What medication is appropriate for a pinched nerve (radiculopathy) in the back?

Medication Management for Pinched Nerve (Radiculopathy) in the Back

For a pinched nerve in the back, start with gabapentin (1200-3600 mg/day titrated) combined with an NSAID like naproxen or ibuprofen, as this targets both the neuropathic and inflammatory components of radicular pain. 1

First-Line Pharmacologic Approach

Gabapentin as Primary Agent

• Gabapentin is the first-choice medication for radiculopathy, showing small to moderate short-term benefits specifically for radicular/sciatic pain 1, 2
• Titrate dosing up to 1200-3600 mg/day, though results were inconsistent across trials 1
• Adjust dosing in patients with renal impairment (eGFR 37-50 mL/min) to avoid accumulation and toxicity 2
• Monitor for sedation, dizziness, and peripheral edema 1
• Note that gabapentin is NOT FDA-approved specifically for low back pain with radiculopathy 1

NSAIDs as Adjunctive Therapy

• Add an NSAID (naproxen or ibuprofen) to target the inflammatory component of pain 1
• For radiculopathy, evidence shows small and inconsistent effects on pain from NSAIDs alone 3
• NSAIDs increase cardiovascular risk with longer use and higher doses 1
• Use the lowest effective dose for the shortest duration necessary 4

Second-Line Options

Muscle Relaxants for Acute Exacerbations

• Tizanidine is the preferred muscle relaxant for lumbar radiculopathy, with demonstrated efficacy in 8 trials for acute low back pain 5
• Start with 2-4 mg and titrate up as needed 5
• Limit treatment to short-term use (7-14 days maximum) 5
• Monitor for hypotension and sedation, the most common dose-related adverse effects 5
• Tizanidine requires monitoring for hepatotoxicity, which is generally reversible 5
• Combining tizanidine with NSAIDs provides consistently greater short-term pain relief than monotherapy, but increases CNS adverse events (RR 2.44) 5

Alternative Muscle Relaxants

• Cyclobenzaprine has limited evidence specifically for radiculopathy 5
• If using cyclobenzaprine, start with 5 mg three times daily and titrate slowly, particularly in elderly patients 6
• Combination therapy of cyclobenzaprine with naproxen was associated with more side effects (primarily drowsiness) than naproxen alone 6

Medications to AVOID

Systemic Corticosteroids

• Do NOT use systemic corticosteroids for radicular low back pain - six trials consistently found no differences between systemic corticosteroids and placebo in pain relief 3
• Oral prednisone increased risk for adverse events (49% vs. 24%), insomnia, nervousness, and increased appetite without providing benefit 3

Benzodiazepines

• Avoid benzodiazepines - one trial found they were associated with no difference in function but MORE pain compared to placebo for radiculopathy 3
• Not FDA-approved for low back pain and carry risks of abuse, addiction, and tolerance 1

Pregabalin

• Pregabalin has inconsistent results for radiculopathy with methodological shortcomings 3
• Shows no benefit for chronic nonradicular back pain and may actually worsen function 2

Treatment Algorithm

1. Initiate gabapentin (start low, titrate to 1200-3600 mg/day) for the neuropathic component 1, 2
2. Add an NSAID (naproxen or ibuprofen) for the inflammatory component 1
3. For acute severe pain, consider adding tizanidine 2-4 mg for short-term use (≤2 weeks) 5
4. If insufficient response after 2-4 weeks, consider adding a tricyclic antidepressant (amitriptyline) or duloxetine 1
5. Reassess efficacy and side effects regularly - discontinue medications that are not providing benefit 1

Critical Pitfalls to Avoid

• Do not use gabapentin for non-radicular back pain - it is only effective for radicular/sciatic pain, not axial low back pain 2
• Do not prescribe muscle relaxants beyond 2 weeks - no evidence supports efficacy beyond this timeframe 5
• Do not use systemic corticosteroids - they are ineffective and cause significant adverse effects 3, 1
• Avoid NSAIDs in elderly patients with renal impairment or cardiovascular disease without careful risk assessment 4
• Do not combine multiple sedating medications (gabapentin + muscle relaxant + benzodiazepine) due to increased fall risk and cognitive impairment 5