From the Guidelines
The medical management of chronic low back pain with radiculopathy typically involves a multimodal approach, including pharmacotherapy with gabapentin (300-3600 mg/day) or pregabalin (150-600 mg/day) for neuropathic pain, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-1200 mg/day) or naproxen (250-1000 mg/day) for inflammatory pain 1. Additionally, muscle relaxants like cyclobenzaprine (5-10 mg/day) may be used for short-term relief of muscle spasm 1.
Key Considerations
- Gabapentin is associated with small, short-term benefits in patients with radiculopathy 1.
- Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.
- Benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief, but are also associated with risks for abuse, addiction, and tolerance 1.
- Nonpharmacologic therapy, such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation, may be considered for patients who do not improve with self-care options 1.
- Tricyclic antidepressants are an option for pain relief in patients with chronic low back pain and no contraindications to this class of medications 1.
Treatment Approach
The treatment approach should be individualized, taking into account the patient's specific needs and medical history. A multimodal approach, including pharmacotherapy and nonpharmacologic therapy, is often the most effective way to manage chronic low back pain with radiculopathy 1.
From the Research
Medical Management of Chronic Low Back Pain with Radiculopathy
The medical management of chronic low back pain with radiculopathy involves a multimodal approach, including pharmacological and non-pharmacological interventions.
- Non-pharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 2.
- Pharmacologic interventions are second-line treatment, with nonsteroidal anti-inflammatory drugs being the initial medication of choice 2.
- For patients with radicular symptoms, epidural steroid injections may be beneficial for short-term symptom relief 3, 2.
- Multimodal management, including a combination of analgesic agents with different mechanisms of action, is a rational treatment approach for chronic low back pain with both nociceptive and neuropathic components 4, 5.
- Surgery may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments 3, 2.
Pharmacological Management
The pharmacological management of chronic low back pain with radiculopathy involves the use of various medications, including:
- Acetaminophen and nonsteroidal anti-inflammatory drugs as first-line medications 3.
- Tramadol, opioids, and other adjunctive medications for patients who do not respond to nonsteroidal anti-inflammatory drugs 3.
- Antidepressants, such as duloxetine, for patients with neuropathic pain components 4, 2.
- Topical preparations, such as lidocaine 5% plaster, for localized neuropathic pain 4.
- Combination therapy, including the use of medications with different mechanisms of action, to manage both nociceptive and neuropathic pain components 4, 5.
Alternative Therapies
Alternative therapies, such as:
- Acupuncture 3, 2.
- Exercise therapy 3, 2.
- Multidisciplinary rehabilitation programs 3.
- Massage 3.
- Behavior therapy 3.
- Spinal manipulation 3, 2. may be effective in certain clinical situations and can be used in conjunction with pharmacological interventions.
Emerging Treatments
Emerging treatments, such as intra-annular fibrin bio-adhesive sealant, have shown promise in alleviating discogenic chronic low back pain and radiculopathy, even in patients who have failed multiple prior treatments 6.