Therapy target
Drug therapy for nucleus pulposus prolapse is intended to relieve pain and thereby increase range of motion.
Therapy recommendations
- Analgesia (pain relief) according to WHO staging scheme:
- Non-opioid analgesic (paracetamol, first-line agent).
- Low-potency opioid analgesic (e.g., tramadol) + non-opioid analgesic.
- High-potency opioid analgesic (eg, morphine) + non-opioid analgesic.
- If necessary, also antiphlogistics / drugs that inhibit inflammatory processes (ie, non-steroidal anti-inflammatory drugs, NSAID), eg, ibuprofen.
- If necessary, also use of muscle relaxants / drugs that relax the muscles, local anesthetics (local anesthesia).
- Also glucocorticoids in acute radiculopathy (irritation or damage to the nerve roots) due to a lumbar (“belonging to the lumbar spine”) disc hernia.
- For chronic low back pain: long-term use of opioids only if a clinically relevant reduction in pain and/or physical impairment experience with absent or minor side effects is reported under time-limited therapy (4 – 12 weeks).
- If applicable, also depressants: act on back pain via distancing from pain; no analgesic (pain-relieving) effect of their own.
- OP indications see under “Operative therapy“.
- See also under “Further therapy”.
Analgesics
Analgesics are pain relievers. There are several different subgroups, such as the NSAIDs (non-steroidal anti-inflammatory drugs) to which ibuprofen and ASA (acetylsalicylic acid) belong, or else the group around the non-acid analgesics paracetamol and metamizole. They are all widely used. Many preparations in these groups carry a risk of gastric ulcers (stomach ulcers) with prolonged use.
Muscle relaxants
Muscle relaxants are medications prescribed primarily for tension. In the clinic, they are used for anesthesia. Muscle relaxants include tolperisone.
- Red-hand letter: tolperisone is approved only for the treatment of poststroke spasticity in adults. Outside of this approved indication, for example, there is a risk for hypersensitivity reactions (up to and including anaphylactic shock), with no proven benefit.
Antidepressants
Antidepressants are medications such as amitriptyline or venlafaxine that are used for depression. For back pain, they are used to reduce pain. Amitriptyline is one of the tricyclic antidepressants. These medications have a mood-lifting effect. Venlafaxine belongs to the “Selective Serotonin and Norepinephrine Reuptake Inhibitors” (SSNRI) and has an antidepressant effect without being sedating (drowsy) at the same time. The most common side effect of this medication is nausea.
Opioids
Opioids are very strong pain relievers that include morphine. They have analgesic (pain-relieving) effects, but also sedative (fatiguing) and antiemetic (anti-nausea) effects. However, they also cause many side effects, such as constipation (constipation), nausea/vomiting, respiratory depression (decrease the stimulus to breathe). Opioids, like other narcotics, are considered narcotics, so their traffic is closely tracked and controlled.
Local anesthetics
Local anesthetics are medications administered to eliminate pain in a limited area of the body. They are usually given before minor surgical procedures.
Glucocorticoids
Glucocorticoids are medications used to treat inflammation. They are also used to treat overactive immune systems-for example, allergic reactions. They can lead to osteoporosis-related fractures (broken bones) when taken as long-term oral therapy (i.e., tablets), resulting in back pain.
- Use of oral steroids (50-100 mg prednisolone) for acute radiculopathy (irritation or damage to nerve roots) due to lumbar disc herniation (herniated disc in the lumbar spine) improves function (after three weeks) but not pain.
- Radicular low back pain: lumbosacral radiculopathy can be treated as well with oral gabapentin (anticonvulsant; 300 mg capsules, target dose 1800-3600 mg/day, titrated up over 15-24 days) as with epidural steroid injections.
Caution.Three months or longer of systemic glucocorticoid therapy increases the risk of osteoporosis by 30-50 percent. This side effect does not occur with metered-dose inhaler therapy, such as that used for bronchial asthma.
