What is the role of duloxetine (Cymbalta) in the management of cervical neuropathy related to OPLL (Ossification of the Posterior Longitudinal Ligament)?

From the Guidelines

Duloxetine may be considered as an off-label option for the treatment of neuropathic pain associated with ossification of the posterior longitudinal ligament (OPLL) related cervical neuropathy, given its established efficacy in other types of neuropathic pain, as supported by the Mayo Clinic Proceedings guidelines 1. When considering duloxetine for OPLL-related cervical neuropathy, it's essential to note that the primary treatment approach typically involves conservative management, including physical therapy and conventional analgesics, with surgical decompression being the definitive treatment for progressive neurological symptoms.

• The dosage of duloxetine should be initiated at 30mg daily for one week, then increased to 60mg daily if tolerated, as recommended by the Mayo Clinic Proceedings guidelines 1.
• Treatment duration should be at least 4-8 weeks to assess efficacy, with continuation based on symptom improvement.
• Duloxetine works by inhibiting serotonin and norepinephrine reuptake, modulating pain signals in the central nervous system.
• Common side effects include nausea, dizziness, dry mouth, and fatigue, as noted in the Mayo Clinic Proceedings guidelines 1.
• Patients should be monitored for mood changes, blood pressure alterations, and potential drug interactions, and duloxetine should be used cautiously in patients with liver disease, uncontrolled glaucoma, or those taking MAOIs, as recommended by the American Society of Clinical Oncology clinical practice guideline 1.
• A multimodal approach combining medication with physical therapy and proper ergonomics is recommended for optimal management, as suggested by the Mayo Clinic Proceedings guidelines 1.

From the Research

Overview of OPLL Related Cervical Neuropathy

• Ossification of the posterior longitudinal ligament (OPLL) is a progressive process that can result in spinal cord compression and myelopathy 2.
• Cervical OPLL can cause various degrees of neurological symptoms and is thought to be more common in the Asian population 3.
• The optimal treatment strategy for OPLL depends on symptoms and is uncertain, with both surgical and non-surgical options available 4, 5.

Diagnosis and Treatment of Cervical OPLL

• CT reconstruction is an important imaging examination to assist in the diagnosis and guide surgical choice for cervical OPLL 3.
• The non-surgical treatment is recommended for patients with no or mild clinical symptoms, or irreversible neurological damage, or failed surgical decompression, or condition cannot tolerate surgery, or refusing surgery 3.
• Surgical treatment can provide notable improvement in neurologic function, and the choice of surgical approach depends on various conditions, such as involved levels, thickness, and type of OPLL, skill-experiences of surgeons 2, 3, 5, 6.

Risks and Benefits of Surgical Treatment

• The incidence rate of cervical spinal cord injury (SCI) in patients with OPLL is significantly higher than in the comparison group, especially when managed with conservative treatment (no surgery) 4.
• Surgical decision making accounts for multiple factors, including patient comorbidities, neurologic status, disease morphology, radiographic findings, and procedure complication profiles 5, 6.
• Successful OPLL surgery relies on careful patient selection, accurate MR/CT documentation of OPLL, and limiting the pros, cons, and complications of these complex procedures by choosing the optimal surgical approach 6.

Duloxetine for OPLL Related Cervical Neuropathy

• There is no direct evidence available in the provided studies regarding the use of duloxetine for OPLL related cervical neuropathy.
• However, duloxetine is often used to treat neuropathic pain, which can be a symptom of OPLL related cervical neuropathy.
• Further research is needed to determine the effectiveness of duloxetine in treating OPLL related cervical neuropathy.

Surgical Approaches for Cervical OPLL

• Anterior, posterior, or combined surgical approaches can be used to treat cervical OPLL, depending on the extent and location of the ossification 2, 3, 5, 6.
• The choice of surgical approach depends on various factors, including the patient's overall health, the severity of the ossification, and the surgeon's experience and preference 2, 3, 5, 6.