Pain Medication for Scoliosis
For scoliosis-related pain, start with NSAIDs (ibuprofen, naproxen, or meloxicam) as first-line therapy after assessing cardiovascular and gastrointestinal risk factors, and reserve acetaminophen for patients with contraindications to NSAIDs. 1
First-Line Pharmacological Management
NSAIDs are the preferred initial medication because they provide superior pain relief compared to acetaminophen, with improvements of approximately 10 points greater on a 100-point visual analogue pain scale. 1 However, you must assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, as NSAIDs carry well-documented risks including gastrointestinal bleeding, myocardial infarction, and renovascular complications. 1
- For patients without significant risk factors: Prescribe NSAIDs such as ibuprofen (400-800 mg three times daily), naproxen (500 mg twice daily), or meloxicam (7.5-15 mg once daily). 1, 2
- For patients with cardiovascular or GI risk factors: Use acetaminophen (up to 4g/day in divided doses) as the safer alternative, despite being a slightly weaker analgesic. 1, 2
- Minimize NSAID risks by prescribing the lowest effective dose for the shortest necessary duration, and consider co-administration with a proton-pump inhibitor in higher-risk patients. 1
Adjunctive Medications for Muscle Spasm
Add short-term muscle relaxants when muscle spasm contributes significantly to pain. 1, 2 Options include cyclobenzaprine (5-10 mg three times daily), tizanidine, or metaxalone. 1, 2
- Critical limitation: Restrict muscle relaxant use to a maximum of 2-3 weeks to avoid risks of tolerance and adverse effects. 3, 2
- Be aware that combining NSAIDs with muscle relaxants increases central nervous system adverse events. 2
Treatment for Radicular Pain Component
If scoliosis pain includes radicular symptoms (leg pain radiating below the knee), add gabapentin for small to moderate short-term benefits. 1, 3, 2
- Dosing: Start gabapentin at 300 mg at bedtime and titrate upward as tolerated. 2
- Evidence: Gabapentin specifically targets the neuropathic pain component in radiculopathy. 1, 3
- Adjust dosing appropriately in patients with renal impairment. 3
Chronic Pain Management
For persistent scoliosis pain lasting beyond 4-8 weeks, consider tricyclic antidepressants as an additional option for patients without contraindications. 1, 3
- Tricyclic antidepressants (such as amitriptyline) provide moderate pain relief for chronic pain with neuropathic features. 1, 3, 2
- Note: Selective serotonin reuptake inhibitors have not been shown effective for back pain. 1
Medications to Avoid
Do not prescribe systemic corticosteroids for scoliosis pain, as three high-quality trials consistently demonstrated no clinically significant benefit compared to placebo. 4
Avoid opioid analgesics except in rare cases of severe, disabling pain uncontrolled by other measures, due to limited efficacy evidence and substantial risks including abuse, addiction, constipation, and sedation. 1, 3
Do not use benzodiazepines, as they are ineffective for spinal pain and carry significant risks of abuse, addiction, and tolerance. 1, 3
Non-Pharmacological Recommendations
Advise patients to remain active rather than resting in bed, as activity is more effective for pain management and bed rest delays recovery. 1, 2, 4
Application of heat using heating pads or heated blankets provides short-term relief for acute pain. 1, 2
Refer for physical therapy and exercise programs as the cornerstone of long-term management, particularly for chronic scoliosis pain. 1, 2, 4
Critical Monitoring Points
- Allow adequate trial periods: NSAIDs require at least 8 weeks to assess full response, as time to effect is approximately 1 month. 3
- Reserve extended medication courses only for patients clearly demonstrating continued benefits without major adverse events. 1, 3
- Monitor for acetaminophen hepatotoxicity: Even at FDA-approved maximum dosing (4g/day), asymptomatic aminotransferase elevations can occur. 1
Common Pitfalls to Avoid
Do not order routine imaging for scoliosis pain without red flags (progressive neurological deficits, severe symptoms, suspected serious underlying conditions), as imaging does not improve outcomes and may lead to unnecessary interventions. 1, 3
Do not recommend prolonged bed rest, which causes deconditioning and worsens outcomes. 1, 2, 4
Do not prescribe muscle relaxants long-term beyond 2-3 weeks maximum. 3, 2
Recognize that corrective treatment with bracing or surgery does not specifically target the pain problem and other causes of back pain should be considered before or during treatment initiation. 5