What is the appropriate treatment for a pinched nerve?

Treatment of Pinched Nerve (Nerve Compression/Entrapment)

For a pinched nerve, begin with NSAIDs as first-line therapy, combined with activity modification and physical therapy; if symptoms persist after 2-4 weeks of conservative management or if there is significant weakness, consider nerve blocks or surgical referral. 1, 2, 3

Initial Conservative Management (First 2-4 Weeks)

Pharmacological Therapy

• Start with NSAIDs as the primary analgesic for nerve compression pain, as they address both pain and inflammation at the compression site 1, 2
• Add acetaminophen 650 mg every 4-6 hours (maximum 4 g/day) either alone or combined with NSAIDs to enhance pain control 1, 2
• If two different NSAIDs fail sequentially, switch to a different therapeutic approach rather than trying additional NSAIDs 1
• Monitor blood pressure, renal function, liver enzymes, complete blood count, and stool occult blood at baseline and every 3 months when using NSAIDs, particularly in elderly patients 1

Activity Modification

• Identify and eliminate or reduce the specific repetitive activities that provoke symptoms, as recovery is faster when aggravating activities are decreased or stopped 3
• Note the temporal relationship between activities and symptom onset (e.g., does pain occur every time with a specific movement, or only with prolonged/overhead activities?) 3

Physical Therapy

• Initiate physical therapy focusing on nerve gliding exercises, stretching, and strengthening of surrounding musculature 3

Neuropathic Pain Component (If Burning, Shooting, or Electric-Type Pain Present)

First-Line Neuropathic Agents

• Start gabapentin at 100-200 mg daily, titrating up to 900-3600 mg/day in 2-3 divided doses as needed for neuropathic symptoms 1
• Alternatively, use pregabalin starting at 25-50 mg daily, titrating to 150-600 mg/day in 2 divided doses 1
• In patients with moderate-to-severe renal impairment, begin with the lowest dose and increase slowly 1
• Titrate gradually because sedation, dizziness, and mental clouding are common, especially in older adults 1

Second-Line Neuropathic Agents

• Consider nortriptyline or desipramine starting at 10 mg daily and titrating gradually if gabapentinoids are ineffective or not tolerated 1
• Obtain an ECG in all patients over age 40 before starting tricyclic antidepressants 1
• Keep the dose ≤100 mg/day in patients with ischemic heart disease or ventricular conduction disorders, and consider cardiac monitoring 1
• Allow 6-8 weeks for a therapeutic trial, including at least 2 weeks at the highest tolerated dose before declaring treatment failure 1

Interventional Management (When Conservative Therapy Fails)

Nerve Blocks

• Perform nerve blocks when systemic analgesics (NSAIDs, acetaminophen, gabapentin/pregabalin, or tricyclics) do not provide sufficient pain relief 1, 2
• Use ultrasound guidance to improve accuracy and reduce complications such as pneumothorax 2
• Single-shot nerve blocks with local anesthetics provide effective short-term relief 2
• Adding adjuvants (such as dexamethasone) to local anesthetics prolongs analgesia duration 2
• Avoid high-dose corticosteroids as adjuvants in patients with poorly controlled diabetes due to hyperglycemia risk 2

Surgical Referral Indications

• Refer for surgical evaluation when pain or weakness is refractory to 2-4 weeks of conservative therapy 3
• Immediate surgical consultation is warranted for progressive motor weakness or muscle atrophy 3
• Recovery of nerve function is more likely with mild injury and shorter duration of compression, making early intervention critical 3

Opioid Therapy (Last Resort Only)

• Short-term opioid or tramadol therapy may be used for severe pain unresponsive to NSAIDs, acetaminophen, and first-line neuropathic agents, but only with careful monitoring and a clear tapering plan 1, 2
• Implement appropriate monitoring protocols to minimize dependence risk 2

Common Pitfalls to Avoid

• Do not obtain plain radiography or MRI for initial evaluation unless there is concern for bone injury, tumor, or vascular compromise; these imaging studies are usually unnecessary for suspected nerve compression 3
• Do not continue trying multiple NSAIDs sequentially—after two failures, change therapeutic strategy 1
• Avoid delaying surgical referral in patients with progressive weakness, as prolonged compression reduces the likelihood of full recovery 3
• Remember that nerve compression can mimic other musculoskeletal disorders (e.g., lateral epicondylitis vs. radial tunnel syndrome, rotator cuff tear vs. suprascapular nerve injury), so maintain a high index of suspicion when typical treatments fail 3