Medication Summary

Various medications are used in the treatment of LBP secondary to the degenerative changes often observed in Z-joint dysfunction. These include acetaminophen, NSAIDs, muscle relaxants, opioid analgesics, and antidepressants. Before prescribing these medications, the physician should be aware of the contraindications, common adverse effects, and mode of action of each agent.

Related Medscape Reference topics include the following:

Class Summary

NSAIDs offer anti-inflammatory benefits compared with acetaminophen. The dose needed to achieve an anti-inflammatory benefit is significantly greater than that needed for an analgesic effect. Risks are associated with NSAIDs, especially in elderly persons or persons with peptic ulcer disease, hypertension, or renal insufficiency. Newer-generation NSAIDs selectively interact with the cyclooxygenase (COX)-2 receptors and have a lower GI risk. Prolonged use of these medications is generally not recommended for most low back dysfunctions.

Ibuprofen (Ibuprin, Motrin, Advil)

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DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Class Summary

Muscle relaxants may be helpful in some patients with LBP and may offer additional benefit when used with NSAIDs. These agents can be used as short-term adjunctive medications and should be taken at bedtime to take advantage of the sedating effects.

Cyclobenzaprine (Flexeril)

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Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to TCAs and thus carries some of their same liabilities.

Class Summary

Opioid analgesics should be limited to pain that is unresponsive to alternative medication. These agents can be prescribed for acute facet syndrome to facilitate participation in an active rehabilitation program, and they should be used on a defined dosing schedule rather than prn. In addition, an adequate baseline dose should be established to achieve analgesia. Long-acting opioids should be considered in patients who require an opioid for greater than 1-2 weeks.

Oxycodone (OxyContin, OxyIR, Roxicodone)

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Indicated for moderate to severe pain.

Class Summary

Tricyclic antidepressants (TCAs) can be used as an adjunctive treatment for pain and sleep if they are taken at bedtime. The initial doses should be low, and subsequent doses can be slowly increased to minimize adverse effects.

Amitriptyline (Elavil)

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Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases the concentration in the CNS. Analgesic for certain chronic forms of pain.

Class Summary

These agents are a complex group of drugs that inhibit serotonin and norepinephrine reuptake. Some drugs in this class are weak inhibitors of dopamine reuptake with sedative effects.

Duloxetine (Cymbalta)

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Duloxetine can be used for chronic musculoskeletal pain or low back pain. It is a potent inhibitor of neuronal serotonin and norepinephrine reuptake.

Questions

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Media Gallery

Dorsal ramus innervation (medial and lateral branches). MAL23 = mamillo-accessory ligament bridging the mamillary and accessory processes of L2 and L3; Z-joint = zygapophyseal joint.
Mamillary process anatomy.

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Author

Gerard A Malanga, MD † Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Coauthor(s)

Gary P Chimes, MD, PhD Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute of Rehabilitation, University of Medicine and Dentistry of New Jersey

Gary P Chimes, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Pietro Memmo, MD Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey

Pietro Memmo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lumbosacral Facet Syndrome Medication

Medication Summary

Nonsteroidal Anti-inflammatory Drugs