Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components

Abstract

Vol. 27, No. 1, 2011, 11-33 To review pharmacological management of chronic low back pain (LBP), with respect to management of nociceptive and neuropathic components. Methods:Studies were identified by a PubMed search of English-language papers from the last 10 years, with additional hand searches of relevant reviews. Discussion:Paracetamol, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors target the nociceptive component of chronic LBP, and do not affect neuropathic pain mechanisms. Antidepressants target the neuropathic component of chronic LBP; however, conflicting efficacy results have been reported. Opioids target both nociceptive and to a lesser extent neuropathic pain. They are effective in chronic LBP, but many patients require higher doses or combination treatment. The long-term efficacy of opioids in chronic LBP has been questioned because of the absence of high-quality data and concerns regarding tolerability and dependence. The topical preparation lidocaine 5% plaster, indicated in post-herpetic neuralgia, is effective in localized neuropathic pain in patients with chronic LBP. Pregabalin is ineffective as monotherapy for chronic LBP but is effective when combined with celecoxib or opioids. Muscle relaxant monotherapy is ineffective in chronic LBP. Combination therapy is often necessary in patients with chronic LBP, in order to manage both nociceptive and neuropathic pain components. Conclusion:Chronic LBP often comprises both nociceptive and neuropathic components, therefore a multimodal and individualized treatment approach is necessary. Combining drugs with different mechanisms of action (e.g. an agent with m-receptor activity plus an agent of a different class) represents a rational approach to management of chronic LBP with both nociceptive and neuropathic components.

Epigallocatechin 3-gallate suppresses interleukin-1β-induced inflammatory responses in intervertebral disc cells in vitro and reduces radiculopathic pain in rats

“…The development of back pain involves both nociceptive and neuropathic pathophysiological mechanisms (Forster et al, 2013;Morlion, 2011), with IVD degeneration being one of the major underlying causes. IVD degeneration is induced by phenotypic changes in the NP cells, leading to tissue degradation , as well as to promotion of neoinnervation of the disc and hence the transmission of pain in vivo (Alimasi et al, 2013;Richardson et al, 2012).…”

The CanPain SCI Clinical Practice Guideline for Rehabilitation Management of Neuropathic Pain after Spinal Cord: recommendations for model systems of care

“…As a consequence of the underlying mixed pathology, patients with chronic low back pain can benefit from treatment with paracetamol, an NSAID or COX-2 inhibitor to target the nociceptive component, and an antidepressant to target the neuropathic component. By targeting the nociceptive and to a lesser extent the neuropathic component, opioids can also play an important role in the management of chronic low back pain, although high doses are often required and their long-term efficacy in this setting is unclear [Sng & Schug 2009;Morlion 2011]. For those patients with chronic low back pain that is solely nociceptive based, adequate pain management may be achieved with a single pharmacological agent [Morlion 2011].…”

Pharmacotherapy for lumbago

“…Хотя препараты, способные уменьшать выраженность «нейропатической составляющей» хронической боли, при-меняются для лечения БНЧС достаточно широко, уровень доказательств эффективности многих представителей этой лекарственной группы относительно низкий [45]. Имеются ограниченные данные об использовании при БНЧС анти-конвульсанта прегабалина, препарата, наиболее популярно-го сегодня для лечения нейропатической боли и фибромиал-гии [46].…”