risk and lack of superior efficacy 1

Diagnostic Testing: When and What to Order

Do NOT routinely order electrodiagnostic testing or imaging for straightforward nerve entrapment. 2 Testing is indicated only when:

• Pain or weakness is refractory to 6-8 weeks of conservative therapy 3
• Clinical presentation is atypical or diagnosis uncertain 2
• Surgical intervention is being considered 7

Specific Testing Recommendations

• DO perform needle EMG with nerve conduction studies together when testing for radiculopathy (never NCS alone) 2
• DO NOT perform four-limb EMG/NCS for neck and back pain after trauma (excessive and unnecessary) 2
• DO NOT order dermatomal somatosensory evoked potentials for pinched nerves—they are unproven 2
• DO NOT order MRI of spine or brain for isolated peripheral neuropathy without central nervous system signs 2

Surgical Considerations

Refer for surgical evaluation if:

• Severe or progressive motor weakness develops 3
• Symptoms persist despite 3-6 months of optimal conservative management 3, 4
• Complete nerve palsy is present 5

Surgical options include nerve decompression or, in refractory cases, peripheral nerve stimulation 4. Recovery of nerve function is more likely with shorter duration of compression before intervention 3.

Special Populations

Elderly patients: Start medications at 50% of standard dose and titrate slowly due to increased side effect risk 1

Renal impairment: Reduce gabapentin and pregabalin doses proportionally to creatinine clearance 1

Hepatic disease: Duloxetine is contraindicated 1, 6

Common Pitfalls to Avoid

• Do not order extensive electrodiagnostic testing immediately—most cases resolve with conservative management 2, 3
• Do not continue the aggravating activity while treating with medications alone—activity modification is essential 3
• Do not use TCAs as first-line in elderly patients or those with cardiac disease—choose gabapentin, pregabalin, or duloxetine instead 6, 1
• Do not delay surgical referral beyond 6 months if conservative treatment fails—prolonged compression reduces likelihood of full recovery 3