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Lumbar (Intervertebral) Disk Disorders: Treatment & Medication
Updated: Jan 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Little is needed in the way of prehospital care. Appropriate spinal immobilization should be considered if the patient has evidence of trauma; otherwise, simple transportation in the position of comfort is all that is indicated.
Emergency Department Care
- Patients should lie in a position in which they are most comfortable.
- Muscle relaxants are of limited use, and clinical studies have not proven their efficacy. This class includes benzodiazepines, methocarbamol, and cyclobenzaprine. Patients should be warned that all of these drugs are sedating.
- Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain.
- Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) all have been used in the treatment of pain from lumbar disk disease, but none of these has been shown to be superior to the others. Acetaminophen lacks anti-inflammatory activity.
Medication
The goals of therapy are to reduce pain and inflammation.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents are used most commonly for the relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen usually is the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderately severe pain if no contraindications.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid or qid
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small body size, to elderly persons, and to those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Flurbiprofen (Ansaid)
May inhibit enzyme cyclooxygenase, which, in turn, inhibits prostaglandin biosynthesis. These effects may be mechanism of its analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, causing decrease in prostaglandin synthesis.
Adult
500 mg followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
More on Lumbar (Intervertebral) Disk Disorders |
| Overview: Lumbar (Intervertebral) Disk Disorders |
| Differential Diagnoses & Workup: Lumbar (Intervertebral) Disk Disorders |
Treatment & Medication: Lumbar (Intervertebral) Disk Disorders |
| Follow-up: Lumbar (Intervertebral) Disk Disorders |
| References |
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References
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Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible. Arch Intern Med. Jul 8 2002;162(13):1444-7; discussion 1447-8. [Medline].
Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. Jun 4 2003;289(21):2810-8. [Medline].
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. Jul 14 1994;331(2):69-73. [Medline].
Carragee E. Surgical treatment of lumbar disk disorders. JAMA. Nov 22 2006;296(20):2485-7. [Medline].
Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine. Jun 15 2005;30(12):1441-5; discussion 1446-7. [Medline].
Dullerud R, Nakstad PH. CT changes after conservative treatment for lumbar disk herniation. Acta Radiol. Sep 1994;35(5):415-9. [Medline].
[Best Evidence] Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. Nov 22 2006;296(20):2441-50. [Medline].
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. Nov 22 2006;296(20):2451-9. [Medline].
Frost H, Lamb SE, Doll HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ. Sep 25 2004;329(7468):708. [Medline].
Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial. Radiology. May 2004;231(2):343-51. [Medline].
Further Reading
Keywords
lumbar disk disorders, lumbar disk disease, low back pain, sciatica, intervertebral disk disorders, back pain, back pain diagnosis, back pain treatment, back pain pictures, back pain x-rays, sciatic nerve, disk herniation, disk bulge, disk protrusion, disk extrusion, disk sequestration, herniated disk
Treatment & Medication: Lumbar (Intervertebral) Disk Disorders