Medication Summary
As in most conditions involving acute and even chronic musculoskeletal pain, many oral medications can provide initial pain relief. NSAIDs are a mainstay and can be combined with acetaminophen for added effect. When the injury is acute and associated with secondary muscle spasm, muscle relaxants, light narcotics (eg, hydrocodone), or benzodiazepines are reasonable options. However, these medications should be administered cautiously and only for the initial acute phase of pain because dependence and tolerance can quickly occur.
Chronic SIJ dysfunction is more difficult to treat. Numerous medications are dispensed in a generic manner. Antidepressants, antiseizure agents, and antiarrhythmic agents are thought to be effective in neuropathic or nerve-related pain (radicular pain) and are not usually indicated for SIJ dysfunction pain.
Analgesics
Class Summary
For most episodes of SIJ pain, oral outpatient analgesics can achieve adequate pain control.
Acetaminophen (Tylenol, FeverAll)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Class Summary
NSAIDs work by decreasing inflammatory reactions and providing direct pain relief. Numerous choices are available, and they are separated into different families of agents. If an NSAID is ineffective, another agent from a different family can often provide relief. Efficacy and adverse effect profiles differ among agents and families.
Cyclooxygenase (COX)–2 inhibitors had been shown to reduce certain adverse effects (eg, gastrointestinal [GI] bleeding) and provide similar efficacy to standard agents. Unfortunately, 2 of the 3 agents (ie, rofecoxib [Vioxx], valdecoxib [Bextra]) were voluntarily removed from the market by their parent companies when an increased potential risk of adverse cardiovascular events was identified in an increased number of patients taking the drugs. Dosing requirements are usually individualized, based on the individual patient and patient response.
Celecoxib (Celebrex)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Anaprox, Naprelan, Naprosyn)
Common NSAID family used for relief of mild to moderate pain.
Ketorolac (Toradol)
Used primarily for control of hyperacute severe pain. Potency is higher than other NSAIDs, and use results in more marked GI upset, platelet inhibition, and renal effects.
Muscle relaxants
Class Summary
Muscle relaxants can provide adjunctive pain relief in the acute setting. These agents usually should not be used in protracted courses.
Cyclobenzaprine hydrochloride (Flexeril)
Centrally acting relaxant of skeletal muscle. Usually gains most of its analgesic effect indirectly as a general relaxant and sedative. Structurally related to TCAs.
Metaxalone (Skelaxin)
Prescribed for use as a muscle relaxant. Mechanism of action not firmly established but may act as a CNS depressant and direct pain reliever. No direct action on the contractile mechanism of striated muscle. Can be used short term as an adjunct pain reliever in situations of severe myofascial strain.
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Flouroscopically guided sacroiliac joint injection. Contrast seen throughout the joint.
