Management of Severe Pain Due to Lumbar Disk Protrusion

ABSTRACT

Lumbar intervertebral disk protrusion can cause excruciating pain in severe cases, which can be exacerbated by activity such as sitting down and straining at stool. Acute sciatica due to disk rupture will improve within 1 to 3 months. The efficacy of drugs used for the management of sciatica in primary care is unclear. Severe cases can require opioid analgesia, however people taking opioids for pain relief frequently present with opioid-induced bowel dysfunction. The use of transforaminal steroid injections is a controversial issue and repeat steroid injections should be considered in light of the risk–benefit profile of the individual patient.

This report is adapted from paineurope 2014; Issue 3, ©Haymarket Medical Publications Ltd, and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.

KEYWORDS :

• disk
• protrusion
• pain
• sciatica
• opioids
• steroids

COMMENTARY FROM SWEDEN

Annica Rhodin

This patient has a few weeks history of severe pain due to right posterolateral disk protrusion with impingement on the L5 spinal nerve but no signs of cauda equina impact. He also has type 2 diabetes. His pain mechanism, as described, would be mixed nociceptive–neuropathic. There is inadequate pain relief with diclofenac 50 mg three times daily and pregabalin 75 mg twice daily. Prolonged release oxycodone 10 mg three times daily and immediate release oxycodone 10–40 mg as needed is added. However, constipation and straining at stool increases the pain.

In the case described, oxycodone is switched to prolonged release oxycodone 20 mg/naloxone 10 mg together with a fecal stool softener/stimulant, relieving the problem with constipation contributing to the pain experience. This certainly improves the situation for the patient. However, the invasive procedure of transforaminal injection of steroid in a patient with acute pain is a controversial issue.^1–3 Even if there is a low risk of complications as cited in many reviews, there are cases of neuronal damage, bleeding and infection.^4–6 Repeat steroid injections should be carefully considered in respect of the risk–benefit profile of this patient with diabetes. Also, this procedure is not easily accessible in most hospitals.

An alternative conservative treatment would be to try a different anti-inflammatory drug to diclofenac, as individual patients may respond differently to different NSAIDs. Furthermore, amitriptyline 10–50 mg could be started at night together with physiotherapy and TENS. Most cases of acute sciatica resolve within 1–3 months.³

COMMENTARY FROM ISRAEL

Elon Eisenberg

This case raises three important issues: first, the majority of patients with acute sciatica due to disk rupture will improve within 1–3 months; only a small proportion of patients, typically those with intractable pain or with significant neurological deficits, require surgery.¹ This means that the majority of the patients with sciatica should be managed in the primary care/pain clinic setting, rather than being referred to spine surgeons. Primary care practitioners should therefore be capable of diagnosing and managing patients with uncomplicated acute sciatica.

Second, although sciatica is the most common form of neuropathic pain, a recent systematic review on drugs for the relief of sciatic pain concluded that “the efficacy and tolerability of drugs commonly prescribed for the management of sciatica in primary care is unclear.”² No wonder therefore that the selection of analgesics prescribed for this condition is often arbitrary. Nonetheless, if pain is severe and image-guided steroid injections are not readily available, the use of a “strong” opioid in combination with an adjuvant drug (anticonvulsants, antidepressants or steroids) or an anti-inflammatory drug may make sense.

Third, studies show that, on average, approximately 40% of patients who consume opioids are constipated.³ Reduced mobility associated with the acute or subacute phases of severe sciatic pain may also be expected to cause constipation.⁴ Constipation, in turn, often exacerbates sciatic pain around strained bowel movements, as seen in the presented patient. Hence, the use of oxycodone/naloxone combination for acute sciatica (and perhaps for additional forms of acute exacerbations of chronic pain) seems reasonable.

Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.