Non Operative Treatment of Neck and Back Conditions
NSAIDs (Non steroidal anti-inflammatory drugs – click to read hand out)
The vast majority of neck and back conditions are related to degenerative changes of spinal joints (facet joints and intervertebral disc). These degenerative changes accumulate over the years and are more likely to be aggravated by the normal bending and twisting stresses of daily life as a person ages. Research has shown inflammation is related to both the development of the degenerative process and the resulting pain. That is why the careful use of an anti-inflammatory is one of the most important first line treatments for neck and back pain. Some of the more common NSAIDs are aspirin, ibuprofen, naproxen (over the counter) and meloxicam, Relafen, Celebrex, and diclofenac (requiring a prescription). Patients with bleeding disorders or on anti coagulants, a history of coronary artery disease, asthma, gastric ulcers, kidney or liver disease, or allergic reactions should not take NSAIDs unless under the specific guidance of their treating physician. Common side effects include gastric irritation, increased risk for bleeding, heart attack, kidney or live injury, and edema (see specific medication handouts for indications and contra-indications). The occasional use of NSAIDs should help decrease acute episodes of pain and allow early mobilization and eventual return to normal activities. More severe or persistent episodes of pain may require evaluation with your MD and or possible use of other modalities including steroids, pain medications, or surgery.
Patients who are unable to take oral NSAIDs (due to coronary artery disease, kidney or GI disease) may benefit from topical NSAIDs. Diclofenac is the most common including Voltaren gel, Pennsaid, and Flector patch.
Acetaminophen (APAP, Paracetamol, or Tylenol) is a non opioid pain medication used to treat mild to moderate pain and fever. It is safe and effective with similar efficacy to aspirin but does not have anti inflammatory effects and therefore less likely to irritate the stomach. It is often used in combination with other medications including ibuprofen (Maxigesic), hydrocodone (Vicodin/Norco), oxycodone (Percocet), and caffeine (Excedrin). However, its frequent use and combination with other pain medications has led to inadvertent overdosage and liver failure. Dosage should not exceed 3.5 gm/day and patients with allergies, liver disease or alcohol abuse should not take acetominophin without guidance from their treating MD.
Muscle relaxants (carisoprodol, cyclobenzaprine, methecarbamol)
Muscle relaxants are used for the treatment of acute back pain, especially when accompanied by muscle spasm. Muscle relaxants work by suppressing the central nervous system and can be especially dangerous in the presence of other central nervous system depressants or sedatives including alcohol. They also have the potential for abuse and dependency and therefore primarily used for short term treatment of acute pain. Common side effects include drowsiness, dry mouth, urinary retention, and dependency.
Anticonvulsants (gabapentin, pregabalin)
Anti convulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) and less frequently Topiramatevare are considered first line treatments for neuropathic pain (burning, numbness, pins or needles, or other disturbances related to injury to the somatosensory nervous system) (link to conditions). This includes patients with painful diabetic neuropathy, post herpetic neuralgia, or pain following neurologic injury such as stroke, herniated discs, or surgical treatment. These medications are initially started at a low dose and gradually increased every 3-7 days as tolerated (1800-3600mg/day for gabapentin, 75-150mg/day for pregabalin). Common side effect include drowsiness, dizziness, and lower extremity edema or swelling and should be used cautiously in elder patients.
Tricyclic anti depressants (amitriptyline, desipramine)
Tricyclic anti depressants such as amitriptyline, nortriptyline , and desipramine are used to treat chronic pain syndromes, especially chronic neuropathic pain such as diabetic neuropathy postherpetic neuralgia, and neuropathic pain following stroke or surgery. They are thought to be particularly helpful for patients who experience some depression or sleep disruption in relation to their chronic pain syndrome. Dosing typically begins with 25 mg at bedtime which can be increased every 3-6 days to a maximum of 150mg at bedtime. Common side effects include anti cholinergic effects (dry mouth, constipation, urinary retention) and cardiac toxicity and therefore maybe contra indicated in elderly patients.
Serotonin and NE uptake inhibitors (duloxetine)
Duloxetine (Cymbalta) is used to treat chronic pain syndromes including diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain. These agents are thought to be particularly helpful in patients who experience depression in relation to their chronic pain syndromes. Dosing begins at 30 mg/day and generally increased to 60 mg/day over the course of 1 week. The most common side effect is nausea and contraindications include patients with liver disease or a history of alcohol abuse. Tramadol (Ultram) should not be used in patients on uptake inhibitors.
Narcotic (Opioid) Pain medications (hydrocodone, oxycodone, tramadol)
Narcotic (opioid) pain medications work by binding to receptors in the brain and spinal cord and inhibit the transmission of pain “messages” to the brain. They do not have ceiling effects (higher dosages will have greater effects) but do have significant side effects and are therefore used primarily to treat moderate to severe pain in the acute setting. Opioids include codeine, hydrocodone, oxycodone, meperidine (Demerol) morphine, hydromorphone, Tramadol, and fentanyl. Common side effects include nausea, constiptation, sedation, respiratory depression, and dependency and addiction. These medications have a significant history of abuse and dependency and an increasing association with mortality. For these reasons opioids should be used sparingly for patients with acute severe pain (ex. post surgical pain) refractory to other modalities under the careful supervision of the treating physician and should be administered with a structured plan for weaning off these medications.