“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #42

Physician Collaborator

Have a patient complaining of low back pain that radiates down the leg? Do you suspect a discogenic etiology? You need to ensure you treat them with an appropriate anti-inflammatory regimen.

Too many providers are trigger happy to just prescribe patients with sciatica 800mg ibuprofen as needed or a Medrol dose pack (this is not strong enough). This often times results in subpar results for the patient.

The goal is to reduce the inflammation around the compressing lesion (herniated disc) on the nerve. Patients need a prolonged course of anti-inflammatory treatment to accomplish this.

My go to regimen is either naproxen (500mg BID) or meloxicam (15mg daily) for 2 weeks. If I feel like the sciatica/lumbar radiculopathy is severe, I will use prednisone 50mg x 5 days and then bridge the anti-inflammatory effect with 1 week of naproxen or meloxicam after they are done with the steroid.

This regimen works well for patients with lumbar radiculopathy. Sometimes, the symptoms will resolve totally and not return. I have personally experienced it! I have a herniated disc with nerve impingement at L4-L5…

Remember though, if they have a history of acid reflux, make sure to also put them on 20mg omeprazole daily during this regimen to prevent an increase in the acid reflux and peptic ulcers!

8 Responses

  1. Good morning Justin,

    My go to treatment for lumbar pain/ sciatica: Toradol 60mg IM and Dexamethasone 8mg IM. After 5-10 minutes I have patient lie on exam table and perform gentle stretching exercises. Several of my patients got total relief within about 30 minutes. They are given stretching exercise instructions to take home and instructed to perform at least 3 times per day. 2 patients required referral to Ortho for severe impingement’s with physical therapy, anti-inflammatory was continued for short period of time and recovered well. Thanks for the information and very helpful to know another Provider follows basically the same regimen for less severe cases and recommendations as you have discussed.

    1. I also use dexamethasone in clinic. I will typically inject 8-10mg on the day of presentation and bridge it with prednisone for a few days afterward. You are 100% correct though, those stretching exercises are critical for long term success. I know, I have been there. Thanks for your comment!

  2. Remember also to consider a referral to physical therapy to help address the reason for the LBP and to be given important exercises and further education to address current injury and prevent further injuries. Their treatment can consist of modalities such as Ultrasound or Electrical Stim to reduce inflammation and new evidence shows increased stem cell activation with pulsed ultrasound and or electrical stimulation, soft tissue mobilization for muscles that are guarded due to pain, biomechanics training and core stabilization to avoid future injury as well as functional exercise programs.

    1. Very good point Stacey! Those modalities will address the underlying problem and get the patient back on their feet while the medications we prescribe decrease the inflammation and allow them to complete PT in less pain. Thanks for the comment!

  3. What about non medication treatments? Ice on 20 minutes and off 20 minutes works great to decrease inflammation. Also, gentle stretching.
    If patient is using a heating pad always follow with ice because the end increases the irritability of the nerve endings, increases blood flow to the area and ultimately causes more pain.

    1. If there are significant radicular symptoms, ice/heat is going to do very little. A mild strain, yes, that will work well, but when there is a nerve impingement, you typically need to resort to medications.

  4. What’s your take with combination as stated with muscle relaxers? This is typically what was prescribed in the ER. Now in the office setting and seeing there is less desire to prescribe muscle relaxers. However, patients did have success with them.

    1. If they are truly having spasms, then they have a place. I personally like tizanadine, patients respond to it well. Otherwise, if there is no spasm or significant muscle tightness, then I usually don’t RX it.

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