Spondylolisthesis — বাংলায় ক্লিনিক্যাল, ড্রাগ ও বাংলাদেশি ব্র্যান্ডসহ নোট

Important clinical note: নিচের dose adult average dose; renal disease, liver disease, pregnancy, elderly, peptic ulcer, anticoagulant use, cardiac disease, diabetes বা neurological deficit থাকলে dose/medicine অবশ্যই individualize করতে হবে। Spondylolisthesis-এ medicine vertebral slip ঠিক করে না—pain, inflammation, muscle spasm ও radicular/nerve pain control করে; মূল চিকিৎসা হলো activity modification, physiotherapy, follow-up imaging, এবং selected case-এ injection/surgery.

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1. Definition — সংজ্ঞা

Spondylolisthesis হলো spine-এর একটি vertebra তার নিচের vertebra-এর তুলনায় সামনে, পাশে বা পিছনের দিকে সরে যাওয়া। সবচেয়ে বেশি দেখা যায় L4–L5 বা L5–S1 level-এ। Degenerative spondylolisthesis সাধারণত older adult, especially female patient-এ বেশি; এতে spinal canal narrowing/stenosis হয়ে neurogenic claudication হতে পারে।

Meyerding grading:

Grade	Slip percentage
Grade I	<25%
Grade II	25–50%
Grade III	50–75%
Grade IV	75–100%
Grade V / Spondyloptosis	complete slip

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2. Causes / Etiology — কারণগুলো

A. Isthmic spondylolisthesis

• Pars interarticularis defect/fracture থেকে হয়।
• Adolescent athlete, cricket fast bowler, gymnast, footballer, weightlifter—যাদের repetitive lumbar extension হয়—তাদের ঝুঁকি বেশি।
• Usually L5–S1 level-এ common.

B. Degenerative spondylolisthesis

• বয়সজনিত disc degeneration, facet joint arthritis, ligament laxity থেকে vertebra ধীরে ধীরে slip করে।
• বেশি দেখা যায় middle-aged/elderly female-এ, often L4–L5 level.
• spinal stenosis ও walking pain/claudication হতে পারে।

C. Congenital / Dysplastic

• জন্মগতভাবে facet joint বা posterior arch abnormal হলে spine unstable হয়।

D. Traumatic

• সরাসরি trauma/fracture-এর কারণে vertebra slip করতে পারে।

E. Pathological

• Tumor, infection, osteoporosis, metabolic bone disease spine দুর্বল করে slip তৈরি করতে পারে।

F. Iatrogenic

• Previous spine surgery, especially decompression/laminectomy-এর পর instability তৈরি হলে হতে পারে।

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3. Pathophysiology — রোগটি কীভাবে সমস্যা করে

• Vertebra slip করলে disc, facet joint, ligament-এর ওপর abnormal mechanical stress পড়ে।
• Neural foramen বা spinal canal narrow হলে nerve root compression হয়।
• এর ফলে low back pain, radicular leg pain, numbness, weakness, neurogenic claudication হতে পারে।
• Lumbar extension করলে canal/foramen আরও narrow হতে পারে, তাই অনেক patient extension বা walking-এ pain বেশি বলে।

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4. Symptoms — লক্ষণগুলো

Pain-related symptoms

• কোমরের নিচের দিকে chronic বা intermittent pain
• দাঁড়ালে, হাঁটলে, পেছনে বাঁকালে pain বাড়ে
• বসলে বা সামনে ঝুঁকলে pain কমতে পারে
• Buttock pain বা posterior thigh pain

Nerve compression symptoms

• পায়ে ব্যথা ছড়িয়ে যাওয়া — sciatica/radicular pain
• পায়ে ঝিনঝিনি, numbness, burning sensation
• পায়ের weakness
• হাঁটলে পা ভারী লাগে, বসলে আরাম — neurogenic claudication

Physical/functional symptoms

• Hamstring tightness
• Gait abnormality
• কোমরে “step-off” অনুভব হতে পারে
• Lumbar lordosis/postural change হতে পারে

Red flag symptoms — emergency

• নতুন bladder/bowel dysfunction
• Saddle anesthesia
• Progressive foot drop/weakness
• Fever, weight loss, night pain
• Trauma history
• Known cancer/infection suspicion

Cauda equina-type symptom থাকলে urgent referral/emergency MRI দরকার।

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5. Clinical Diagnosis — clinically কীভাবে diagnosis করবেন

A. History

• Pain duration, site, radiation
• Standing/walking/extension-এ pain বাড়ে কিনা
• Sitting/flexion-এ relief হয় কিনা
• Trauma, sports, heavy lifting history
• Previous spine surgery
• Neurological symptom: numbness, weakness, bladder/bowel problem
• Red flag: fever, weight loss, cancer, infection, night pain

B. Examination

• Posture, gait, lumbar lordosis
• Lumbar range of motion
• Palpable step-off at lumbosacral area
• Hamstring tightness
• Neurological exam:
  • Motor: L2–S1 myotomes
  • Sensory: dermatomes
  • Reflex: knee jerk, ankle jerk
  • Straight leg raise / femoral stretch test
• Stork test / single-leg hyperextension test: pars stress pain suggestive, especially adolescent athlete.

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6. Investigations — specific test

First-line imaging

1. Standing AP & lateral X-ray lumbosacral spine

• Slip confirm করতে
• Meyerding grade measure করতে
• Standing view বেশি useful, কারণ supine position-এ slip reduce হয়ে underdiagnosis হতে পারে।

2. Flexion–extension lateral X-ray

• Dynamic instability আছে কিনা দেখতে
• Surgery planning বা persistent pain-এ useful

Advanced imaging

3. MRI lumbosacral spine

Indication:

• Radicular pain
• Neurological deficit
• Neurogenic claudication
• Suspected spinal stenosis/disc prolapse
• Conservative treatment fail
• Preoperative assessment

Degenerative spondylolisthesis-এ stenosis/nerve root impingement confirm করতে MRI preferred non-invasive test।

4. CT scan

Indication:

• Pars defect detail দেখতে
• Bony anatomy
• Preoperative planning
• MRI contraindicated হলে

5. CT myelography

• MRI contraindicated বা inconclusive হলে stenosis/nerve compression evaluate করতে use করা যায়।

6. SPECT / bone scan

• Adolescent athlete-এ early pars stress injury সন্দেহ কিন্তু X-ray normal হলে useful হতে পারে।

Laboratory test

Routine spondylolisthesis diagnosis-এ lab লাগে না। তবে red flag থাকলে:

• CBC, ESR, CRP — infection/malignancy suspicion
• Calcium, vitamin D, renal profile — osteoporosis/metabolic risk
• DEXA scan — elderly/postmenopausal/fragility fracture suspicion

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7. Differential Diagnosis

• Lumbar disc herniation
• Lumbar spinal stenosis
• Facet joint arthropathy
• Sacroiliac joint dysfunction
• Ankylosing spondylitis / inflammatory back pain
• Vertebral compression fracture
• Discitis/osteomyelitis/TB spine
• Spinal tumor/metastasis
• Hip osteoarthritis
• Peripheral neuropathy

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8. Complications — রোগের জটিলতা

• Progressive vertebral slip: grade বাড়তে পারে, especially high-grade/young patient.
• Chronic low back pain: daily activity, sleep, work affected হয়।
• Radiculopathy: nerve root pressure হয়ে leg pain, numbness, tingling হয়।
• Spinal stenosis: হাঁটলে পা ব্যথা/ভারী লাগে; বসলে কমে।
• Motor weakness/foot drop: severe nerve compression হলে।
• Cauda equina syndrome: bladder/bowel dysfunction, saddle anesthesia—emergency.
• Postural deformity/gait problem: hamstring tightness, sagittal imbalance.
• Surgical complications: infection, bleeding, dural tear, hardware failure, adjacent segment disease—selected surgical cases-এ possible.

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9. Treatment Management — guideline-based

A. Non-pharmacological treatment — first-line

Most low-grade symptomatic spondylolisthesis-এ first-line হলো conservative treatment: activity modification, pain control, physiotherapy, core stabilization, hamstring stretching, lumbar flexibility, follow-up।

Core treatment

• Relative rest: complete bed rest নয়
• Pain-provoking hyperextension, heavy lifting, jumping, twisting avoid
• Physiotherapy:
  • Core stabilization
  • Pelvic tilt exercise
  • Hamstring stretching
  • Hip flexor stretching
  • Gluteal strengthening
  • Neutral-spine training
• Weight reduction if overweight
• Heat/ice short-term symptom relief
• Brace: selected adolescent/isthmic symptomatic case-এ short-term use
• Patient education: active lifestyle maintain করা; fear-avoidance কমানো

NICE low back pain guideline অনুযায়ী non-specialist setting-এ routine imaging করা উচিত নয়; imaging তখনই করা উচিত যখন result management change করবে। NSAID lowest effective dose, shortest duration—এটাই recommended; paracetamol alone low back pain-এর জন্য recommended নয়।

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10. Bangladesh Doctors commonly prescription-এ যে drug groups use করেন

Prescription pattern — কেন use হয়

1. NSAID + PPI
   • Mechanical/inflammatory low back pain কমাতে
   • PPI দেওয়া হয় gastritis/ulcer risk কমাতে
   • Example: Aceclofenac/Diclofenac/Naproxen/Etoricoxib + Pantoprazole/Esomeprazole
2. Muscle relaxant
   • Painful paraspinal muscle spasm থাকলে
   • Example: Tolperisone, Tizanidine
3. Neuropathic pain medicine
   • Radicular burning pain, tingling, numbness থাকলে
   • Example: Pregabalin/Gabapentin
   • Note: NICE sciatica/low back pain guideline routine gabapentinoid, oral steroid, benzodiazepine use discourage করে; তাই monitored short trial/selected patient-এ specialist judgment দরকার।
4. Short-term opioid-like analgesic
   • Acute severe pain, NSAID contraindicated/ineffective হলে
   • Example: Tramadol or Paracetamol + Tramadol
   • Chronic use avoid
5. Epidural steroid injection
   • Acute severe sciatica/radicular pain with nerve compression হলে pain/spine specialist দিতে পারে; routine axial low back pain-এর জন্য নয়। NICE severe acute sciatica-এ epidural local anaesthetic + steroid consider করতে বলে।

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11. Pharmacological drugs — Bangladesh brandসহ

MedEx Bangladesh medicine directory হিসেবে Bangladesh-available brand/strength verify করা হয়েছে; brand availability time-to-time বদলাতে পারে।

A. Analgesic / NSAID group

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Adult dose & duration	Side effects	Important interaction/caution
Paracetamol	Non-opioid analgesic, antipyretic	Central prostaglandin/COX pathway analgesic	Napa 500 mg, Napa Extend 665 mg, Napa One 1000 mg, Feva 500/1000 mg, Fast 500 mg, Pyrex 500 mg, Tamino 500 mg/ER 665 mg	Mild pain; NSAID contraindicated হলে safer option	500 mg 6–8 hourly PRN; max usually 3 g/day; 3–5 days	Liver toxicity overdose, nausea, rash	Alcohol, liver disease, warfarin long-term use caution
Ibuprofen	NSAID analgesic	Non-selective COX inhibitor	Flamex 200/400 mg, Intaflam 400 mg, Neurofen 400 mg, Profen 400 mg, Reumafen 200/400 mg	Acute inflammatory back pain	400 mg TID after food; 3–5 days	Gastritis, ulcer, renal injury, BP rise, edema	Anticoagulant, steroid, ACEi/ARB+diuretic, CKD, PUD caution
Naproxen	NSAID analgesic	Non-selective COX inhibitor	Naproxen 500 mg, Naproxen SR 500 mg, Naproxin 250/500 mg, Napsod 275/550 mg, Naxin 250/500 mg/SR 500 mg	Longer-acting NSAID for mechanical/inflammatory pain	250–500 mg BID after food; 5–7 days	GI bleed, renal injury, edema	Avoid multiple NSAIDs; caution anticoagulant, CKD, heart failure
Aceclofenac	NSAID analgesic	COX inhibitor, phenylacetic acid derivative	Carepain 100 mg, Ceclofen 100 mg, Dolonac 100 mg, Ectinac 100 mg, Flexi 100 mg/SR 200 mg, Flexivan 100 mg/ER 200 mg	Commonly used for low back pain/inflammation	100 mg BID after food; 5–7 days	Dyspepsia, ulcer, renal risk, dizziness	Warfarin/DOAC, steroid, SSRI, ACEi/ARB+diuretic caution
Diclofenac sodium	NSAID analgesic	Non-selective COX inhibitor	Diclorex 50 mg/75 mg IM/RTD 100 mg, Diclovir 50 mg/SR 100 mg, Dilock 50 mg/SR/TR 100 mg, Fastfit gel 1%, Fengel gel 1%, Proflam 50/SR 100 mg	Acute severe inflammatory pain; gel for localized pain	Oral 50 mg BID–TID after food, max 150 mg/day; 3–5 days. Gel local 2–4 times/day	Gastritis, GI bleed, renal injury, ↑CV risk	Avoid IHD/stroke/high CV risk if possible; anticoagulant/steroid caution
Etoricoxib	NSAID analgesic	Selective COX-2 inhibitor	Eroflam 60/90/120 mg, Etocox 90/120 mg, Etonil 60/90/120 mg, Etorica 60/90/120 mg, Etovan 60/90/120 mg	NSAID needed but GI risk relatively concern; acute pain	60 mg OD; severe short-term 90 mg OD; 3–7 days	BP rise, edema, dyspepsia, renal injury, CV risk	Avoid uncontrolled HTN, IHD, stroke, HF; warfarin caution

NSAID rule: একসাথে ২টা NSAID নয়। NSAID সবসময় lowest effective dose + shortest duration। Peptic ulcer, CKD, heart failure, uncontrolled hypertension, anticoagulant use, pregnancy third trimester—এগুলোতে avoid/consult. NICE NSAID ব্যবহারে এই shortest-duration principle recommend করে।

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B. Gastroprotection — NSAID দিলে commonly used

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Adult dose & duration	Side effects	Interaction/caution
Pantoprazole	Anti-ulcerant	Proton pump inhibitor, H+/K+ ATPase inhibitor	Pantodac 20/40 mg, Pantogen 20/40 mg, Pantogut 20/40 mg/IV 40 mg, Pantolok 20/40 mg/IV, Pantonix 20/40 mg/IV, Pantopra 20/40 mg, Protozin 20/40 mg	NSAID-induced gastritis/ulcer risk কমাতে	20–40 mg OD before breakfast during NSAID course; often 1–2 weeks	Headache, diarrhea/constipation, hypomagnesemia long-term	Clopidogrel interaction less than omeprazole but still review; long-term unnecessary use avoid
Esomeprazole	Anti-ulcerant	Proton pump inhibitor	Esonix 40 mg, Esonix IV 40 mg, Esoral IV 40 mg/oral powder 20 mg, Esosav 20/40 mg	Gastric protection with NSAID; GERD/gastritis	20 mg OD; 1–2 weeks with NSAID, GERD হলে 4–8 weeks	Headache, nausea, diarrhea, B12/Mg issue long-term	Clopidogrel interaction concern; long-term overuse avoid

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C. Muscle relaxant group

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Adult dose & duration	Side effects	Interaction/caution
Tolperisone	Skeletal muscle relaxant	Centrally acting muscle relaxant	A-Calm 50 mg, Mexaton 50 mg, Musclex 50 mg, Myoson 100 mg, Myotol 50 mg, Myoxan 50 mg, Rison 50 mg, Tolcalm 50 mg, Tolson 50/100 mg	Paraspinal muscle spasm, painful stiffness	50–150 mg TID after food; 5–10 days	Dizziness, weakness, nausea, hypersensitivity	Alcohol/sedatives caution; driving avoid if dizzy
Tizanidine	Skeletal muscle relaxant	Central α2-adrenergic agonist	Relentus 2 mg, Sirdalud 2 mg, Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg	Significant muscle spasm, night spasm	Start 2 mg HS or 2 mg TID; short 3–7 days; titrate carefully	Sleepiness, dizziness, hypotension, dry mouth, liver enzyme rise	Avoid ciprofloxacin/fluvoxamine; alcohol, benzodiazepine, antihypertensive caution

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D. Neuropathic / radicular pain group

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Adult dose & duration	Side effects	Interaction/caution
Pregabalin	Neuropathic pain agent, anticonvulsant	Gabapentinoid; α2δ calcium-channel ligand	Nervaid 50/75 mg, Nervalin 50/75 mg, Pregaran 50/75 mg, Prelica 25/75/150 mg & CR 82.5/165 mg, Prelin 25/50/75/100/150 mg, Rebalin 25/50/75 mg, Regab 25/50/75/100/150 mg	Burning radicular pain, tingling, numbness—selected patient	Start 50 mg TID or 75 mg BID; usual 150–300 mg/day; reassess 2–4 weeks; taper ≥1 week	Dizziness, somnolence, weight gain, edema, blurred vision	Opioid/benzodiazepine/alcohol → respiratory depression/sedation; renal dose adjust
Gabapentin	Neuropathic pain agent, anticonvulsant	Gabapentinoid; α2δ calcium-channel ligand	Gaba 300 mg, Gabahil 100/300 mg, Gabamax 300 mg, Gabantin 100/300 mg, Gabapen 100/300 mg, Gabatin 300 mg, Neurotin 300 mg	Radicular neuropathic pain if selected	Day 1: 300 mg HS; Day 2: 300 mg BID; Day 3: 300 mg TID; titrate 900–1800 mg/day; reassess 2–4 weeks	Dizziness, ataxia, fatigue, edema, weight gain, somnolence	Antacid reduces absorption; opioid/sedative caution; renal dose adjust
Duloxetine	Neuropathic pain agent, antidepressant	SNRI	Diliner DR 20/30 mg, Dulox 20/30 mg, Duloxen 20/30/60 mg, Loxetine 20/30 mg, Stresin 20/30 mg, Xinolax DR 20/30/60 mg	Chronic pain with neuropathic feature/anxiety-depression overlap—selected case	30 mg OD 1 week, then 60 mg OD; reassess 4–6 weeks	Nausea, insomnia/somnolence, sweating, BP rise, sexual dysfunction	Avoid MAOI/linezolid; caution SSRI/tramadol—serotonin syndrome; liver disease caution
Amitriptyline	Neuropathic pain agent, antidepressant	Tricyclic antidepressant	Amilin 10/25 mg, Amit 10/25 mg, Amitip 10/25 mg, Amtylin 10/25 mg, Reptylin 10/25 mg, Tryptin 10 mg	Night pain, sleep disturbance with neuropathic pain—selected case	10–25 mg HS; increase weekly if needed; usual 25–75 mg HS	Dry mouth, constipation, urinary retention, sedation, QT prolongation	Avoid glaucoma/BPH/arrhythmia; caution elderly; avoid with MAOI, tramadol/SSRI serotonin risk

Guideline caution: NICE NG59 sciatica/low back pain-এ routine gabapentinoids, oral steroids, benzodiazepines, antidepressants discourage করে; তাই pregabalin/gabapentin/duloxetine/amitriptyline indiscriminate use না করে radicular neuropathic pain phenotype, risk–benefit, renal function ও follow-up দেখে ব্যবহার করা উচিত।

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E. Severe acute pain — short-term rescue

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Adult dose & duration	Side effects	Interaction/caution
Tramadol	Opioid analgesic	Weak μ-opioid agonist + serotonin/norepinephrine reuptake inhibition	Tramadol brands Bangladesh-এ বিভিন্ন strength-এ available; MedEx tramadol is indicated for moderate–severe pain including back pain	Acute severe pain, NSAID contraindicated/ineffective	50–100 mg every 4–6 h PRN; max 400 mg/day; usually 3–5 days only	Nausea, vomiting, constipation, dizziness, sedation, dependence, seizure	Avoid alcohol/benzodiazepine/opioid; caution epilepsy; SSRI/SNRI/TCA → serotonin syndrome
Paracetamol + Tramadol	Combination analgesic	Non-opioid analgesic + weak opioid	Aceta-T 325/37.5 mg, Anadol Plus 325/37.5 mg, Atopen-X 325/37.5 mg	Acute severe breakthrough pain	1 tablet 6–8 hourly PRN; max 8 tablets/day; short-term ≤5 days	Tramadol effects + paracetamol liver toxicity if overdose	Don’t combine with extra paracetamol unknowingly; avoid sedatives/alcohol

NICE acute low back pain-এ weak opioid only তখন consider করতে বলে যখন NSAID contraindicated, not tolerated, বা ineffective; chronic low back pain-এ opioid avoid করা উচিত।

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F. Epidural steroid injection — specialist use only

Generic name	Therapeutic category	Pharmacological class	Bangladesh available brand examples	Why used	Dose/duration	Side effects	Interaction/caution
Methylprednisolone acetate injection	Corticosteroid anti-inflammatory	Glucocorticoid	Medrol 40 mg/ml, Medrol 80 mg/2 ml, Methsolon 40 mg/ml, Uni-Medrol 80 mg/2 ml	Acute severe sciatica/radicular pain due nerve inflammation—epidural route by specialist	Dose/route depends on pain/spine specialist protocol	Hyperglycemia, infection risk, flushing, transient pain, adrenal suppression	Diabetes, infection, anticoagulant, immunosuppression caution
Triamcinolone acetonide injection	Corticosteroid anti-inflammatory	Glucocorticoid	Alfacort 40 mg/ml, Cenolon 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml, Intracort 40 mg/ml	Epidural/local steroid option for severe radicular pain	Specialist procedure only	Same steroid risks	Same caution; avoid self-use

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12. When surgery is needed

Surgery consider করা হয় যখন:

• Conservative treatment 6–12 weeksেও severe pain/function limitation থাকে
• Progressive neurological deficit
• Severe spinal stenosis with neurogenic claudication
• High-grade slip/instability
• Cauda equina syndrome — emergency

NASS guideline symptomatic spinal stenosis with degenerative spondylolisthesis-এ decompression ± fusion consider করে; single-level low-grade slip without foraminal stenosis-এ decompression alone selected patient-এ fusion-এর comparable হতে পারে। NEJM trial-এ degenerative lumbar spondylolisthesis-এর অনেক patient-এ surgery nonoperative care-এর তুলনায় better pain/function improvement দেখিয়েছে; আবার newer trial-এ decompression alone selected cases-এ fusion-এর non-inferior পাওয়া গেছে।

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13. Prevention — কীভাবে প্রতিরোধ করবেন

• Core muscle strengthening: transversus abdominis, multifidus, gluteal muscle
• Hamstring ও hip flexor stretching
• Heavy lifting করলে neutral spine technique
• Repetitive lumbar hyperextension avoid, especially adolescent athlete
• Long sitting হলে posture break
• Body weight control
• Smoking cessation
• Osteoporosis risk থাকলে vitamin D, calcium, DEXA, fall prevention
• Sudden high-load gym/weightlifting avoid
• Early physiotherapy if recurrent low back pain
• Red flag symptom হলে দ্রুত doctor/spine specialist review

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14. Overview / Summary

Spondylolisthesis হলো vertebra slip; common types হলো isthmic ও degenerative। Main presentation: mechanical low back pain, hamstring tightness, radicular leg pain, numbness, weakness, neurogenic claudication। Diagnosis clinically suspect করা যায়, কিন্তু confirmation হয় standing lateral X-ray দিয়ে; nerve compression/stenosis দেখতে MRI best। Low-grade disease-এ first-line হলো physiotherapy + activity modification + short-course analgesic/NSAID। Medicine pain control করে, slip cure করে না। Neurological deficit, bladder/bowel symptom বা failed conservative care হলে spine referral জরুরি।

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15. Actionable Plan / Steps

1. Red flag screen: bladder/bowel, saddle anesthesia, progressive weakness, fever, cancer, trauma.
2. Initial test: standing AP/lateral lumbosacral X-ray ± flexion-extension view.
3. MRI: radicular pain, neuro deficit, claudication, severe/persistent pain, surgery planning.
4. First 2–6 weeks: activity modification + physiotherapy + short course NSAID if safe + PPI if GI risk.
5. Spasm থাকলে: short-course muscle relaxant.
6. Radicular neuropathic pain থাকলে: selected short monitored trial pregabalin/gabapentin; renal dose adjust; stop if no benefit.
7. Severe acute sciatica: specialist epidural steroid injection consider.
8. Surgery referral: progressive neuro deficit, high-grade slip, severe stenosis, failed conservative treatment.

নিচে Spondylolisthesis-এ commonly prescription-এ ব্যবহৃত সব drug point-list আকারে দিলাম।
Note: এগুলো pain/spasm/nerve pain control করে; vertebra slip “সোজা” করে না। NSAID lowest effective dose + shortest duration—NICE guideline এটাই বলে।

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1. Paracetamol

• Generic name: Paracetamol
• Therapeutic category: Analgesic, Antipyretic
• Pharmacological class: Non-opioid analgesic
• বাংলাদেশি Brand: Napa 500 mg, Napa Extend 665 mg, Napa One 1000 mg, Ace 500 mg, Ace XR 665 mg, Ace Power 1000 mg, Fast 500 mg, Feva 500/1000 mg
• কেন used হয়: Mild back pain; NSAID contraindicated হলে pain relief
• Dose: 500 mg 6–8 hourly PRN; max সাধারণত 3 g/day
• Duration: 3–5 days PRN
• Side effect: Liver toxicity overdose, nausea, rash
• Interaction: Alcohol, warfarin long-term, liver disease caution

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2. Ibuprofen

• Generic name: Ibuprofen
• Therapeutic category: NSAID analgesic
• Pharmacological class: Non-selective COX inhibitor
• বাংলাদেশি Brand: Flamex 200/400 mg, Intaflam 400 mg, Neurofen 400 mg, Profen 400 mg, Reumafen 200/400 mg
• কেন used হয়: Acute inflammatory/mechanical low back pain
• Dose: 400 mg TID after food
• Duration: 3–5 days
• Side effect: Gastritis, ulcer, renal injury, BP rise
• Interaction: Anticoagulant, steroid, ACEi/ARB + diuretic, CKD/PUD caution

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3. Naproxen

• Generic name: Naproxen Sodium
• Therapeutic category: NSAID analgesic
• Pharmacological class: Non-selective COX inhibitor
• বাংলাদেশি Brand: Naproxen 500 mg, Naproxen SR 500 mg, Naproxin 250/500 mg, Napsod 275/550 mg, Naxin 250/500 mg/SR 500 mg
• কেন used হয়: Longer-acting back pain/inflammation
• Dose: 250–500 mg BID after food
• Duration: 5–7 days
• Side effect: Dyspepsia, GI bleed, renal injury, edema
• Interaction: Warfarin/DOAC, steroid, SSRI, CKD, heart failure caution

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4. Aceclofenac

• Generic name: Aceclofenac
• Therapeutic category: NSAID analgesic
• Pharmacological class: Phenylacetic acid derivative, COX inhibitor
• বাংলাদেশি Brand: Carepain 100 mg, Ceclofen 100 mg, Dolonac 100 mg, Ectinac 100 mg, Flexi 100 mg/SR 200 mg, Flexivan 100 mg/ER 200 mg
• কেন used হয়: Mechanical low back pain + inflammation
• Dose: 100 mg BID after food
• Duration: 5–7 days
• Side effect: Gastritis, ulcer, renal injury, dizziness
• Interaction: Anticoagulant, steroid, SSRI, ACEi/ARB + diuretic caution

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5. Diclofenac Sodium

• Generic name: Diclofenac Sodium
• Therapeutic category: NSAID analgesic
• Pharmacological class: Non-selective COX inhibitor
• বাংলাদেশি Brand: Diclorex 50 mg/75 mg IM/RTD 100 mg, Diclovir 50 mg/SR 100 mg, Dilock 50 mg/SR 100 mg, Fastfit gel 1%, Fengel gel 1%, Proflam 50 mg/SR 100 mg
• কেন used হয়: Acute severe inflammatory back pain; gel localized pain-এ
• Dose: 50 mg BID–TID after food; max 150 mg/day
• Duration: 3–5 days
• Side effect: Gastritis, GI bleed, renal injury, CV risk
• Interaction: Anticoagulant, steroid, CKD, IHD/stroke risk caution

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6. Etoricoxib

• Generic name: Etoricoxib
• Therapeutic category: NSAID analgesic
• Pharmacological class: Selective COX-2 inhibitor
• বাংলাদেশি Brand: Eroflam 60/90/120 mg, Etocox 90/120 mg, Etonil 60/90/120 mg, Etorica 60/90/120 mg, Etovan 60/90/120 mg
• কেন used হয়: Back pain/inflammation; GI risk তুলনামূলক কম দরকার হলে
• Dose: 60 mg OD; severe short-term pain-এ 90 mg OD
• Duration: 3–7 days
• Side effect: BP rise, edema, renal injury, CV risk
• Interaction: Warfarin, uncontrolled HTN, IHD, stroke, heart failure caution

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7. Pantoprazole

• Generic name: Pantoprazole Sodium
• Therapeutic category: Anti-ulcerant
• Pharmacological class: Proton Pump Inhibitor, PPI
• বাংলাদেশি Brand: Pantodac 20/40 mg, Pantogen 20/40 mg, Pantogut 20/40 mg/IV 40 mg, Pantolok 20/40 mg/IV, Pantonix 20/40 mg/IV, Pantopra 20/40 mg
• কেন used হয়: NSAID-induced gastritis/ulcer prevention
• Dose: 20–40 mg OD before breakfast
• Duration: NSAID চলাকালীন; usually 1–2 weeks
• Side effect: Headache, diarrhea/constipation, long-term hypomagnesemia/B12 deficiency
• Interaction: Clopidogrel caution, long-term unnecessary use avoid

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8. Esomeprazole

• Generic name: Esomeprazole
• Therapeutic category: Anti-ulcerant
• Pharmacological class: Proton Pump Inhibitor, PPI
• বাংলাদেশি Brand: Esonix 40 mg/IV 40 mg, Esoral IV 40 mg/oral powder 20 mg, Esosav 20/40 mg
• কেন used হয়: NSAID-associated gastritis/GERD/ulcer protection
• Dose: 20 mg OD before breakfast
• Duration: 1–2 weeks with NSAID; GERD হলে 4–8 weeks
• Side effect: Headache, nausea, diarrhea, long-term B12/Mg issue
• Interaction: Clopidogrel interaction concern

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9. Tolperisone

• Generic name: Tolperisone Hydrochloride
• Therapeutic category: Skeletal muscle relaxant
• Pharmacological class: Centrally acting muscle relaxant
• বাংলাদেশি Brand: A-Calm 50 mg, Mexaton 50 mg, Musclex 50 mg, Myoson 100 mg, Myotol 50 mg, Myoxan 50 mg, Rison 50 mg, Tolcalm 50 mg, Tolson 50/100 mg
• কেন used হয়: Paraspinal muscle spasm, stiffness, painful tightness
• Dose: 50–150 mg TID after food
• Duration: 5–10 days
• Side effect: Dizziness, weakness, nausea, hypersensitivity
• Interaction: Alcohol/sedatives caution; dizziness হলে driving avoid

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10. Tizanidine

• Generic name: Tizanidine Hydrochloride
• Therapeutic category: Skeletal muscle relaxant
• Pharmacological class: Central α2-adrenergic agonist
• বাংলাদেশি Brand: Relentus 2 mg, Sirdalud 2 mg, Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg
• কেন used হয়: Severe muscle spasm/night spasm
• Dose: 2 mg HS বা 2 mg TID; titrate carefully
• Duration: 3–7 days
• Side effect: Sleepiness, dizziness, hypotension, dry mouth, ↑LFT
• Interaction: Ciprofloxacin/fluvoxamine avoid; alcohol, benzodiazepine, antihypertensive caution

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11. Pregabalin

• Generic name: Pregabalin
• Therapeutic category: Neuropathic pain agent, anticonvulsant
• Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
• বাংলাদেশি Brand: Nervaid 50/75 mg, Nervalin 50/75 mg, Pregaran 50/75 mg, Prelica 25/75/150 mg & CR 82.5/165 mg, Prelin 25/50/75/100/150 mg, Rebalin 25/50/75 mg, Regab 25/50/75/100/150 mg
• কেন used হয়: Radicular burning pain, tingling, numbness—selected case
• Dose: Start 50 mg TID বা 75 mg BID; usual 150–300 mg/day
• Duration: 2–4 weeks trial; benefit না হলে taper করে stop
• Side effect: Dizziness, somnolence, weight gain, edema, blurred vision
• Interaction: Opioid/benzodiazepine/alcohol → sedation/respiratory depression; renal dose adjust
• Guideline note: Sciatica-তে routine gabapentinoid use NICE recommend করে না।

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12. Gabapentin

• Generic name: Gabapentin
• Therapeutic category: Neuropathic pain agent, anticonvulsant
• Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
• বাংলাদেশি Brand: Gaba 300 mg, Gabahil 100/300 mg, Gabamax 300 mg, Gabantin 100/300 mg, Gabapen 100/300 mg, Gabatin 300 mg, Neurotin 300 mg
• কেন used হয়: Radicular neuropathic pain—selected case
• Dose: Day 1: 300 mg HS; Day 2: 300 mg BID; Day 3: 300 mg TID
• Duration: 2–4 weeks trial; benefit না হলে taper করে stop
• Side effect: Dizziness, ataxia, fatigue, edema, somnolence
• Interaction: Antacid absorption কমায়; opioid/sedative caution; renal dose adjust

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13. Duloxetine

• Generic name: Duloxetine Hydrochloride
• Therapeutic category: Neuropathic pain agent, antidepressant
• Pharmacological class: SNRI
• বাংলাদেশি Brand: Deloxi 20/60 mg, Diliner DR 20/30/60 mg, Dulox 20/30 mg, Duloxen 20/30/60 mg, Loxetine 20/30 mg, Stresin 20/30 mg, Xinolax DR 20/30/60 mg
• কেন used হয়: Chronic pain with neuropathic feature; anxiety/depression overlap থাকলে selected case
• Dose: 30 mg OD 1 week, then 60 mg OD
• Duration: 4–6 weeks reassess
• Side effect: Nausea, insomnia/somnolence, sweating, BP rise, sexual dysfunction
• Interaction: MAOI/linezolid avoid; SSRI/TCA/tramadol → serotonin syndrome risk; liver disease caution

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14. Amitriptyline

• Generic name: Amitriptyline Hydrochloride
• Therapeutic category: Neuropathic pain agent, antidepressant
• Pharmacological class: Tricyclic antidepressant, TCA
• বাংলাদেশি Brand: Amilin 10/25 mg, Amit 10/25 mg, Amitip 10/25 mg, Amtylin 10/25 mg, Reptylin 10/25 mg, Tripsina 10/25 mg, Tryptin 10/25 mg
• কেন used হয়: Night pain, sleep disturbance with neuropathic pain—selected case
• Dose: 10–25 mg HS; weekly titration if needed
• Duration: 4–6 weeks reassess
• Side effect: Dry mouth, constipation, urinary retention, sedation, QT prolongation
• Interaction: MAOI avoid; SSRI/SNRI/tramadol serotonin risk; glaucoma/BPH/arrhythmia caution

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15. Tramadol

• Generic name: Tramadol Hydrochloride
• Therapeutic category: Opioid analgesic
• Pharmacological class: Weak μ-opioid agonist + SNRI-like action
• বাংলাদেশি Brand: MedEx-listed tramadol brands available; common use moderate–severe pain-এ
• কেন used হয়: Acute severe pain; NSAID contraindicated/ineffective হলে short rescue
• Dose: 50–100 mg every 4–6 hourly PRN; max 400 mg/day
• Duration: 3–5 days only
• Side effect: Nausea, vomiting, constipation, dizziness, sedation, dependence, seizure
• Interaction: Alcohol/benzodiazepine/opioid avoid; SSRI/SNRI/TCA → serotonin syndrome; epilepsy caution
• Guideline note: Weak opioid acute low back pain-এ শুধু NSAID contraindicated/not tolerated/ineffective হলে consider। Chronic pain-এ opioid avoid।

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16. Paracetamol + Tramadol

• Generic name: Paracetamol + Tramadol Hydrochloride
• Therapeutic category: Combination analgesic
• Pharmacological class: Non-opioid analgesic + weak opioid
• বাংলাদেশি Brand: Aceta-T 325/37.5 mg, Anadol Plus 325/37.5 mg, Atopen-X 325/37.5 mg
• কেন used হয়: Acute severe breakthrough back pain
• Dose: 1 tablet 6–8 hourly PRN; max 8 tab/day
• Duration: ≤5 days
• Side effect: Sedation, nausea, constipation, liver toxicity if overdose
• Interaction: Extra paracetamol avoid; alcohol/sedative/opioid avoid

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17. Methylprednisolone Acetate Injection

• Generic name: Methylprednisolone Acetate
• Therapeutic category: Corticosteroid anti-inflammatory
• Pharmacological class: Glucocorticoid
• বাংলাদেশি Brand: Medrol 40 mg/ml, Medrol 80 mg/2 ml, Methsolon 40 mg/ml, Uni-Medrol 80 mg/2 ml
• কেন used হয়: Severe acute radicular pain/sciatica-তে epidural steroid injection—specialist procedure
• Dose: Specialist decides; self-use নয়
• Duration: Single/limited injection protocol
• Side effect: Hyperglycemia, infection risk, flushing, adrenal suppression
• Interaction: Diabetes, infection, anticoagulant, immunosuppression caution
• Guideline note: NICE acute severe sciatica-তে epidural local anaesthetic + steroid consider করতে বলে; low back pain alone-এ spinal injection নয়।

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18. Triamcinolone Acetonide Injection

• Generic name: Triamcinolone Acetonide
• Therapeutic category: Corticosteroid anti-inflammatory
• Pharmacological class: Glucocorticoid
• বাংলাদেশি Brand: Alfacort 40 mg/ml, Cenolon 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml, Intracort 40 mg/ml
• কেন used হয়: Severe radicular pain/sciatica-তে epidural/local steroid option—specialist procedure
• Dose: Specialist decides; self-use নয়
• Duration: Single/limited injection protocol
• Side effect: Hyperglycemia, infection, flushing, local pain, adrenal suppression
• Interaction: Diabetes, anticoagulant, infection, immunosuppression caution

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Prescription shortcut list — Doctorরা সাধারণত group-wise যেভাবে লেখেন

1. Pain only: Paracetamol ± NSAID
2. Inflammatory/mechanical pain: Aceclofenac / Diclofenac / Naproxen / Ibuprofen / Etoricoxib + PPI
3. Muscle spasm: Tolperisone বা Tizanidine
4. Radicular burning pain/numbness: Pregabalin বা Gabapentin — selected case only
5. Chronic neuropathic pain + sleep issue: Amitriptyline
6. Chronic pain + mood/anxiety overlap: Duloxetine
7. Acute severe pain: Tramadol বা Paracetamol + Tramadol, very short course
8. Severe acute sciatica: Epidural steroid injection by specialist only

Core rule: একসাথে ২টা NSAID দেবেন না; NSAID + steroid/anticoagulant দিলে GI bleed risk বাড়ে; pregabalin/gabapentin/tramadol একসাথে দিলে sedation/respiratory depression risk বাড়ে।

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16. Reference List — Textbook + Guideline + DOI

Textbooks

1. Harrison’s Principles of Internal Medicine, 21st ed. Section: Back and Neck Pain.
2. Davidson’s Principles and Practice of Medicine, 24th ed. Section: Musculoskeletal pain / low back pain.
3. Campbell’s Operative Orthopaedics, 14th ed. Spine section: Spondylolysis and Spondylolisthesis.
4. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Bone/joint degeneration and musculoskeletal pathology sections.
5. Guyton and Hall Textbook of Medical Physiology, 14th ed. Pain pathways and muscle physiology sections.

Guidelines

1. NICE NG59 — Low back pain and sciatica in over 16s: assessment and management.
2. North American Spine Society — Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis.

Peer-reviewed articles with DOI

1. Li N, et al. Spondylolisthesis. Orthopedic Reviews. 2022;14(3). DOI: 10.52965/001c.36917.
2. Weinstein JN, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. New England Journal of Medicine. 2007. DOI: 10.1056/NEJMoa070302.
3. Austevoll IM, et al. Decompression with or without fusion in degenerative lumbar spondylolisthesis. New England Journal of Medicine. 2021. DOI: 10.1056/NEJMoa2100990.

Md.Rafiqul Islam Lipu,Date:-12-06-2026 Friday Time:-10-12-11 Am