What muscle relaxer can be prescribed for a patient with severe sciatic pain, already on oral steroids and naproxen (nonsteroidal anti-inflammatory drug), to help with sleep and sitting tolerance during a long flight?

Muscle Relaxer Recommendation for Severe Sciatic Pain During Long Flight

For this patient with severe sciatic pain on a long flight, prescribe tizanidine 2-4 mg taken 1-2 hours before the flight, as it is the most effective muscle relaxant for radiculopathy with sedative properties that will aid sleep and sitting tolerance. 1

Why Tizanidine is the Optimal Choice

Tizanidine is specifically recommended by the American College of Physicians as the preferred muscle relaxant for lumbar radiculopathy due to superior efficacy and safety profile. 1 The evidence supporting tizanidine includes:

• Demonstrated efficacy in 8 clinical trials for acute low back pain, the strongest evidence base among muscle relaxants 1, 2
• When combined with NSAIDs (which this patient is already taking with naproxen), tizanidine consistently provides greater short-term pain relief than NSAID monotherapy in high-quality trials 3, 1
• The sedative properties of tizanidine will specifically address the patient's dual goals of sleep facilitation and pain control during the flight 1, 2

Specific Dosing for Flight Scenario

• Start with 2-4 mg taken 1-2 hours before the flight 1
• The sedation effect, while typically considered an adverse event, becomes therapeutic in this context where sleep is desired 1, 2
• Duration of action is 4-6 hours, so a second dose may be considered mid-flight for longer international flights 4

Why NOT Other Muscle Relaxants

Cyclobenzaprine should be avoided because:

• Only 1 lower-quality trial exists for chronic low back pain with no data on pain intensity or global efficacy 1
• No evidence specifically supports its use in radiculopathy 1
• Essentially identical to amitriptyline with significant anticholinergic side effects 2

Methocarbamol is not recommended because:

• Does not directly relax skeletal muscles and has no evidence of efficacy 1, 2
• Not favored due to potential adverse effects without proven benefit 1

Critical Considerations for This Patient

The oral steroids this patient already received are ineffective and should not be continued. Three high-quality trials consistently found systemic corticosteroids provide no clinically significant benefit for sciatica compared to placebo. 3

The combination of tizanidine with the patient's current naproxen regimen is evidence-based. Adding a muscle relaxant to NSAIDs increases CNS adverse events (RR 2.44) but may reduce gastrointestinal adverse events (RR 0.54), with overall adverse events not significantly different. 3

Additional Medication to Consider

Gabapentin should be considered as first-line therapy for lumbar radiculopathy with demonstrated small, short-term benefits specifically in patients with radiculopathy. 1 If the patient has not tried gabapentin, prescribe 300 mg starting dose with titration up to 900 mg three times daily. 5 However, for the immediate flight scenario, tizanidine's sedative properties make it more suitable.

Safety Monitoring

• Monitor for hypotension and sedation, the most common dose-related adverse effects 1
• All skeletal muscle relaxants increase CNS adverse events 2-fold compared to placebo 2
• Limit treatment duration to 7-14 days maximum for acute pain 1, 2
• Tizanidine requires monitoring for hepatotoxicity, though this is generally reversible 1

Practical Prescribing Instructions

Write the prescription as:

• Tizanidine 2-4 mg tablets
• Take 1 tablet 1-2 hours before flight
• May repeat once during flight if needed (for flights >8 hours)
• Warn patient about sedation and avoid alcohol
• Advise against driving or operating machinery after taking