Raiyyan Tahsan

Raiyyan Tahsan
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TC(1044).(05).Orthopedics Case No 122:- Lumbar radiculopathy

Lumbar Radiculopathy — বাংলা Clinical Note

Prescription safety note: নিচের doseগুলো adult, non-pregnant patient ধরে লেখা। CKD, CLD, peptic ulcer, CAD/HF, uncontrolled HTN, anticoagulant use, pregnancy/lactation, elderly patient—এ dose/choice পরিবর্তন হবে। Bangladesh brand availability পরিবর্তনশীল; নিচে MedEx-listed verified common examples দেওয়া হলো, generic-based prescribing সবচেয়ে নিরাপদ।

1) Definition / সংজ্ঞা

Lumbar radiculopathy হলো lumbar/lumbosacral nerve root-এর compression, irritation বা inflammation-এর কারণে কোমর/নিতম্ব থেকে পায়ে dermatomal distribution-এ ব্যথা, ঝিনঝিনি, numbness, weakness বা reflex কমে যাওয়ার clinical syndrome। সাধারণ ভাষায় একে অনেক সময় sciatica বলা হয়, তবে sciatica সাধারণত L4–S1 root irritation-এর leg-radiating pain বোঝায়। Disc herniation, spondylosis, osteophyte ও spinal/foraminal stenosis common cause।

2) Causes / কারণ — বাংলায় point আকারে

A. Mechanical / Degenerative কারণ

  • Lumbar disc herniation / prolapse
    • Disc-এর nucleus pulposus posterior/posterolateral দিকে বের হয়ে nerve root চাপ দেয়।
    • L4–L5 ও L5–S1 level সবচেয়ে common।
    • Young-to-middle age patient-এ acute radicular pain-এর common cause।
  • Degenerative spondylosis / osteophyte
    • বয়সের সাথে disc height কমে, facet joint arthropathy ও osteophyte তৈরি হয়।
    • Foraminal narrowing হয়ে exiting nerve root compress করতে পারে।
  • Lumbar spinal canal stenosis
    • Central canal বা lateral recess সংকুচিত হয়।
    • Elderly patient-এ common।
    • হাঁটলে pain/numbness বাড়ে, বসলে বা forward bending করলে কমে—এটা neurogenic claudication।
  • Spondylolisthesis
    • একটি vertebra অন্যটির উপর slip করে।
    • Nerve root stretch/compression হতে পারে।
  • Facet cyst / synovial cyst
    • Degenerative facet joint থেকে cyst হয়ে nerve root compress করতে পারে।

B. Traumatic কারণ

  • Fall, heavy lifting injury, vertebral fracture, traumatic disc extrusion।
  • Osteoporotic vertebral compression fracture থাকলে elderly patient-এ radicular pain হতে পারে।

C. Inflammatory / Infective / Neoplastic কারণ — red flag

  • Spinal infection: discitis, vertebral osteomyelitis, epidural abscess।
  • Tumor/metastasis: breast, lung, prostate, kidney, thyroid malignancy থেকে vertebral metastasis।
  • Inflammatory spondyloarthritis: ankylosing spondylitis-type inflammatory back pain।
  • NICE guideline অনুযায়ী cancer, infection, trauma, inflammatory disease—এসব serious cause সবসময় screen করতে হবে।

D. Metabolic / Neuropathic mimic

  • Diabetes-related radiculoplexopathy।
  • Herpes zoster radiculitis।
  • Peripheral neuropathy বা peroneal neuropathy radiculopathy mimic করতে পারে।

3) Symptoms / লক্ষণ — Bangla point আকারে

Main symptoms

  • কোমর থেকে পায়ে ছড়িয়ে যাওয়া ব্যথা
    • Buttock → thigh → calf → foot পর্যন্ত যেতে পারে।
    • Pain nature: shooting, electric shock-like, burning, sharp।
  • Dermatomal pain
    • নির্দিষ্ট nerve root অনুযায়ী pain/numbness যায়।
    • যেমন L5 হলে lateral leg ও dorsum of foot; S1 হলে posterior calf ও lateral foot।
  • Numbness / tingling / pins-and-needles
    • পায়ে ঝিনঝিনি, অবশভাব, burning sensation।
  • Weakness
    • L4: knee extension বা ankle dorsiflexion weakness।
    • L5: great toe extension weakness, heel walking difficulty।
    • S1: plantar flexion weakness, toe walking difficulty।
  • Reflex কমে যাওয়া
    • L4: knee jerk কমে।
    • S1: ankle jerk কমে।
  • Cough/sneeze/straining-এ pain বাড়া
    • Disc herniation-এ common, কারণ intrathecal pressure বাড়ে।
  • Sitting বা forward bending-এ pain pattern
    • Disc pain অনেক সময় sitting-এ বাড়ে।
    • Spinal stenosis-এ walking/standing-এ বাড়ে, sitting বা flexion-এ কমে।

Root-wise clinical pattern

Nerve rootPain / sensory areaMotor weaknessReflex
L2Anterior thighHip flexionUsually no reliable reflex
L3Anterior thigh, medial kneeKnee extensionPatellar reflex may reduce
L4Medial leg, medial ankleKnee extension, ankle dorsiflexionKnee jerk ↓
L5Lateral leg, dorsum foot, great toeGreat toe extension, ankle dorsiflexionNo classic deep tendon reflex
S1Posterior calf, lateral foot/solePlantar flexionAnkle jerk ↓

Emergency red flag symptoms

  • New urinary retention বা urinary incontinence।
  • Saddle anesthesia।
  • Bilateral leg weakness/numbness।
  • Progressive motor weakness বা foot drop।
  • Fever, severe night pain, unexplained weight loss।
  • Cancer history।
  • Recent trauma।
  • Immunosuppression/IV drug use।
  • These suggest cauda equina, infection, malignancy বা fracture—urgent MRI/referral দরকার।

4) Clinical Diagnosis / Clinically কীভাবে diagnosis করবেন

Lumbar radiculopathy primarily clinical diagnosis—history + neurological examination। Imaging clinical findings-এর সাথে match করলেই অর্থপূর্ণ; incidental disc bulge অনেক asymptomatic patient-এও থাকতে পারে।

A. History

  • Pain onset: acute after lifting/twisting, gradual degenerative, trauma।
  • Pain radiation: back → buttock → leg → foot?
  • Pain below knee গেলে radiculopathy probability বাড়ে।
  • Exacerbating factors: cough, sneeze, sitting, walking।
  • Neurological symptoms: numbness, weakness, gait difficulty।
  • Bladder/bowel/sexual dysfunction।
  • Constitutional symptoms: fever, weight loss, night pain।
  • Past history: malignancy, TB, diabetes, steroid use, anticoagulant, osteoporosis।

B. Physical examination

  • Inspection: posture, scoliosis, antalgic gait।
  • Gait test: heel walk = L5; toe walk = S1।
  • SLR / Lasègue test
    • Supine patient-এ straight leg raise 30–70° এ radiating pain below knee হলে positive।
    • Disc herniation-related L4–S1 radiculopathy-এ useful।
  • Crossed SLR
    • Opposite leg raise করলে affected leg pain—disc herniation-এর জন্য more specific।
  • Slump test
    • Neural tension test; SLR equivocal হলে helpful।
  • Femoral nerve stretch test
    • L2–L4 radiculopathy সন্দেহে।
  • Motor exam
    • Hip flexion, knee extension, ankle dorsiflexion, great toe extension, plantar flexion।
  • Sensory exam
    • Dermatome অনুযায়ী light touch/pinprick।
  • Reflex
    • Knee jerk L3–L4, ankle jerk S1।
  • Cauda equina screen
    • Saddle sensation, anal tone, urinary retention suspicion হলে urgent assessment।

5) Investigations / Specific investigation

A. When imaging দরকার নয়

  • Acute uncomplicated low back pain/radicular pain-এ routine X-ray/MRI করা উচিত নয় যদি red flag বা progressive neurological deficit না থাকে। NICE guideline non-specialist setting-এ routine imaging না করতে বলেছে।

B. MRI lumbosacral spine — investigation of choice

Indications:

  • Severe/progressive neurological deficit।
  • Foot drop।
  • Cauda equina symptoms।
  • Infection/tumor/fracture red flag।
  • Conservative treatment 4–6 weeks পরেও disabling radicular pain persist করলে।
  • Epidural injection বা surgery plan করলে।
  • Recurrent/post-operative radicular pain—contrast MRI লাগতে পারে।

MRI report-এ specifically দেখবেন:

  • Level: L3–L4, L4–L5, L5–S1।
  • Disc bulge/protrusion/extrusion/sequestration।
  • Central canal stenosis, lateral recess stenosis, foraminal stenosis।
  • Nerve root compression—clinical side/dermatome-এর সাথে match করছে কিনা।
  • Spondylolisthesis, facet arthropathy।
  • Infection/tumor signs।

C. X-ray lumbosacral spine

Routine radiculopathy diagnosis-এর জন্য low yield, তবে useful যদি:

  • Trauma।
  • Suspected fracture।
  • Spondylolisthesis।
  • Deformity।
  • Chronic mechanical back pain।
  • Flexion-extension view instability দেখার জন্য।

D. CT / CT myelogram

  • MRI contraindicated হলে।
  • Bony foraminal stenosis/osteophyte detail দেখতে।
  • Post-surgical complex anatomy।

E. EMG/NCS

  • Diagnosis unclear হলে।
  • MRI finding ও clinical picture mismatch করলে।
  • Radiculopathy vs peripheral neuropathy/peroneal neuropathy/plexopathy differentiate করতে।
  • Usually symptom onset-এর 3–4 weeks পর বেশি useful।

F. Laboratory tests — selective

Testকখন করবেন
CBC, ESR, CRPInfection, malignancy, inflammatory disease suspicion
Fasting glucose/HbA1cDiabetes/neuropathy suspicion
Serum creatinine/eGFRNSAID শুরু করার আগে high-risk patient
LFTDuloxetine, chronic medication, systemic illness
Calcium, Vitamin D, ALPOsteoporosis/metabolic bone disease suspicion
Urine R/ERenal/urinary mimic pain suspicion
HLA-B27Inflammatory back pain/spondyloarthritis suspicion

6) Differential Diagnosis

  • Hip osteoarthritis।
  • Sacroiliac joint dysfunction।
  • Piriformis/deep gluteal syndrome।
  • Peripheral neuropathy।
  • Common peroneal neuropathy।
  • Diabetic lumbosacral radiculoplexus neuropathy।
  • Vascular claudication/PAD।
  • Herpes zoster radiculitis।
  • Renal colic।
  • Epidural abscess।
  • Spinal malignancy/metastasis।
  • Cauda equina syndrome।

7) Complications / রোগের জটিলতা — বাংলায় বুঝিয়ে

  • Chronic neuropathic pain
    • nerve root দীর্ঘদিন irritate হলে pain chronic হয়ে যায়; burning/shooting pain persistent হতে পারে।
  • Motor weakness
    • untreated compression থাকলে foot drop, toe walking/heel walking difficulty হতে পারে।
  • Muscle wasting
    • দীর্ঘদিন nerve supply কম থাকলে affected muscle atrophy হতে পারে।
  • Sensory loss
    • পায়ে numbness থাকলে injury/fall risk বাড়ে।
  • Functional disability
    • হাঁটা, বসা, কাজ, ঘুম—সবকিছুতে সমস্যা হয়; productivity কমে।
  • Psychological impact
    • chronic pain থেকে anxiety, depression, sleep disturbance হতে পারে।
  • Cauda equina syndrome
    • severe central disc prolapse হলে bladder/bowel dysfunction, saddle anesthesia, sexual dysfunction হতে পারে—এটি neurosurgical emergency।
  • Drug-related complications
    • NSAID → gastritis, GI bleeding, renal injury, BP বাড়া।
    • Pregabalin/gabapentin → sedation, dizziness, fall risk, dependence risk।
    • Opioid/tramadol → dependence, constipation, sedation, respiratory depression risk।

8) Treatment / Management

A. Non-pharmacological management — first-line

  • Patient education: majority acute radiculopathy conservative treatment-এ improve করে।
  • Bed rest avoid; tolerable activity continue।
  • Heavy lifting, forward bending, twisting temporarily avoid।
  • Heat therapy short-term pain relief দিতে পারে।
  • Physiotherapy:
    • McKenzie/extension-based exercise, যদি extension preference থাকে।
    • Core stabilization।
    • Neural mobilization।
    • Hip/gluteal strengthening।
    • Hamstring stretching।
  • Manual therapy only exercise package-এর অংশ হিসেবে।
  • Early return to work/normal activity encourage।
  • Weight reduction, smoking cessation।
  • Red flag থাকলে immediate referral।

NICE guideline self-management, normal activity, exercise, and selected manual therapy as part of package support করে; traction recommend করে না।

9) Pharmacological Treatment — Drug list with Bangladesh brands

Important prescribing principles

  • একসাথে দুই NSAID দেবেন না — যেমন diclofenac + naproxen একসাথে নয়।
  • NSAID দিলে high-risk patient-এ PPI consider করবেন।
  • Pregabalin ও gabapentin একসাথে নয়।
  • Tramadol/opioid chronic sciatica-তে avoid।
  • NICE sciatica-তে gabapentinoids, oral corticosteroids, benzodiazepines routine use discourage করেছে due to limited benefit and harm risk।
  • NSAID use করলে lowest effective dose, shortest duration, GI/renal/CV risk assess করতে হবে।

9.1 Paracetamol

  1. Generic name: Paracetamol / Acetaminophen
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
  4. Bangladesh available brand examples: Napa 500 mg, Napa Rapid 500 mg, Ace 500 mg, Ace XR 665 mg, Ace 1000 mg, Feva Rapid 500 mg, Feva One 1000 mg, Fevac 500 mg। MedEx lists Napa/Ace/Feva preparations as available brands.

Dose: 500–1000 mg orally every 6–8 hours PRN। Practical max 3 g/day; selected low-risk adult-এ absolute max 4 g/day, but liver risk থাকলে কম। FDA acetaminophen total daily dose 4000 mg-এর বেশি না নিতে বলে।
Duration: 3–7 days PRN।
কেন used হয়: Mild–moderate nociceptive back pain relief; NSAID contraindicated হলে adjunct।
Side effects: Usually safe; overdose → severe hepatotoxicity; rash rare।
Interactions: Alcohol, warfarin long-term use, enzyme-inducing antiepileptics; cold/flu medicine-এ duplicate paracetamol avoid।
Clinical note: Radicular neuropathic pain-এ alone usually insufficient; NICE low back pain-এ paracetamol alone recommend করে না।

9.2 NSAIDs — inflammatory radicular pain কমাতে

A. Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Propionic acid derivative NSAID; non-selective COX inhibitor
  4. Bangladesh brand examples: Advel 400 mg, Flamex 400 mg, Profen 400 mg, Reumafen 400 mg। MedEx ibuprofen page NSAID therapeutic class, backache/muscular pain indication, contraindication ও side effect list করে।

Dose: 400 mg orally 2–3 times daily after food।
Duration: 3–5 days; severe acute pain হলে 7 days পর্যন্ত reassess সহ।
Purpose: Nerve root inflammation-associated pain, acute flare।
Side effects: Dyspepsia, gastritis, GI ulcer/bleeding, renal impairment, edema, BP rise, bronchospasm।
Interactions: Anticoagulants/antiplatelets, SSRI/SNRI, steroid, ACEI/ARB + diuretic, lithium, methotrexate।
Avoid: Active peptic ulcer, severe CKD, decompensated HF, uncontrolled HTN, aspirin-sensitive asthma, 3rd trimester pregnancy।

B. Naproxen

  1. Generic name: Naproxen / Naproxen sodium
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Propionic acid derivative NSAID
  4. Bangladesh brand examples: Naprosyn 500 mg; Releve 500 mg। MedEx lists Naprosyn 500 mg and NSAID class.

Dose: 250–500 mg orally twice daily after food।
Duration: 5–10 days with review।
Purpose: Longer-acting NSAID; acute radicular inflammatory pain।
Side effects/interactions: NSAID class effects—GI bleed, renal injury, BP/CV risk; anticoagulant/ACEI/ARB/diuretic/lithium/methotrexate interaction।
Clinical note: One NSAID at a time only।

C. Diclofenac

  1. Generic name: Diclofenac sodium/potassium
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Acetic acid derivative NSAID; non-selective COX inhibitor
  4. Bangladesh brand examples: Diclofen 25 mg, Diclofen 50 mg, Diclofen SR 100 mg, Diclomol SR 100 mg, Ultrafen SR 100 mg, DCF 50 mg, Diclofen Gel 1%, Diclofen IM 75 mg/3 ml। MedEx lists these diclofenac brands/strengths.

Dose: 50 mg orally 2–3 times daily after food or SR 100 mg once daily।
Duration: 3–5 days; avoid prolonged unsupervised use।
Purpose: Acute severe inflammatory back/radicular pain।
Side effects: GI ulcer/bleeding, renal injury, edema, BP rise; diclofenac has relatively higher CV concern than some NSAIDs।
Interactions: Anticoagulants, antiplatelets, steroid, SSRI/SNRI, ACEI/ARB + diuretic, lithium, methotrexate।
Clinical note: IM diclofenac repeated use avoid; renal/GI/CV risk assess করুন।

D. Aceclofenac

  1. Generic name: Aceclofenac
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Phenylacetic acid derivative NSAID
  4. Bangladesh brand examples: Flexi 100 mg, Flexi SR 200 mg, Movex 100 mg, Movex SR 200 mg, Reservix 100 mg, Ternilla 100 mg। MedEx lists these brands and NSAID class/interactions.

Dose: 100 mg orally twice daily after food।
Duration: 5–7 days।
Purpose: Pain + inflammation control।
Side effects: Dyspepsia, abdominal pain, GI ulcer/bleed, renal impairment, edema।
Interactions: Lithium, digoxin, diuretics, anticoagulants, methotrexate; NSAID hypersensitivity/peptic ulcer caution।

E. Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Selective COX-2 inhibitor
  4. Bangladesh brand examples: Setorib 60 mg/90 mg/120 mg, Torcox 60 mg/90 mg/120 mg। MedEx lists these etoricoxib brands/strengths.

Dose: 60–90 mg orally once daily।
Duration: 5–7 days; shortest duration।
Purpose: Pain/inflammation; GI intolerance history থাকলে sometimes preferred, but CV risk assess essential।
Side effects: Edema, hypertension, renal impairment, dyspepsia, increased CV thrombotic risk।
Interactions: Warfarin/anticoagulants, ACEI/ARB/diuretic, lithium, methotrexate।
Avoid/caution: IHD, stroke history, uncontrolled HTN, HF, CKD, pregnancy।

9.3 PPI — NSAID gastroprotection

Pantoprazole / Esomeprazole

  1. Generic name: Pantoprazole / Esomeprazole
  2. Therapeutic category: Anti-ulcerant
  3. Pharmacological class: Proton pump inhibitor
  4. Bangladesh brand examples: Pantoprazole—Pantoprox 20 mg; Esomeprazole—Sompraz 40 mg, S-Ome 20 mg। MedEx lists pantoprazole/esomeprazole as PPI preparations and NSAID-induced ulcer indication.

Dose: Pantoprazole 20–40 mg once daily before breakfast or Esomeprazole 20–40 mg once daily।
Duration: NSAID course চলাকালীন 5–14 days; high GI risk হলে longer physician-supervised।
কেন used হয়: NSAID-induced gastritis/ulcer/bleeding risk কমাতে।
Side effects: Headache, diarrhea/constipation, nausea; long-term use → hypomagnesemia, B12 deficiency, fracture risk।
Interactions: Clopidogrel interaction concern especially omeprazole/esomeprazole; ketoconazole/itraconazole absorption কমতে পারে।

9.4 Skeletal Muscle Relaxants — paraspinal spasm থাকলে

A. Tolperisone

  1. Generic name: Tolperisone hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Centrally acting skeletal muscle relaxant
  4. Bangladesh brand examples: A-Calm 50 mg, Mexaton 50 mg, Musclex 50 mg, Mydocalm 50 mg, Myolax 50/100 mg, Myoson 50/100 mg, Tolmus 50 mg, Tolson 50/100 mg, Toperin 50 mg। MedEx lists adult dose, therapeutic class and brands.

Dose: 50–150 mg orally three times daily after meal।
Duration: 5–7 days।
কেন used হয়: Muscle spasm-associated back pain কমাতে; nerve compression cure করে না।
Side effects: Weakness, headache, nausea/vomiting, rare hypersensitivity।
Interactions/contraindications: Myasthenia gravis, hypersensitivity, nursing mother; methocarbamol with tolperisone visual accommodation problem করতে পারে।

B. Tizanidine

  1. Generic name: Tizanidine hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Centrally acting α2-adrenergic agonist skeletal muscle relaxant
  4. Bangladesh brand examples: Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg, Relentus 2 mg। MedEx lists these tizanidine 2 mg brands.

Dose: 2 mg at night initially; if needed 2–4 mg three times daily।
Duration: 3–7 days; elderly/renal impairment-এ low dose।
কেন used হয়: Painful lumbar muscle spasm; sleep-disturbing spasm।
Side effects: Somnolence, dizziness, dry mouth, hypotension, bradycardia, fatigue, transaminase rise।
Interactions: Ciprofloxacin/fluvoxamine contraindicated; alcohol, benzodiazepines, opioids → sedation; antihypertensives → hypotension/bradycardia। MedEx tizanidine page CYP1A2 inhibitor interaction and dose cautions list করে।

9.5 Neuropathic pain medicines — burning/shooting pain dominant হলে

Guideline caveat: NICE sciatica-তে gabapentinoids routine recommend করে না, কারণ overall benefit কম এবং harm risk আছে। তবে Bangladesh clinical practice-এ selected severe neuropathic phenotype বা sleep-disturbing radiating pain-এ physician-supervised short trial দেখা যায়।

A. Pregabalin

  1. Generic name: Pregabalin
  2. Therapeutic category: Neuropathic pain agent; antiepileptic
  3. Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
  4. Bangladesh brand examples: Egaba 25/50/75/100 mg, GABA-P 25/50/75 mg, Gabarol 25/50/75/100/150 mg, Lirica 25/50/75 mg, Lyric 25/50/75/150 mg, Pregaben 50/75/150 mg, Pregabid 25/50/75 mg, Prelin 50/75/150 mg। MedEx lists these pregabalin brands.

Dose: 50–75 mg at night initially or 75 mg twice daily; titrate to 150–300 mg/day according to response। Max 600 mg/day selected cases, renal dose adjustment mandatory।
Duration: Trial 2–4 weeks; effective হলে reassess; stop করতে হলে at least 1 week taper। Incepta/MedEx-type dosing information notes 150 mg/day start and titration to 300–600 mg/day.
কেন used হয়: Burning, electric shock-like neuropathic leg pain; sleep disturbance।
Side effects: Dizziness, somnolence, blurred vision, edema, weight gain, mood change/suicidal ideation, dependence/withdrawal risk। MedEx Lirica page lists sleepiness, vision issue, mood/depression warning and weight gain.
Interactions: Alcohol, benzodiazepines, opioids, sedatives → CNS depression/fall risk; renal impairment-এ dose কমাতে হবে।
Avoid: Combine with gabapentin নয়; driving/machinery caution।

B. Gabapentin

  1. Generic name: Gabapentin
  2. Therapeutic category: Neuropathic pain agent; antiepileptic
  3. Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
  4. Bangladesh brand examples: Gabapen 100/300 mg, Gabastar 100/300 mg, Gabantin 100/300 mg, Gabahil 100/300 mg, Gabamax 300 mg, Gpentin 300 mg, Nepsy 300 mg, Neuropen 300 mg, Neurotin 300 mg, Gaba 300 mg। MedEx lists these gabapentin brands.

Dose: 100–300 mg at night initially; titrate to 300 mg three times daily। Usual neuropathic range 900–3600 mg/day in divided doses।
Duration: 2–4 week trial; discontinue by gradual taper।
কেন used হয়: Neuropathic radiating pain, paresthesia, sleep disturbance।
Side effects: Dizziness, sedation, ataxia, edema, weight gain, cognitive slowing।
Interactions: Alcohol, opioids, benzodiazepines → sedation/respiratory depression risk; antacid may reduce absorption; renal dose adjustment।
Clinical note: Pregabalin-এর সাথে একসাথে নয়। MedEx describes gabapentin as used for neuropathic pain and adjunct seizure therapy.

C. Amitriptyline

  1. Generic name: Amitriptyline
  2. Therapeutic category: Antidepressant; neuropathic pain modulator
  3. Pharmacological class: Tricyclic antidepressant
  4. Bangladesh brand examples: Amilin 10/25 mg, Amit 10/25 mg, Amitip 10/25 mg, Amtylin 10/25 mg, Reptylin 10/25 mg, Tryptin 10/25 mg। MedEx lists these amitriptyline brands and TCA class.

Dose: 10–25 mg at night; titrate slowly to 25–75 mg at night if needed/tolerated।
Duration: Chronic neuropathic pain হলে 4–6 week trial; taper when stopping।
কেন used হয়: Chronic neuropathic pain + insomnia; selected patient।
Side effects: Dry mouth, constipation, urinary retention, blurred vision, sedation, weight gain, orthostatic hypotension, QT prolongation/arrhythmia।
Interactions: Alcohol/opioid/benzodiazepine sedation; MAOI contraindicated; QT-prolonging drugs; SSRI/SNRI may increase serotonin/CNS effects।
Avoid/caution: Recent MI, arrhythmia, heart block, narrow-angle glaucoma, BPH/urinary retention, elderly fall risk।

D. Duloxetine

  1. Generic name: Duloxetine
  2. Therapeutic category: Antidepressant; neuropathic/chronic pain agent
  3. Pharmacological class: SNRI
  4. Bangladesh brand examples: Deloxi 20/60 mg, Diliner DR 20/30/60 mg, Dulox 20/30 mg, Duloxen 20/30/60 mg, Duzela 20 mg, Loxetine 20/30 mg, Stresin 20/30 mg, Xinolax DR 20/30/60 mg। MedEx lists these duloxetine brands.

Dose: 30 mg once daily for 1 week, then 60 mg once daily।
Duration: 4–6 week trial; continue only if benefit।
কেন used হয়: Chronic neuropathic pain with depression/anxiety features; chronic musculoskeletal pain phenotype।
Side effects: Nausea, dry mouth, sweating, insomnia/somnolence, BP rise, sexual dysfunction, withdrawal symptoms।
Interactions: MAOI contraindicated; tramadol/SSRI/SNRI/linezolid → serotonin syndrome risk; alcohol/hepatic disease caution।
Clinical note: Duloxetine is an SNRI; MedEx describes serotonin/norepinephrine reuptake inhibition.

9.6 Tramadol / weak opioid — severe acute pain only

A. Tramadol

  1. Generic name: Tramadol hydrochloride
  2. Therapeutic category: Opioid analgesic
  3. Pharmacological class: Weak μ-opioid receptor agonist + serotonin/norepinephrine reuptake inhibitor
  4. Bangladesh brand examples: Tramadol 50 mg, Lucidol 50 mg capsule/100 mg/2 ml injection, Utramal 50 mg capsule/100 mg suppository/100 mg/2 ml injection, Winpain 50 mg capsule/100 mg/2 ml injection, Trado 50 mg capsule/100 mg/2 ml injection, Syndol 50 mg capsule/100 mg/2 ml injection, Tramamax 50 mg tablet। MedEx lists these tramadol brands/strengths.

Dose: 50 mg orally every 6–8 hours PRN; max 400 mg/day।
Duration: 3–5 days only; chronic use avoid।
কেন used হয়: Severe acute pain when NSAID contraindicated, not tolerated, or insufficient।
Side effects: Nausea, vomiting, constipation, dizziness, sedation, dependence, seizure risk, serotonin syndrome।
Interactions: Alcohol, benzodiazepines, opioids, sedatives; SSRI/SNRI/TCA/MAOI; CYP2D6/CYP3A4 inhibitors/inducers।
Guideline note: NICE chronic sciatica-তে opioid avoid করতে বলে।

B. Paracetamol + Tramadol combination

  1. Generic name: Paracetamol 325 mg + Tramadol 37.5 mg
  2. Therapeutic category: Analgesic combination
  3. Pharmacological class: Non-opioid analgesic + weak opioid
  4. Bangladesh brand examples: Aceta-T 325/37.5 mg, Anadol Plus 325/37.5 mg, P-Dol 325/37.5 mg, Pangesic 325/37.5 mg, Renova T 325/37.5 mg, Resadol 325/37.5 mg, Syndol Plus 325/37.5 mg, Trado Plus 325/37.5 mg, Tramatol 325/37.5 mg। MedEx lists these combination brands.

Dose: 1 tablet every 6–8 hours PRN; max paracetamol daily limit হিসাব করতে হবে।
Duration: ≤5 days।
Purpose: Short-term moderate–severe acute pain।
Side effects/interactions: Tramadol + paracetamol দুটির adverse effects; duplicate paracetamol avoid।

9.7 Corticosteroid — routine নয়

Methylprednisolone / oral steroid

  1. Generic name: Methylprednisolone
  2. Therapeutic category: Corticosteroid
  3. Pharmacological class: Glucocorticoid anti-inflammatory
  4. Bangladesh brand examples: Medrol 4/16 mg, Melpred 2/4/8/16 mg, Mepcort 4/8/16 mg, Mepred 4/8 mg, Methigic 4/8 mg। MedEx lists these methylprednisolone brands.

Use: Routine lumbar radiculopathy/sciatica-তে oral steroid recommended নয়।
Why sometimes used: Severe acute inflammatory radicular flare-এ কিছু physician short taper দেন, কিন্তু evidence pain improvement strong নয়। JAMA trial-এ oral prednisone acute radiculopathy due to herniated disc-এ function modestly improve করলেও pain improve করেনি।
Side effects: Hyperglycemia, gastritis, mood change, insomnia, fluid retention, BP rise, infection risk।
Interactions: NSAID → GI bleed risk; warfarin; diabetes medicines; live vaccine caution।
Clinical note: Diabetes, infection, peptic ulcer, uncontrolled HTN, psychiatric history—caution।

Epidural steroid injection

  • Indication: Acute severe sciatica with imaging-correlated nerve root compression, conservative treatment inadequate, specialist setting।
  • NICE acute severe sciatica-তে epidural local anaesthetic + steroid consider করতে বলে।
  • Complications: dural puncture headache, bleeding, infection, transient neurological symptoms, hyperglycemia।

9.8 Vitamin B-complex / Neurotropic vitamin — supportive only

  1. Generic name: Thiamine B1 + Pyridoxine B6 + Cyanocobalamin B12
  2. Therapeutic category: Vitamin preparation
  3. Pharmacological class: Combined neurotropic vitamin
  4. Bangladesh brand examples: Neuro-B 100 mg + 200 mg + 200 mcg। MedEx lists Neuro-B composition, indication including neuralgia/lumbago/sciatica, and therapeutic class.

Dose: 1 tablet 1–3 times daily after meal।
Duration: 2–4 weeks; deficiency থাকলে longer।
কেন used হয়: B-vitamin deficiency, neuritis-like symptoms, adjunct; mechanical compression cure করে না।
Side effects: Usually well tolerated; allergic reaction rare; chronic high-dose B6 neuropathy করতে পারে।
Interactions: Levodopa without carbidopa/benserazide-এর সাথে pyridoxine interaction; MedEx levodopa therapy contraindication/caution উল্লেখ করে।

10) Bangladesh doctors’ common prescription pattern — কেন কোন drug দেন

নিচেরগুলো common clinical patterns, universal rule নয়।

  1. NSAID + PPI
    • Example: Naproxen/Diclofenac/Aceclofenac/Etoricoxib + Pantoprazole।
    • কেন: Acute inflammatory radicular pain কমানো + gastric protection।
  2. NSAID + muscle relaxant
    • Example: Aceclofenac + Tolperisone / Tizanidine।
    • কেন: Pain-এর সাথে paraspinal muscle spasm থাকলে।
  3. Pregabalin or Gabapentin
    • কেন: Burning/electric shock-like leg pain, paresthesia, night pain।
    • Caution: Routine sciatica-তে guideline-supported নয়; sedation/dependence/renal dose issue।
  4. Paracetamol ± Tramadol
    • কেন: Severe acute pain, NSAID contraindicated/insufficient হলে short-term rescue।
    • Caution: Tramadol dependence, sedation, serotonin syndrome risk।
  5. Amitriptyline/Duloxetine
    • কেন: Chronic neuropathic pain phenotype, poor sleep, depression/anxiety overlap।
    • Caution: Cardiac/anticholinergic effect, serotonin interaction।
  6. Oral steroid
    • কেন: কিছু clinician severe acute radicular flare-এ short course দেন।
    • Evidence caution: Pain benefit limited; routine use guideline-supported নয়।
  7. Epidural steroid injection
    • কেন: Acute severe sciatica, MRI-correlated compression, conservative treatment fail।
    • Setting: Spine/pain specialist।
  8. MRI + neurosurgery/orthopedic spine referral
    • কেন: Progressive weakness, foot drop, cauda equina, persistent disabling pain >4–6 weeks, or imaging-clinical match with failed conservative therapy।

11) Surgical / Interventional Management

Urgent surgical referral

  • Cauda equina syndrome।
  • Progressive motor deficit।
  • Severe foot drop।
  • Infection/abscess/tumor suspicion।
  • Uncontrolled severe pain with major neurological signs।

Elective surgery

  • MRI-confirmed disc herniation/stenosis correlating with symptoms।
  • Conservative management 6–12 weeks failed।
  • Persistent disabling radicular pain।
  • NICE decompression consider করতে বলে যখন non-surgical treatment fail করে এবং imaging symptoms-এর সাথে consistent।

Procedures

  • Microdiscectomy।
  • Laminectomy/decompression।
  • Foraminotomy।
  • Fusion only selected instability/spondylolisthesis cases।

12) Prevention / প্রতিরোধ

  • Regular core strengthening: abdominal, multifidus, gluteal strengthening।
  • Proper lifting technique: কোমর বাঁকিয়ে নয়; knee bend করে load body-এর কাছে রেখে ওঠা।
  • Long sitting avoid: প্রতি 30–45 মিনিটে দাঁড়ানো/হাঁটা।
  • Ergonomic chair: lumbar support, screen eye level।
  • Weight control: abdominal obesity disc load বাড়ায়।
  • Smoking cessation: disc degeneration risk কমাতে helpful।
  • Diabetes control: neuropathic pain overlap কমে।
  • Regular walking/swimming: low-impact aerobic exercise।
  • Sudden heavy lifting avoid: especially flexion + rotation posture।
  • Sleep posture: side-lying with pillow between knees or supine with knee support।
  • Early treatment: numbness/weakness শুরু হলে delay না করে evaluation।

Overview / Summary

Lumbar radiculopathy হলো lumbar nerve root compression/irritation-এর syndrome, যেখানে কোমর থেকে পায়ে dermatomal pain, numbness, weakness ও reflex loss হতে পারে। Common cause হলো disc herniation, spondylosis, foraminal stenosis ও spinal canal stenosis। Diagnosis মূলত clinical—history, SLR/crossed SLR, motor-sensory-reflex exam। MRI routine নয়; red flag, progressive deficit, persistent disabling symptoms, or procedure/surgery planning থাকলে MRI indicated। Management প্রথমে education, activity, physiotherapy, NSAID-based short course; selected patient-এ neuropathic pain medicine, short rescue analgesic, epidural injection বা surgery দরকার হতে পারে।

Actionable Plan / Steps

  1. Red flag screen করুন: bladder/bowel, saddle anesthesia, progressive weakness, fever, cancer, trauma।
  2. Root localization করুন: pain dermatome + motor + reflex।
  3. No red flag হলে: 2–6 weeks conservative management—activity, physiotherapy, NSAID ± PPI, short muscle relaxant if spasm।
  4. Neuropathic severe pain হলে: pregabalin/gabapentin/amitriptyline/duloxetine carefully select; sedation, renal dose, dependence risk explain করুন।
  5. MRI করুন যদি: foot drop/progressive deficit/red flag অথবা 4–6 weeks persistent disabling radicular pain।
  6. Specialist referral: cauda equina/progressive weakness urgent; persistent MRI-correlated radiculopathy elective spine referral।
  7. Prevention: core exercise, ergonomic correction, weight control, smoking cessation, safe lifting।

Reference List

Textbook references

  1. Harrison’s Principles of Internal Medicine, 21st ed. Section: Back and Neck Pain; radiculopathy/nerve root compression discussion.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Neurology section: spinal nerve root lesions and back pain.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Musculoskeletal/spine degenerative disease concepts.
  4. Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. NSAIDs, opioids, antidepressants, antiepileptic/gabapentinoid pharmacology.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Analgesics, anti-inflammatory drugs, opioids, antidepressants.

Guideline references

  1. NICE Guideline NG59. Low back pain and sciatica in over 16s: assessment and management. Published 2016, updated 2020.
  2. American College of Physicians Clinical Practice Guideline. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. Ann Intern Med. 2017. DOI: 10.7326/M16-2367.
  3. North American Spine Society guideline. Lumbar disc herniation with radiculopathy. Spine Journal. 2014;14(1):180–191. DOI: 10.1016/j.spinee.2013.08.003.

Peer-reviewed journal references with DOI

  1. Berry JA, Elia C, Saini HS, Miulli DE. A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus. 2019. DOI: 10.7759/cureus.5934.
  2. Goldberg H, Firtch W, Tyburski M, et al. Oral Steroids for Acute Radiculopathy Due to a Herniated Lumbar Disk. JAMA. 2015. DOI: 10.1001/jama.2015.4468.
  3. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018. DOI: 10.1016/S0140-6736(18)30489-6.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Wednesday,Time:-11-39-12 Am

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