What medication is recommended for an adult patient with chronic shoulder and neck pain due to multiple tears and multilevel cervical spondylotic changes, awaiting surgery?

Medication Management for Chronic Shoulder and Neck Pain Awaiting Surgery

NSAIDs should be your first-line pharmacologic treatment for chronic pain from rotator cuff tears and cervical spondylosis while awaiting surgery, with careful consideration of gastrointestinal and cardiovascular risk factors. 1

First-Line Pharmacologic Treatment

NSAIDs as Primary Therapy

• NSAIDs are the recommended first-line drug treatment for musculoskeletal pain involving the spine and shoulder, with Level Ib evidence showing improvement in spinal pain, peripheral joint pain, and function. 1
• Naproxen specifically has demonstrated efficacy in reducing joint pain, increasing range of motion, and improving capacity to perform activities of daily living in patients with musculoskeletal conditions. 2
• Use NSAIDs at the lowest effective dose for the shortest duration necessary, as prolonged use increases risk of gastrointestinal bleeding and cardiovascular events. 1, 2

Risk Stratification for NSAID Selection

• For patients with increased gastrointestinal risk factors (age >65, history of ulcers, concurrent corticosteroid use, smoking, alcohol use), prescribe either a non-selective NSAID plus gastroprotective agent OR a selective COX-2 inhibitor. 1
• Consider cardiovascular risk factors when selecting between traditional NSAIDs and COX-2 inhibitors, as both carry cardiovascular toxicity signals. 1
• Never use NSAIDs immediately before or after cardiac surgery. 2

Second-Line and Adjunctive Medications

When NSAIDs Are Insufficient or Contraindicated

• Analgesics such as acetaminophen (paracetamol) should be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated. 1
• Short-term opioids may be considered with extreme caution, for the shortest period possible, with careful consideration of risks versus benefits. 1
• Opioids should NOT be used routinely and carry conflicting recommendations in musculoskeletal pain guidelines. 1

Neuropathic Pain Components

• For neuropathic pain from cervical radiculopathy, consider antiepileptic drugs (gabapentin, pregabalin), tricyclic antidepressants, or serotonin-norepinephrine reuptake inhibitors (SNRIs). 1
• These medications specifically target nerve pain that may accompany cervical spondylotic changes with radicular symptoms. 1

Multimodal Non-Pharmacologic Approaches (Essential Adjuncts)

Physical Therapy and Exercise

• Patient education and regular exercise should be implemented alongside pharmacologic treatment, as activity/exercise recommendations are consistent across all high-quality musculoskeletal pain guidelines. 1
• Individual or group physical therapy should be considered, with evidence showing improved patient global assessment with supervised programs. 1
• Manual therapy should ONLY be used in conjunction with other treatments (exercise, education, activity advice), never as stand-alone treatment. 1

Conservative Management Duration

• For rotator cuff disorders specifically, a 3-month trial of non-surgical management is recommended before surgical review, unless there is a symptomatic full-thickness tear. 1
• For cervical spondylotic myelopathy, mild cases (modified Japanese Orthopaedic Association score >12) may respond to conservative treatment including neck immobilization, activity modification, and anti-inflammatory medications for up to 3 years. 1
• More severe cervical myelopathy (mJOA ≤12) should be considered for earlier surgical intervention. 1

Critical Pitfalls to Avoid

Medication-Related Warnings

• Monitor for NSAID-related complications including gastrointestinal bleeding (which can occur without warning), cardiovascular events, renal dysfunction, and hepatotoxicity. 2
• Avoid combining NSAIDs with aspirin, as aspirin increases naproxen excretion rates and the combination increases adverse event frequency without demonstrated superior efficacy. 2
• Do not delay necessary surgery in patients with progressive neurologic deficits while attempting prolonged conservative management. 1

Diagnostic Considerations

• Ensure shoulder pathology is not being mistaken for cervical pathology or vice versa, as unrecognized shoulder disorders can cause persistent pain despite successful cervical surgery. 3, 4
• Radiological imaging should be discouraged unless serious pathology is suspected, there has been unsatisfactory response to conservative care, or imaging will change management. 1

When to Escalate Care

• Refer to pain management services for interventional procedures (nerve blocks, TENS) if pain remains refractory to pharmacologic and physical therapy approaches. 1
• Consider corticosteroid injections directed to the local site of musculoskeletal inflammation for targeted symptom relief. 1
• Surgical intervention should not be delayed if there is moderate to severe myelopathy with progressive neurologic deficits, as outcomes are better when symptoms have been present for less than one year. 1, 5, 6, 7