Cervical Radiculopathy — বাংলায় ক্লিনিক্যালভাবে সাজানো নোট
Clinical note: নিচের dose গুলো সাধারণ adult dosing। রোগীর age, pregnancy status, renal/hepatic disease, peptic ulcer, HTN/CVD, diabetes, anticoagulant use, allergy—এসব দেখে prescription individualize করতে হবে। Progressive weakness, myelopathy, bowel/bladder symptom, fever/cancer history/night pain/weight loss থাকলে urgent referral/MRI দরকার।
1) Definition / সংজ্ঞা
Cervical radiculopathy হলো cervical spine-এর nerve root compression বা irritation/inflammation-এর কারণে ঘাড় থেকে কাঁধ–হাত–আঙুল পর্যন্ত dermatomal pain, numbness/tingling, muscle weakness, reflex change হওয়া। সাধারণত disc herniation বা degenerative foraminal stenosis এর কারণে হয়।
2) Etiology / Causes — কারণগুলো
A. Common causes
- Cervical disc herniation
- তরুণ/মধ্যবয়সীদের মধ্যে common।
- nucleus pulposus posterior-lateral দিকে বের হয়ে nerve root চাপ দেয়।
- acute neck movement, lifting, trauma বা repetitive strain-এর পর হতে পারে।
- Degenerative cervical spondylosis
- বয়স বাড়ার সাথে disc height কমে, uncovertebral/facet joint osteophyte তৈরি হয়।
- neural foramen narrow হয়ে nerve root compress করে।
- older patients-এ বেশি common।
- Foraminal stenosis
- nerve root বের হওয়ার পথ সরু হয়ে যায়।
- pain সাধারণত unilateral, neck extension/rotation-এ বাড়ে।
- Facet joint arthropathy / uncovertebral osteophyte
- bony spur nerve root irritate করে।
B. Less common কিন্তু clinically important causes
- Trauma / cervical fracture-dislocation
- Tumor / metastasis
- Spinal infection: epidural abscess, discitis, osteomyelitis
- Inflammatory disease: rheumatoid arthritis, ankylosing spondylitis
- Post-surgical fibrosis বা recurrent disc
- Congenital narrow canal/foramen
3) Pathophysiology — রোগটি কীভাবে হয়
- Mechanical compression: disc/osteophyte nerve root চাপ দেয়।
- Inflammatory irritation: disc material cytokine-mediated inflammation করে, তাই compression কম হলেও severe pain হতে পারে।
- Ischemia/edema: nerve root vascular supply impaired হয়ে numbness, paresthesia, weakness হয়।
- Dermatomal distribution: যে nerve root affected, সেই root-এর sensory–motor–reflex pattern অনুযায়ী symptom হয়।
4) Symptoms — লক্ষণগুলো
Main symptoms
- ঘাড় ব্যথা
- ঘাড় থেকে কাঁধ/হাত/আঙুলে ছড়িয়ে যায়।
- coughing/sneezing/neck extension বা rotation-এ বাড়তে পারে।
- Radicular arm pain
- sharp, burning, electric shock-like pain।
- এক পাশে বেশি হয়।
- Numbness / tingling
- নির্দিষ্ট dermatome অনুযায়ী আঙুল বা হাতে ঝিনঝিন/অবশ ভাব।
- Muscle weakness
- হাত তুলতে সমস্যা, elbow flex/extend দুর্বল, grip weakness।
- Reflex কমে যাওয়া
- C5/C6/C7 root involvement অনুযায়ী biceps, brachioradialis, triceps reflex কমতে পারে।
- Shoulder abduction relief sign
- রোগী হাত মাথার ওপরে রাখলে pain কমতে পারে।
Root-wise clinical pattern
| Affected root | Pain/sensory area | Motor weakness | Reflex |
| C5 | lateral arm, shoulder | deltoid, elbow flexion | biceps reflex ↓ |
| C6 | lateral forearm, thumb | biceps, wrist extension | brachioradialis reflex ↓ |
| C7 | middle finger, dorsal forearm | triceps, wrist flexion | triceps reflex ↓ |
| C8 | ring/little finger, medial forearm | finger flexors, grip | usually no specific reflex |
| T1 | medial forearm | intrinsic hand muscles | usually no specific reflex |
C7 এবং C6 root involvement সবচেয়ে common।
5) Clinical Diagnosis — clinically কীভাবে diagnose করবেন
A. History
Point-wise জিজ্ঞেস করবেন:
- Pain onset: sudden না gradual?
- Neck pain থেকে arm pain radiation আছে কি?
- কোন আঙুলে numbness/tingling?
- Weakness: grip, writing, buttoning, lifting object?
- Pain aggravating factor: neck extension, rotation, coughing/sneezing?
- Relieving factor: hand over head?
- Trauma history?
- Red flags:
- fever, IV drug use, immunosuppression
- cancer history, unexplained weight loss
- night pain
- gait disturbance, hand clumsiness
- urinary urgency/incontinence
- progressive motor weakness
B. Physical examination
- Inspection
- posture, torticollis, muscle spasm
- Range of motion
- neck flexion, extension, lateral bending, rotation
- Neurological exam
- sensory: dermatome mapping
- motor: myotome testing
- reflex: biceps, brachioradialis, triceps
- upper motor neuron sign: hyperreflexia, clonus, Hoffmann sign, Babinski
- Provocative tests
- Spurling test: neck extension + lateral flexion + axial compression করলে radicular pain reproduce হলে positive।
- Upper limb tension test: very sensitive; negative হলে radiculopathy less likely।
- Shoulder abduction test: hand on head দিলে pain কমলে supportive।
C. Diagnosis মূলত কী দিয়ে হয়?
Uncomplicated cervical radiculopathy সাধারণত history + physical examination দিয়ে diagnose করা যায়। Imaging সব রোগীর প্রথম visit-এ দরকার হয় না, যদি trauma/red flag/progressive deficit না থাকে।
6) Investigations — specificভাবে কী করবেন
1. X-ray cervical spine
Indication:
- trauma suspicion
- chronic neck pain
- deformity
- spondylosis/instability suspect
- pre-surgical assessment
Views:
- AP, lateral
- oblique view: foraminal narrowing
- flexion–extension view: instability suspicion
X-ray degenerative change দেখাতে পারে, কিন্তু nerve root compression confirm করতে পারে না।
2. MRI cervical spine — investigation of choice
Indication:
- red flag present
- progressive neurological deficit
- myelopathy sign
- infection/tumor suspect
- severe persistent radicular pain
- conservative treatment 4–6 weeksেও improvement না হলে
- surgical/epidural injection planning
Chronic cervical pain with radiculopathy-তে MRI without contrast usually appropriate; infection/tumor suspect হলে contrast MRI দরকার হতে পারে।
3. CT / CT myelography
Indication:
- MRI contraindicated
- bony foraminal stenosis detail দরকার
- MRI equivocal কিন্তু clinical suspicion strong
- post-operative hardware artifact
CT myelography MRI equivocal হলে nerve root impingement clarify করতে helpful।
4. EMG/NCS
Routine দরকার হয় না।
Indication:
- diagnosis unclear
- peripheral neuropathy vs radiculopathy differentiate
- carpal tunnel/cubital tunnel/brachial plexopathy suspect
- medico-legal বা chronic weakness assessment
AAFP অনুযায়ী peripheral neuropathy alternative diagnosis হলে EMG useful, routine use নয়।
5. Lab tests
Routine uncomplicated case-এ lab দরকার নেই।
যদি infection/malignancy/inflammatory disease suspect হয়:
- CBC
- ESR, CRP
- fasting glucose/HbA1c
- blood culture if fever
- calcium/ALP, tumor markers only if clinically indicated
7) Differential Diagnosis — কোন রোগের সাথে confuse হতে পারে
- Cervical myelopathy
- Shoulder rotator cuff disease
- Adhesive capsulitis
- Carpal tunnel syndrome
- Cubital tunnel syndrome
- Brachial plexopathy
- Thoracic outlet syndrome
- Herpes zoster
- Parsonage–Turner syndrome
- Cardiac ischemia, especially left arm pain
- Pancoast tumor
- Spinal infection/tumor
8) Complications — রোগের জটিলতা
- Chronic neuropathic pain
- nerve irritation দীর্ঘদিন থাকলে burning/electric pain persistent হতে পারে।
- Persistent numbness
- sensory nerve damage দীর্ঘ হলে numbness পুরোপুরি না-ও ফিরতে পারে।
- Motor weakness / muscle wasting
- দীর্ঘদিন root compression থাকলে grip weakness, triceps/biceps weakness, thenar/intrinsic hand wasting হতে পারে।
- Functional disability
- writing, typing, driving, lifting, sleep disturbance, work limitation হয়।
- Cervical myelopathy
- spinal cord compression যুক্ত হলে hand clumsiness, gait imbalance, hyperreflexia, urinary urgency হতে পারে—এটি urgent condition।
- Psychological impact
- chronic pain থেকে anxiety, depression, sleep disturbance হতে পারে।
- Drug-related complications
- NSAID-induced gastritis/ulcer/AKI, steroid-induced hyperglycemia, pregabalin/gabapentin sedation/fall risk, tramadol dependence/serotonin syndrome—তাই rational prescription দরকার।
9) Treatment / Management
A. General management principle
বেশিরভাগ cervical radiculopathy conservative treatment-এ improve করে। Evidence অনুযায়ী অনেক রোগী 4 weeks-এর মধ্যে clinically improve করে; refractory case-এ 4–8 weeks পরে epidural steroid injection বা surgical referral consider করা যায়।
B. Non-pharmacological treatment
- Patient education
- রোগীকে বুঝাতে হবে, অধিকাংশ case conservative management-এ ভালো হয়।
- sudden neck manipulation, heavy lifting, prolonged phone bending avoid।
- Activity modification
- acute severe pain phase-এ heavy work, overhead activity, long driving কমানো।
- complete bed rest নয়; tolerable activity চালু রাখতে হবে।
- Short-term soft cervical collar
- severe acute pain/spasm-এ 2–7 দিন।
- দীর্ঘদিন collar দিলে muscle weakness/stiffness বাড়তে পারে।
- Physiotherapy
- cervical stabilization exercise
- scapular strengthening
- stretching
- posture correction
- nerve gliding
- supervised traction selected patients-এ
- Heat/ice therapy
- acute spasm-এ ice, chronic stiffness-এ heat helpful হতে পারে।
10) Pharmacological Management — Bangladesh brand সহ
Important: নিচের brand list “commonly used examples”। MedEx-এ একই generic-এর আরও অনেক brand থাকতে পারে। একই সাথে দুই NSAID একসাথে দেবেন না। GI/renal/CV risk থাকলে NSAID carefully use করবেন।
1. Paracetamol
- Generic name: Paracetamol / Acetaminophen
- Therapeutic category: Analgesic, antipyretic
- Pharmacological class: Para-aminophenol derivative; central COX/prostaglandin inhibition
- Bangladesh available brand examples:
- Napa 500 mg — Paracetamol 500 mg
- Ace 500 mg — Paracetamol 500 mg
- Renova 500 mg — Paracetamol 500 mg
- Tamen 500 mg — Paracetamol 500 mg
Dose:
- 500–1000 mg orally every 6–8 hours PRN
- Max usually 3–4 g/day; liver disease/alcohol use/elderly হলে lower max prefer
- Duration: 3–7 days, pain অনুযায়ী
কেন used হয়:
- mild to moderate neck/arm pain control
- NSAID contraindicated হলে safer first-line analgesic
Side effects:
- usually safe
- overdose → severe hepatotoxicity
- rare rash/allergy
Interactions:
- alcohol, isoniazid, enzyme-inducing antiepileptics → liver toxicity risk বাড়ে
- warfarin long-term high-dose use করলে INR বাড়তে পারে
2. NSAIDs — inflammatory radicular pain-এর জন্য
NSAID cervical radiculopathy-তে pain/inflammation কমাতে commonly prescribed, যদিও long-term use avoid করা উচিত।
2A. Aceclofenac
- Generic name: Aceclofenac
- Therapeutic category: Analgesic, anti-inflammatory
- Pharmacological class: NSAID; COX inhibitor
- Bangladesh available brand examples:
- Acflam 100 mg
- Aclo 100 mg
- Aclonac 100 mg
- Flexi 100 mg / Flexi SR 200 mg
- Movex 100 mg / Movex SR 200 mg
- Reservix 100 mg
Dose:
- 100 mg orally twice daily after food
- Duration: 5–10 days; prolonged use avoid
কেন used হয়:
- neck pain + inflammatory root irritation কমাতে
- associated cervical spondylosis/facet inflammation pain কমাতে
Side effects:
- dyspepsia, gastritis, peptic ulcer, GI bleeding
- renal function worsening
- fluid retention, BP rise
- bronchospasm in NSAID-sensitive asthma
Interactions:
- anticoagulant/antiplatelet/steroid/SSRI → GI bleeding risk ↑
- ACEi/ARB + diuretic → AKI risk ↑
- lithium/methotrexate toxicity risk ↑
2B. Naproxen
- Generic name: Naproxen / Naproxen sodium
- Therapeutic category: Analgesic, anti-inflammatory
- Pharmacological class: NSAID
- Bangladesh available brand examples:
- Naproxen 500 mg
- Naptodin 500 mg
- Nasox 500 mg
- Anaflex Max 500 mg + Esomeprazole 20 mg
- Nimovo 500 mg + Esomeprazole 20 mg
- Novaxen Plus 500 mg + Esomeprazole 20 mg
Dose:
- 250–500 mg orally twice daily after food
- Duration: 5–10 days
কেন used হয়:
- moderate inflammatory pain
- longer duration analgesia দরকার হলে
Side effects/interactions:
- NSAID class adverse effects same: gastritis, ulcer, renal injury, BP rise
- anticoagulant/steroid/SSRI/ACEi/ARB/diuretic interaction important
2C. Ibuprofen
- Generic name: Ibuprofen
- Therapeutic category: Analgesic, anti-inflammatory
- Pharmacological class: NSAID
- Bangladesh available brand examples:
- Flam 400 mg
- Flamex 200 mg / 400 mg
- Iburex 400 mg
- Inflam 200 mg / 400 mg
- Profen 400 mg
- Reumafen 200 mg / 400 mg
Dose:
- 400 mg orally 2–3 times daily after food
- Duration: 3–7 days
- Avoid exceeding recommended daily limit
কেন used হয়:
- mild–moderate acute neck pain
- short-term anti-inflammatory effect
Side effects/interactions:
- dyspepsia, GI bleeding, renal impairment, BP rise
- avoid with other NSAIDs, anticoagulants, high-dose aspirin
2D. Diclofenac
- Generic name: Diclofenac sodium/potassium
- Therapeutic category: Analgesic, anti-inflammatory
- Pharmacological class: NSAID
- Bangladesh available brand examples:
- Diclorex 50 mg
- Diclovir 50 mg / SR 100 mg
- Difenac 50 mg
- Dilock 50 mg / SR 100 mg
- Fengel gel 1%
- Fastfit gel 1%
- A-Fenac K 50 mg — diclofenac potassium
Dose:
- Oral: 50 mg 2–3 times daily after food, অথবা SR 100 mg once daily
- Topical gel: affected neck/shoulder area-তে 2–4 times daily
- Duration oral: 3–7 days ideally
কেন used হয়:
- acute painful spasm + inflammatory pain
- topical form local pain-এ systemic adverse effect কম
Side effects/interactions:
- GI bleeding, renal injury, fluid retention
- diclofenac CV risk তুলনামূলক বেশি হতে পারে—CVD/HTN রোগীতে cautious
- warfarin/DOAC/steroid/SSRI interaction
2E. Etoricoxib
- Generic name: Etoricoxib
- Therapeutic category: Analgesic, anti-inflammatory
- Pharmacological class: Selective COX-2 inhibitor NSAID
- Bangladesh available brand examples:
- Eto 60 mg / 90 mg / 120 mg
- Etocox 60 mg / 90 mg
- Etoben 90 mg / 120 mg
- Etorix 60 mg
Dose:
- 60 mg once daily; severe short-term pain-এ 90 mg once daily
- Duration: 3–7 days; lowest effective dose
কেন used হয়:
- NSAID দরকার কিন্তু GI intolerance বেশি হলে COX-2 selective option
- inflammatory neck/arm pain control
Side effects:
- BP rise, edema, renal impairment
- cardiovascular thrombotic risk
- dyspepsia; GI risk কম হলেও zero নয়
Interactions:
- ACEi/ARB/diuretic → renal risk
- anticoagulant → bleeding risk
- lithium/methotrexate toxicity risk
3. PPI — NSAID gastroprotection
Pantoprazole / Omeprazole
- Generic name: Pantoprazole / Omeprazole
- Therapeutic category: Anti-ulcerant
- Pharmacological class: Proton pump inhibitor
- Bangladesh available brand examples:
- Pantoprazole: Pantodac 20/40 mg, Pantofast 20 mg, Pantolok 20/40 mg, Pantonix 20/40 mg, Protozin 20/40 mg
- Omeprazole: Neome 20 mg, O-20/O-40, Omecent 20/40 mg, Omecron 20 mg
Dose:
- Pantoprazole 20–40 mg once daily, breakfast-এর 30 min আগে
- Omeprazole 20 mg once daily
- Duration: NSAID যতদিন, সাধারণত 5–14 days; high GI risk হলে longer
কেন used হয়:
- NSAID-induced gastritis/ulcer risk কমাতে
- dyspepsia থাকলে symptom control
Side effects:
- headache, diarrhea/constipation, nausea
- long-term: B12/Mg deficiency, fracture risk, C. difficile risk
Interactions:
- omeprazole clopidogrel activation কমাতে পারে
- warfarin/phenytoin interaction possible
- long-term PPI unnecessary avoid
4. Neuropathic pain medicines
Radicular burning/electric pain, paresthesia, sleep disturbance থাকলে neuropathic agent দেওয়া হয়।
4A. Pregabalin
- Generic name: Pregabalin
- Therapeutic category: Neuropathic pain agent, anticonvulsant
- Pharmacological class: α2δ calcium-channel ligand
- Bangladesh available brand examples:
- Pregaba 75 mg
- Lirica 75 mg
- Pegamax 50 mg / 75 mg
- Pegaron 50 mg / 75 mg
- Gabarol CR 82.5/165/330 mg
Dose:
- Start: 25–75 mg at night
- Common: 75 mg twice daily
- Titrate according to response; renal dose adjustment needed
- Duration: 2–6 weeks then reassess; stop করলে taper
কেন used হয়:
- burning/electric radicular pain
- sleep-disturbing neuropathic pain
- paresthesia-dominant cases
Side effects:
- dizziness, somnolence
- blurred vision
- peripheral edema
- weight gain
- mood change/suicidal ideation rare but important
Interactions:
- alcohol, benzodiazepine, opioid, sedative antihistamine → CNS depression/fall risk ↑
- renal impairmentে accumulation
4B. Gabapentin
- Generic name: Gabapentin
- Therapeutic category: Neuropathic pain agent, anticonvulsant
- Pharmacological class: α2δ calcium-channel ligand
- Bangladesh available brand examples:
- Gaba 300 mg
- Gabapen 300 mg
- Gabastar 100 mg / 300 mg
- Gabatin 300 mg
- Gabahil 300 mg
Dose:
- Day 1: 300 mg at night
- Day 2: 300 mg twice daily
- Day 3 onward: 300 mg three times daily
- Titrate as needed; renal dose adjustment required
- Duration: 2–6 weeks, then reassess/taper
কেন used হয়:
- neuropathic radicular pain
- pregabalin intolerant/expensive হলে alternative
Side effects:
- dizziness, fatigue, ataxia
- somnolence
- peripheral edema
- weight gain
- dry mouth
Interactions:
- antacid gabapentin absorption কমাতে পারে—2 hours gap
- CNS depressants sedation বাড়ায়
- cimetidine renal excretion alter করতে পারে
4C. Amitriptyline
- Generic name: Amitriptyline
- Therapeutic category: Neuropathic pain adjuvant, antidepressant
- Pharmacological class: Tricyclic antidepressant
- Bangladesh available brand examples:
- Amilin 10 mg / 25 mg
- Amit 10 mg / 25 mg
- Amitip 10 mg / 25 mg
- Amtylin 10 mg / 25 mg
- Reptylin 10 mg / 25 mg
- Tryptin 10 mg / 25 mg
Dose:
- 10–25 mg at night
- Increase gradually to 25–50 mg HS if needed
- Duration: 4–8 weeks then reassess
কেন used হয়:
- chronic neuropathic pain
- sleep disturbance সহ radicular pain
- anxiety/insomnia associated pain
Side effects:
- dry mouth, constipation, urinary retention
- sedation
- postural hypotension
- QT prolongation/arrhythmia risk
- elderly/BPH/glaucoma/cardiac diseaseে cautious
Interactions:
- alcohol/opioid/benzodiazepine → sedation ↑
- MAOI contraindicated
- QT-prolonging drug যেমন moxifloxacin → arrhythmia risk
- cimetidine metabolism inhibit করতে পারে
4D. Duloxetine
- Generic name: Duloxetine
- Therapeutic category: Neuropathic pain agent, antidepressant
- Pharmacological class: SNRI / SSNRI
- Bangladesh available brand examples:
- Deloxi 20 mg / 60 mg
- Diliner DR 20 mg / 30 mg / 60 mg
- Dulox 20 mg
Dose:
- 30 mg once daily for 1 week
- Then 60 mg once daily
- Duration: 4–8 weeks then reassess; stop করলে taper
কেন used হয়:
- chronic neuropathic pain
- depression/anxiety associated chronic pain
- pregabalin/gabapentin intolerance হলে option
Side effects:
- nausea, dry mouth, dizziness
- somnolence or insomnia
- sweating
- constipation
- BP slightly increase হতে পারে
Interactions:
- MAOI contraindicated
- SSRI/SNRI/tramadol/linezolid → serotonin syndrome risk
- CYP1A2 inhibitor যেমন ciprofloxacin/fluvoxamine → level ↑
- liver disease/heavy alcohol use এ avoid/cautious
5. Muscle relaxants — neck spasm থাকলে short course
Muscle relaxant radiculopathy cure করে না; associated painful cervical muscle spasm কমানোর জন্য দেওয়া হয়।
5A. Tizanidine
- Generic name: Tizanidine
- Therapeutic category: Skeletal muscle relaxant
- Pharmacological class: Centrally acting α2-adrenergic agonist
- Bangladesh available brand examples:
- Sirdalud 2 mg
- Relentus 2 mg
- Tizadin 2 mg
- Tizalex 2 mg
- Tizalud 2 mg
- Tizan 2 mg
Dose:
- 2 mg at night or 2 mg 2–3 times daily
- Usual: 2–4 mg TID if needed
- Duration: 3–7 days
কেন used হয়:
- painful neck muscle spasm
- sleep-disturbing spasm
Side effects:
- sedation, dizziness
- hypotension
- dry mouth
- bradycardia
- LFT elevation rare
Interactions:
- ciprofloxacin/fluvoxamine contraindicated বা avoid—tizanidine level markedly ↑
- antihypertensive → hypotension ↑
- alcohol/sedatives → sedation ↑
5B. Tolperisone
- Generic name: Tolperisone
- Therapeutic category: Skeletal muscle relaxant
- Pharmacological class: Centrally acting muscle relaxant
- Bangladesh available brand examples:
- Mydocalm 50 mg
- Myolax 50/100 mg
- Myoson 50/100 mg
- Myotol 50 mg
- Myoxan 50 mg
- Rison 50 mg
- Tolcalm 50 mg
- Tolpa 50 mg
Dose:
- 50 mg three times daily after meal
- Sometimes 100 mg 2–3 times daily
- Duration: 5–10 days
কেন used হয়:
- cervical paraspinal muscle spasm
- pain-related muscle tightness
Side effects:
- dizziness, weakness
- nausea, GI upset
- hypersensitivity reaction rare
Interactions:
- other muscle relaxants/sedatives সঙ্গে sedation বাড়তে পারে
- hypersensitivity history থাকলে avoid
5C. Eperisone
- Generic name: Eperisone
- Therapeutic category: Skeletal muscle relaxant
- Pharmacological class: Centrally acting muscle relaxant
- Bangladesh available brand examples:
- Eprel 50 mg
- Ezymas 50 mg
- Myonil 50 mg
Dose:
- 50 mg three times daily after meal
- Duration: 5–10 days
কেন used হয়:
- neck stiffness/spasm
- acute painful restriction of neck movement
Side effects:
- dizziness, drowsiness
- nausea, GI upset
- weakness
Interactions:
- tolperisone/methocarbamol-এর সাথে avoid বা caution
- CNS depressants sedation বাড়ায়
5D. Baclofen
- Generic name: Baclofen
- Therapeutic category: Skeletal muscle relaxant, antispasticity agent
- Pharmacological class: GABA-B receptor agonist
- Bangladesh available brand examples:
- Baclon 5/10 mg
- Bacofen 5/10 mg
- Bacspa 10 mg
- Beclovan 5/10 mg
- Lioresal 10 mg
- Myorel 5/10/25 mg
Dose:
- 5 mg three times daily initially
- If needed 10 mg three times daily
- Duration: short course for spasm; long-term only clear spasticity indication থাকলে
কেন used হয়:
- severe spasm/spasticity-like tightness
- not routine first choice for simple radiculopathy
Side effects:
- sedation, weakness
- dizziness
- hypotonia
- confusion, especially elderly/renal impairment
Interactions:
- alcohol/opioid/benzodiazepine → CNS depression ↑
- renal impairmentে toxicity risk
6. Oral corticosteroid — selected acute severe radicular pain
Routine সব রোগীতে steroid নয়। Severe acute radicular pain, significant inflammation suspicion, no contraindication থাকলে short course consider করা যায়। একটি RCT-তে prednisolone 50 mg/day 5 days followed by taper over 5 days short-term improvement দেখিয়েছে, তবে safety/long-term evidence সীমিত।
Prednisolone
- Generic name: Prednisolone
- Therapeutic category: Corticosteroid
- Pharmacological class: Glucocorticoid
- Bangladesh available brand examples:
- Pred 10 mg
- Predimax 5/10/20 mg
- Rayox 20 mg
- P-Cort 5 mg
- Peron 5/10/20 mg
- Precodil 5/10/20 mg
Dose example:
- Prednisolone 40–50 mg once daily after breakfast for 5 days
- তারপর taper over next 5 days, e.g., 30 → 20 → 10 mg pattern
- Total duration: usually 5–10 days
কেন used হয়:
- acute nerve root inflammation/edema কমাতে
- severe arm pain দ্রুত কমানোর জন্য selected case
Side effects:
- gastritis, dyspepsia
- hyperglycemia
- BP rise, fluid retention
- mood change, insomnia
- infection worsening
- long-term use: osteoporosis, adrenal suppression
Interactions/contraindications:
- NSAID + steroid → GI bleeding risk ↑; PPI consider
- diabetes, uncontrolled HTN, active infection, peptic ulcer, glaucoma, osteoporosis, pregnancy—cautious/avoid
- live vaccine, warfarin interaction possible
Methylprednisolone
- Generic name: Methylprednisolone
- Therapeutic category: Corticosteroid
- Pharmacological class: Glucocorticoid
- Bangladesh available brand examples:
- Medrol 4 mg
- Depomed 2/4/8/16 mg
- Mepcort 4/8/16 mg
- Mepred 4/8 mg
- Methilon 2/4/8/16 mg
- Predixa 4/8/16 mg
Dose:
- Short tapering course; commonly 4–16 mg/day equivalent taper depending on severity
- Avoid repeated courses without specialist review
কেন used হয়:
- prednisolone alternative
- acute inflammatory radicular flare
Side effects/interactions: prednisolone-এর মতোই।
7. Opioid-like analgesic — severe short-term pain only
Tramadol
- Generic name: Tramadol
- Therapeutic category: Analgesic
- Pharmacological class: Opioid analgesic; μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
- Bangladesh available brand examples:
- Anadol 50/100 mg
- Dolonil 50/100 mg
- Dolorex 50/100 mg
- Kadol 50 mg
- Syndol 50/100 mg
- Trado 50/100 mg
- Utramal 100 mg/2 ml injection
Dose:
- 50 mg orally every 8–12 hours PRN
- Severe pain: 50–100 mg every 6 hours PRN
- Max: 400 mg/day
- Duration: ideally 2–3 days, maximum short course
কেন used হয়:
- severe acute radicular pain যখন paracetamol/NSAID insufficient
- sleep-breaking pain short-term control
Side effects:
- nausea, vomiting
- dizziness, sedation
- constipation
- dependence/misuse risk
- seizure risk
- respiratory depression in overdose
Interactions:
- SSRI/SNRI/TCA/MAOI/linezolid → serotonin syndrome risk
- benzodiazepine/alcohol/opioid → CNS/respiratory depression
- epilepsy/seizure disorderে avoid/caution
Paracetamol + Tramadol combination
- Generic name: Paracetamol 325 mg + Tramadol 37.5 mg
- Therapeutic category: Analgesic combination
- Pharmacological class: Non-opioid analgesic + opioid analgesic
- Bangladesh available brand examples:
- Anadol Plus 325/37.5 mg
- Pangesic 325/37.5 mg
- Renova T 325/37.5 mg
- Syndol Plus 325/37.5 mg
- Trado Plus 325/37.5 mg
Dose:
- 1 tablet every 6–8 hours PRN
- Paracetamol total daily dose হিসাব করতে হবে
- Duration: 2–3 days short course
কেন used হয়:
- severe pain where single analgesic insufficient
- short-term rescue analgesia
Side effects/interactions: paracetamol + tramadol দুইটির combined risk।
11) Bangladesh doctors commonly prescription-এ যেসব drug group দেন
নিচের list clinical practice-এ commonly দেখা যায়; সব রোগীর জন্য সব drug নয়।
- Paracetamol
- mild pain, feverish discomfort, NSAID contraindication থাকলে।
- Example: Napa/Ace/Renova 500 mg।
- NSAID
- inflammatory neck/arm pain কমাতে।
- Example: Aceclofenac 100 mg, Naproxen 500 mg, Ibuprofen 400 mg, Diclofenac 50/SR100, Etoricoxib 60/90 mg।
- PPI
- NSAID-related gastritis/ulcer prevention।
- Example: Pantoprazole 20/40 mg, Omeprazole 20 mg।
- Muscle relaxant
- neck muscle spasm, restricted ROM, painful stiffness থাকলে।
- Example: Tizanidine 2 mg, Tolperisone 50 mg, Eperisone 50 mg।
- Neuropathic pain medicine
- burning/electric pain, numbness/tingling, sleep disturbance থাকলে।
- Example: Pregabalin 75 mg, Gabapentin 300 mg, Amitriptyline 10/25 mg, Duloxetine 30/60 mg।
- Short-course oral steroid
- severe acute radicular pain, marked inflammation; contraindication না থাকলে।
- Example: Prednisolone 20/10/5 mg brands, Methylprednisolone 4/8/16 mg brands।
- Tramadol or Paracetamol+Tramadol
- severe pain short-term rescue analgesia।
- dependence/serotonin syndrome/sedation risk থাকার কারণে routine long-term নয়।
12) Interventional and Surgical Treatment
Epidural steroid injection
Consider করবেন যদি:
- 4–6 weeks conservative managementেও severe radicular pain থাকে
- MRI-confirmed nerve root compression থাকে
- surgery delay/avoid করতে চান
- no infection/coagulopathy
Risk:
- dural puncture headache
- infection
- bleeding/epidural hematoma
- nerve injury
- rare catastrophic vascular complication
AAFP review অনুযায়ী 4–6 weeks persistent symptoms হলে epidural steroid injection consider করা যায়, তবে higher-risk complication explain করা জরুরি।
Surgical referral
Indication:
- progressive motor weakness
- cervical myelopathy
- bowel/bladder involvement
- severe persistent radicular pain despite 6–12 weeks adequate conservative treatment
- MRI lesion clinical root pattern-এর সাথে match করে
- tumor/infection/instability
Common operations:
- ACDF — anterior cervical discectomy and fusion
- cervical disc replacement
- posterior cervical foraminotomy
13) Prevention — কীভাবে প্রতিরোধ করবেন
- Ergonomics ঠিক করা
- computer monitor eye level-এ
- mobile neck flexion কমানো
- দীর্ঘক্ষণ নিচের দিকে তাকিয়ে কাজ না করা
- Neck strengthening
- deep neck flexor strengthening
- scapular stabilizer exercise
- physiotherapist-guided posture training
- Frequent break
- প্রতি 30–45 মিনিটে posture change/stretch
- Heavy lifting technique
- মাথা/ঘাড় বাঁকিয়ে heavy load না তোলা
- sudden jerky neck movement avoid
- Sleep posture
- very high pillow avoid
- neutral cervical alignment বজায় রাখা
- Smoking cessation
- disc degeneration risk কমাতে সাহায্য করে।
- Weight control and physical activity
- musculoskeletal load কমে, chronic pain risk কমে।
- Red flag awareness
- weakness, gait problem, urinary symptom, fever, cancer history, severe night pain হলে delay করবেন না।
Overview / Summary
Cervical radiculopathy হলো cervical nerve root compression/irritation-এর কারণে neck-to-arm dermatomal pain, numbness, tingling, weakness এবং reflex change। Common cause হলো disc herniation ও degenerative foraminal stenosis। Diagnosis সাধারণত history + neurological examination দিয়ে হয়; MRI দরকার red flag, progressive deficit, myelopathy, অথবা 4–6 weeks conservative care-এ improvement না হলে। Treatment-এর mainstay হলো education, activity modification, physiotherapy, short-course analgesic/NSAID, spasm থাকলে muscle relaxant, neuropathic pain থাকলে pregabalin/gabapentin/amitriptyline/duloxetine। Severe selected acute case-এ short steroid course; refractory case-এ epidural steroid injection বা surgery।
Actionable Plan / Steps
- প্রথম visit: red flag screen + neuro exam + Spurling/ULTT/shoulder abduction test।
- No red flag: paracetamol ± NSAID + PPI, short muscle relaxant if spasm, physiotherapy advice।
- Neuropathic pain prominent: pregabalin/gabapentin বা night amitriptyline consider; renal/cardiac/elderly caution।
- Severe acute radicular pain: contraindication না থাকলে short oral steroid; rescue analgesic হিসেবে tramadol only short-term।
- Follow-up: 2–4 weeks পরে pain, sensory, motor power, reflex reassess।
- MRI: progressive weakness/myelopathy/red flag হলে immediately; otherwise 4–6 weeks persistent symptom হলে।
- Referral: motor deficit, myelopathy, intractable pain, MRI-confirmed surgical lesion হলে spine/neurosurgery/orthopedic spine referral।
Reference List — Textbook + Guideline + DOI
Textbooks
- Harrison’s Principles of Internal Medicine, 21st ed. Neurologic disorders; radiculopathy/peripheral nerve disorder sections.
- Davidson’s Principles and Practice of Medicine, 24th ed. Neurology and musculoskeletal pain chapters.
- Robbins & Cotran Pathologic Basis of Disease, 10th ed. Degenerative joint disease and intervertebral disc pathology.
- Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. NSAIDs, corticosteroids, opioid analgesics, antidepressants, anticonvulsants.
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Analgesics, anti-inflammatory drugs, corticosteroids, neuropathic pain pharmacology.
Guidelines / Reviews
- AAFP. Nonoperative Management of Cervical Radiculopathy, 2016.
- ACR Appropriateness Criteria. Cervical Pain or Cervical Radiculopathy, 2024 update; published J Am Coll Radiol 2025. DOI: 10.1016/j.jacr.2025.02.035.
- North American Spine Society evidence-based guideline. Diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011. DOI: 10.1016/j.spinee.2010.10.023.
- Blanpied PR, et al. Neck Pain: Revision 2017 Clinical Practice Guidelines. J Orthop Sports Phys Ther. 2017. DOI: 10.2519/jospt.2017.0302.
Peer-reviewed DOI
- Ghasemi M, et al. Oral prednisolone in the treatment of cervical radiculopathy: randomized placebo-controlled trial. J Res Med Sci. 2013.
- Rubinstein SM, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007. DOI: 10.1007/s00586-006-0225-6.
- Carette S, Fehlings MG. Cervical radiculopathy. N Engl J Med. 2005. DOI: 10.1056/NEJMcp043887.
Polston DW. Cervical radiculopathy. Neurol Clin. 2007. DOI: 10.1016/j.ncl.2007.01.012.
Md.Rafiqul Islam Lipu,Date:-15-06-2026 Wednesday,Time:-11-38-12 Am