Medication Summary
Various medications can be used in the treatment of thoracic disc herniations, including acetaminophen, NSAIDs, muscle relaxants, opioid analgesics, oral corticosteroids, and antidepressants. Before prescribing these medications, the physician should be aware of the contraindications, common adverse effects, and mode of action of each agent.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
Acetaminophen is used for its anti-inflammatory effects. The dose needed to produce anti-inflammatory effects substantially differs from that for analgesic effects. Most NSAIDs achieve only analgesic effects because the dosage prescribed is too small and too infrequent to produce an anti-inflammatory effect.
The risks associated with NSAIDs are particularly pertinent in elderly persons and patients with a history of peptic ulcer diseases, hypertension, or renal insufficiency. Newer-generation NSAIDs selectively interact with the cyclooxygenase-2 (COX-2) receptors and have a lower gastrointestinal risk. Prolonged use of these medications generally is not recommended for most low back problems.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, one induced with pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose for each patient.
Analgesics
Class Summary
Use of opioids should be limited to pain that is unresponsive to alternative medication. Opioids can be prescribed for acute disc herniation to facilitate participation in an active rehabilitation program. These agents should be used on a defined dosing schedule and not on an as-needed basis. An adequate baseline dose should be established to achieve analgesia. Use of nonopioid analgesics, such as tramadol, is also an option.
Oxycodone (OxyContin)
Analgesic with multiple actions similar to those of morphine; may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.
Muscle Relaxants
Class Summary
Medications categorized as muscle relaxants may be helpful in some patients with low back pain; these agents seem to have additional beneficial effects when used in conjunction with NSAIDs. Muscle relaxants can be used as short-term adjunctive medications, and they should be taken at bedtime to take advantage of their sedating effects.
Cyclobenzaprine (Flexeril)
Skeletal muscle relaxant that acts centrally and reduces the motor activity of tonic somatic origins that influence both alpha and gamma motor neurons. Structurally related to TCAs and, thus, has some of the same liabilities.
Metaxalone (Skelaxin)
Prescribed for use as a muscle relaxant. The mechanism of action not firmly established, but it may act as a CNS depressant and direct pain reliever. No direct action on contractile mechanism of striated muscle. Can be used as an adjunct pain reliever for the short term in situations of severe myofascial strain.
Corticosteroids
Class Summary
Corticosteroids are potent anti-inflammatory medications, and they represent a theoretically useful agent in the treatment of patients with radiculopathy due to local inflammation that results from disc injury or herniation.
Related eMedicine topics:
Corticosteroid-Induced Myopathy
Corticosteroid Injections of Joints and Soft Tissues
Prednisone (Deltasone, Orasone, Meticorten)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
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Axial magnetic resonance image of a thoracic herniated disc.
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Sagittal magnetic resonance image of a lower thoracic herniated disc.
