Raiyyan Tahsan

Raiyyan Tahsan
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TC(1045).(05).Orthopedics Case No 123:- Lumbar Disc Prolapse / Lumbar Disc Herniation

Lumbar Disc Prolapse / Lumbar Disc Herniation — বাংলায় ক্লিনিক্যাল নোট

নোট: নিচের ডোজগুলো adult patient-এর জন্য clinical reference; renal disease, liver disease, peptic ulcer, anticoagulant use, pregnancy, elderly, uncontrolled HTN/IHD/CKD থাকলে ডোজ/ড্রাগ বদলাতে হবে। Lumbar disc prolapse-এ guideline অনুযায়ী NSAID lowest effective dose, shortest duration; routine gabapentinoid/oral steroid/opioid ব্যবহার evidence-based নয়—তবে বাংলাদেশে অনেক clinician selected case-এ symptomatic trial দেন। NICE sciatica guideline gabapentinoids, oral corticosteroids, benzodiazepines এবং chronic sciatica-তে opioids avoid করতে বলেছে; NSAID দিলে GI/liver/cardio-renal risk assess করে gastroprotection বিবেচনা করতে বলেছে।

1. Definition / সংজ্ঞা

Lumbar disc prolapse হলো lumbar intervertebral disc-এর nucleus pulposus বা disc material annulus fibrosus-এর দুর্বল/ফাটা অংশ দিয়ে posterior বা posterolateral দিকে বের হয়ে nerve root compression / chemical inflammation তৈরি করা। এর ফলে low back pain, sciatica/radicular leg pain, numbness, weakness হতে পারে। NASS lumbar disc herniation with radiculopathy guideline-এর উদ্দেশ্যই symptomatic lumbar disc herniation with radiculopathy-এর diagnosis ও treatment নিয়ে evidence-based recommendation দেওয়া।

Common level: L4–L5 ও L5–S1 বেশি।
Most common direction: posterolateral, কারণ posterior longitudinal ligament মাঝখানে শক্তিশালী।

2. Cause / Etiology — কারণগুলো

A. Mechanical / Degenerative cause

  • Disc degeneration: বয়সের সাথে disc dehydration, proteoglycan কমে যাওয়া, annulus fibrosus fissure।
  • Repeated flexion + rotation injury: সামনের দিকে ঝুঁকে ভারী জিনিস তোলা, twisting movement।
  • Heavy lifting / manual work: sudden raised intradiscal pressure।
  • Prolonged sitting: especially flexed posture, driving, desk work।
  • Poor core muscle strength: abdominal–paraspinal support কমে যায়।
  • Obesity: lumbar spine-এর axial load বাড়ায়।
  • Smoking: disc nutrition ও healing capacity কমাতে পারে।
  • Trauma: fall, road traffic accident, sudden jerk।
  • Genetic predisposition: family history থাকলে early degeneration হতে পারে।

B. Pathophysiology — সহজভাবে

  • Disc-এর outer ring = annulus fibrosus দুর্বল/ফেটে যায়।
  • Inner gelatinous material nucleus pulposus বের হয়।
  • বের হওয়া disc nearby nerve root চাপ দেয়।
  • শুধু compression নয়—disc material inflammatory mediators ছাড়ে, তাই chemical radiculitis হয়।
  • ফলে nerve root pain pathway activate হয়ে buttock → thigh → leg → foot পর্যন্ত radiating pain হয়।

3. Symptoms — লক্ষণগুলো

A. Pain pattern

  • Low back pain: কোমরের নিচে ব্যথা; bending, sitting, coughing/sneezing-এ বাড়তে পারে।
  • Sciatica / radicular pain: কোমর থেকে নিতম্ব হয়ে পায়ের দিকে নামা sharp, burning, electric shock-like pain।
  • Dermatomal pain distribution:
    • L4 root: anterior thigh/medial leg, knee reflex কমতে পারে।
    • L5 root: lateral leg, dorsum of foot, great toe extension weakness।
    • S1 root: posterior thigh/calf, lateral foot, ankle reflex কমতে পারে।

B. Sensory symptoms

  • পায়ে ঝিনঝিন/পিন-নিডল sensation।
  • নির্দিষ্ট dermatome-এ numbness।
  • পায়ের পাতায় burning sensation।

C. Motor symptoms

  • পা দুর্বল লাগা।
  • Foot drop: L5 involvement হলে ankle dorsiflexion / great toe extension weak।
  • Toe walking difficulty: S1 weakness।
  • Heel walking difficulty: L4/L5 weakness।

D. Red flag symptoms — emergency

  • Urinary retention/incontinence
  • Fecal incontinence
  • Saddle anaesthesia
  • Bilateral sciatica with neurological deficit
  • Progressive motor weakness / foot drop
  • Fever, weight loss, history of cancer, IV drug use, TB risk
  • Major trauma বা osteoporosis patient-এ sudden severe back pain

এগুলো থাকলে urgent MRI + neurosurgery/orthospine referral।

4. Clinical Diagnosis — clinically কীভাবে ধরবেন

A. History

  • Pain onset: sudden lifting/twisting after?
  • Back pain vs leg pain dominance: disc prolapse-এ leg pain often more prominent।
  • Pain below knee গেলে radiculopathy বেশি suggestive।
  • Cough/sneeze/strain-এ pain বাড়ে কি না।
  • Weakness, numbness, bladder/bowel symptom।
  • Previous episodes, occupation, smoking, trauma।
  • Red flags: cancer, fever, TB, immunosuppression, steroid use।

B. Physical examination

1. Inspection

  • Antalgic posture
  • Lumbar lordosis loss
  • Sciatic scoliosis
  • Gait abnormality

2. Range of motion

  • Forward flexion painful/restricted
  • Extension may aggravate foraminal narrowing

3. Neurological exam — must do

RootMotor testSensory areaReflex
L4Knee extension, ankle dorsiflexion partlymedial legpatellar reflex
L5Great toe extension, ankle dorsiflexiondorsum foot, great toeno reliable deep tendon reflex
S1Plantar flexion, toe walkinglateral foot/soleAchilles reflex

4. Special tests

  • Straight Leg Raise / SLR / Lasègue test: supine অবস্থায় leg raise করলে 30–70°-এ radicular pain হলে positive। এটি lumbosacral nerve root irritation suggest করে।
  • Crossed SLR: asymptomatic leg raise করলে affected leg pain—less sensitive but more specific for disc herniation।
  • Slump test: seated neural tension test; subtle radiculopathy ধরতে helpful।
  • Femoral nerve stretch test: L2–L4 upper lumbar radiculopathy suspicion হলে।

5. Investigations — specificভাবে

NICE guideline অনুযায়ী non-specialist setting-এ low back pain/sciatica হলে routine imaging করা উচিত নয়; specialist setting-এ imaging করবেন যদি result management change করে।

A. MRI lumbosacral spine — investigation of choice

Indication:

  • Severe/progressive neurological deficit
  • Cauda equina suspicion
  • Persistent radicular pain > 6 weeks despite conservative therapy
  • Surgery/epidural injection planning
  • Diagnostic uncertainty

MRI report-এ দেখতে হবে:

  • Disc level: L3–L4, L4–L5, L5–S1
  • Type: bulge, protrusion, extrusion, sequestration
  • Direction: central, paracentral, foraminal, extraforaminal
  • Nerve root compression
  • Canal stenosis / foraminal stenosis

B. X-ray lumbosacral spine

Disc prolapse diagnose করার test নয়। তবে trauma, deformity, spondylolisthesis, infection/malignancy suspicion, instability evaluation-এ helpful।

C. CT scan / CT myelogram

MRI contraindicated হলে—pacemaker/metal implant/claustrophobia—CT বা CT myelogram consider।

D. EMG/NCS

  • Diagnosis unclear হলে
  • Radiculopathy vs peripheral neuropathy differentiate করতে
  • Chronicity/denervation assess করতে

NASS guideline summary অনুযায়ী EMG/NCS/F-wave limited diagnostic utility; H-reflex S1 radiculopathy-তে helpful হতে পারে, কিন্তু disc herniation-specific নয়।

E. Lab tests — only if red flag

  • CBC, ESR, CRP: infection, TB, malignancy suspicion
  • Calcium/ALP: malignancy/metabolic bone disease suspicion
  • Urine R/M/E: renal/urinary differential
  • HLA-B27, inflammatory markers: inflammatory back pain suspicion

6. Differential Diagnosis

  • Lumbar spinal stenosis
  • Spondylolisthesis
  • Facet joint arthropathy
  • Sacroiliitis / ankylosing spondylitis
  • Piriformis syndrome
  • Hip osteoarthritis
  • Peripheral neuropathy / diabetic neuropathy
  • Peroneal neuropathy
  • Vertebral fracture
  • Spinal infection / TB spine
  • Metastatic spinal disease
  • Renal colic / pelvic pathology

7. Complications — রোগের জটিলতা

  • Chronic sciatica: nerve irritation দীর্ঘস্থায়ী হলে pain sensitization হয়।
  • Persistent numbness: nerve compression দীর্ঘদিন থাকলে sensory recovery incomplete হতে পারে।
  • Motor weakness / foot drop: L5 root severely compressed হলে হাঁটতে সমস্যা।
  • Cauda equina syndrome: central large disc bladder/bowel ও saddle area nerve compress করে—এটি surgical emergency।
  • Chronic low back pain: pain avoidance → muscle deconditioning → recurrent pain cycle।
  • Depression/anxiety/sleep disturbance: chronic pain functional life নষ্ট করে।
  • Work disability: দীর্ঘদিন বসা/ভারী কাজ করা কঠিন।
  • Recurrent disc herniation: surgery বা conservative treatment—দুই অবস্থাতেই recurrence হতে পারে।

8. Treatment / Management

A. Emergency management

নিচের যেকোনোটি থাকলে urgent MRI + emergency spine referral:

  • Cauda equina symptoms
  • Progressive motor deficit
  • Acute foot drop
  • Severe bilateral sciatica
  • Infection/malignancy suspicion
  • Major trauma

B. Conservative non-pharmacological management

NICE self-management, normal activity চালিয়ে যাওয়া, exercise programme, manual therapy only with exercise package, return-to-work facilitation recommend করে; traction/TENS/ultrasound routine recommend করে না। ACP guideline acute/subacute low back pain-এ non-drug options আগে বিবেচনা করতে বলে; drug needed হলে NSAID বা skeletal muscle relaxant ব্যবহার করা যায়।

করণীয়

  • Relative rest 24–48 hours: absolute bed rest avoid।
  • Activity as tolerated: pain limit অনুযায়ী হাঁটা, normal activity।
  • Physiotherapy: McKenzie extension exercise, core strengthening, hamstring stretch, neural mobilization।
  • Heat therapy: muscle spasm থাকলে।
  • Posture correction: sitting ergonomics, lumbar support।
  • Weight reduction if overweight।
  • Smoking cessation।
  • Work modification: heavy lifting, forward flexion, twisting avoid।

9. Pharmacological Management — Bangladesh prescription-style drug list

গুরুত্বপূর্ণ guideline সতর্কতা

  • Paracetamol alone low back pain-এ routine effective নয়—NICE recommend করে না; তবে বাংলাদেশে mild pain/NSAID contraindication-এ adjunct হিসেবে ব্যবহার হয়।
  • NSAID হলো common first-line analgesic; lowest effective dose + shortest duration।
  • Gabapentin/Pregabalin/Duloxetine/Amitriptyline pure sciatica/low back pain-এ routine recommend নয়; selected neuropathic phenotype, comorbidity বা specialist-supervised trial হতে পারে। NICE gabapentinoids/antiepileptics/SNRI/TCA routine avoid করতে বলেছে।
  • Oral steroid sciatica-তে routine avoid; acute severe sciatica-তে epidural local anaesthetic + steroid specialist setting-এ consider করা যায়।
  • Weak opioid/tramadol acute severe pain-এ NSAID contraindicated/ineffective হলে very short course; chronic sciatica/low back pain-এ avoid।

1) Generic name: Paracetamol

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
  • কেন used হয়: mild–moderate pain relief; NSAID contraindication থাকলে safer adjunct। Disc inflammation কমায় না, শুধু pain control।
  • Adult dose: 500–1000 mg PO 6–8 hourly PRN; maximum সাধারণত 3–4 g/day, liver disease/alcohol use-এ কম।
  • Duration: 3–7 days PRN; chronic daily use avoid unless reviewed।
  • Side effects: usually well tolerated; overdose → hepatotoxicity।
  • Interaction: alcohol, warfarin long-term high dose, enzyme-inducing anticonvulsants।
  • Bangladesh available brand examples:
    • Napa 500 mg, Napa Extend 665 mg, Napa One 1000 mg, Napa Rapid 500 mg — Beximco
    • Ace 500 mg — Square
    • Fast One 1000 mg — ACME
      MedEx lists Napa 500, Napa Extend 665, Napa One 1000 and other paracetamol strengths/brands in Bangladesh.

2) Generic name: Naproxen Sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • কেন used হয়: radicular/back pain-এর inflammatory component কমাতে; longer duration NSAID হওয়ায় BD prescription-এ common।
  • Adult dose: 250–500 mg PO twice daily after food।
  • Duration: 3–7 days; persistent severe pain হলে reassess।
  • Side effects: dyspepsia, gastritis/ulcer, GI bleeding, renal impairment, fluid retention, BP rise, bronchospasm in NSAID-sensitive asthma।
  • Interaction: anticoagulant/antiplatelet, steroid, SSRI/SNRI, ACEi/ARB + diuretic, lithium, methotrexate।
  • Bangladesh available brand examples:
    • Naproxen 500 mg
    • Naproxin 250/500 mg
    • Napryn 250 mg
    • Napxon-P 250/500 mg
      MedEx lists Naproxen 500 mg, Naproxin 250/500 mg, Napryn 250 mg and related brands.

3) Generic name: Naproxen Sodium + Esomeprazole Magnesium

  • Therapeutic category: Analgesic + gastroprotective combination
  • Pharmacological class: NSAID + Proton pump inhibitor
  • কেন used হয়: NSAID pain relief + gastric protection একসাথে; dyspepsia/ulcer-risk patient-এ অনেক clinician ব্যবহার করেন।
  • Adult dose: 375/20 mg or 500/20 mg PO twice daily before meal/after clinical judgement।
  • Duration: 3–7 days commonly; high GI risk হলে review।
  • Side effects: NSAID-related GI/renal/CV risk; PPI-related headache, diarrhea, long-term B12/Mg deficiency risk।
  • Interaction: NSAID interactions + PPI may reduce clopidogrel activation theoretically; warfarin/anticoagulant caution।
  • Bangladesh available brand examples:
    • Naxin Plus 375/20 mg, 500/20 mg — Opsonin
    • Naxipraz 375/20 mg, 500/20 mg — Sun Pharma Bangladesh
    • Naprox Plus 375/20 mg, 500/20 mg — Eskayef
    • Nasopain 375/20 mg, 500/20 mg — Jenphar
    • NapExa 375/20 mg, 500/20 mg — UniMed UniHealth
      These strengths and brands are listed in MedEx Bangladesh.

4) Generic name: Aceclofenac

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • কেন used হয়: lumbago/back pain, musculoskeletal inflammation; Bangladesh prescription-এ খুব common।
  • Adult dose: 100 mg PO twice daily after food; SR 200 mg once daily।
  • Duration: 3–7 days; prolonged use only with risk assessment।
  • Side effects: dyspepsia, ulcer/bleeding, renal impairment, edema, BP rise, rash।
  • Interaction: anticoagulant, antiplatelet, steroid, SSRI/SNRI, ACEi/ARB/diuretic, lithium, methotrexate।
  • Bangladesh available brand examples:
    • Flexi 100 mg, Flexi SR 200 mg — Square
    • Movex 100 mg, Movex SR 200 mg — Opsonin
    • Avenac 100 mg — Radiant
    • Ceclofen 100 mg — Renata
    • Labenac 100 mg, Labenac SR 200 mg — Labaid
      MedEx lists many aceclofenac 100 mg and SR 200 mg brands including Flexi/Flexi SR, Movex/Movex SR, Avenac, Ceclofen and Labenac SR.

5) Generic name: Diclofenac Sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • কেন used হয়: acute severe musculoskeletal pain; IM form অনেক সময় short-term severe pain-এ ব্যবহৃত হয়।
  • Adult dose: 50 mg PO 2–3 times daily after food; IM 75 mg once daily short course only when necessary।
  • Duration: PO 3–5 days; IM ideally 1–2 days only, then oral/alternative।
  • Side effects: gastritis/ulcer/GI bleed, renal injury, edema, BP rise, hepatic enzyme rise; diclofenac has relatively higher CV risk than some NSAIDs।
  • Interaction: anticoagulant/antiplatelet, steroid, ACEi/ARB/diuretic, lithium, methotrexate।
  • Bangladesh available brand examples:
    • G-Diclofenac 50 mg tablet, 75 mg/3 ml IM injection
    • Genac 50 mg tablet, 75 mg/3 ml IM injection
      MedEx lists these diclofenac sodium tablet and IM injection strengths in Bangladesh.

6) Generic name: Etoricoxib

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • কেন used হয়: NSAID-needed pain with relatively lower gastric irritation expectation; কিন্তু CV risk/HTN/CKD থাকলে caution।
  • Adult dose: 60–90 mg once daily; acute severe pain-এ 90 mg OD; 120 mg OD খুব short course only if indicated।
  • Duration: 3–7 days; shortest possible।
  • Side effects: edema, BP rise, dyspepsia, renal impairment, increased CV thrombotic risk।
  • Interaction: warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, oral contraceptives, rifampicin।
  • Bangladesh available brand examples:
    • Etorix 60/90/120 mg — Eskayef
    • Etoshine 60/90/120 mg — Sun Pharma Bangladesh
    • Etovan 60/90/120 mg — Aristopharma
    • Etorica 60/90/120 mg — Labaid
      MedEx lists these etoricoxib brands and strengths in Bangladesh.

7) Generic name: Esomeprazole

  • Therapeutic category: Anti-ulcerant, gastroprotective
  • Pharmacological class: Proton pump inhibitor
  • কেন used হয়: NSAID-induced gastritis/ulcer risk কমাতে; elderly, ulcer history, steroid/anticoagulant use-এ gastroprotection।
  • Adult dose: 20 mg once daily before breakfast; high risk/active dyspepsia হলে 40 mg OD।
  • Duration: NSAID course চলাকালীন; ulcer/GERD থাকলে 4–8 weeks as indicated।
  • Side effects: headache, diarrhea/constipation, nausea; long-term hypomagnesemia, B12 deficiency, fracture/C. difficile risk।
  • Interaction: clopidogrel with PPI caution, warfarin monitoring, diazepam/phenytoin level issue possible।
  • Bangladesh available brand examples:
    • Sergel 20/40 mg — Healthcare
    • Maxpro MUPS 20/40 mg — Renata
    • Esonix 40 mg capsule/injection — Incepta
    • Exium MUPS 20/40 mg — Radiant
      MedEx lists esomeprazole 20/40 mg tablets/capsules/MUPS and IV preparations including Sergel, Maxpro MUPS, Esonix and Exium MUPS.

8) Generic name: Tizanidine Hydrochloride

  • Therapeutic category: Muscle relaxant
  • Pharmacological class: Centrally acting α2-adrenergic agonist skeletal muscle relaxant
  • কেন used হয়: acute painful paraspinal muscle spasm কমাতে; disc prolapse-এর nerve compression ঠিক করে না, spasm relief দেয়।
  • Adult dose: 2 mg at night or 2 mg 2–3 times daily; severe spasm-এ 2–4 mg TDS। MedEx usual dose 2–4 mg three times daily উল্লেখ করে।
  • Duration: 3–7 days; sedation হলে night dose only।
  • Side effects: drowsiness, dizziness, dry mouth, hypotension, bradycardia, liver enzyme elevation।
  • Interaction: ciprofloxacin/fluvoxamine contraindicated or avoid, alcohol/CNS depressants, antihypertensives।
  • Bangladesh available brand examples:
    • Relentus 2 mg — Beximco
    • Sirdalud 2 mg — Sandoz
    • Tizadin 2 mg — ACI
    • Tizalud 2 mg — Opsonin
    • Tizan 2 mg — Sun Pharma Bangladesh
      MedEx lists these tizanidine 2 mg brands in Bangladesh.

9) Generic name: Tolperisone Hydrochloride

  • Therapeutic category: Muscle relaxant
  • Pharmacological class: Centrally acting skeletal muscle relaxant
  • কেন used হয়: painful muscle spasm, paraspinal spasm; sedation তুলনামূলক কম হতে পারে, তবে patient-specific।
  • Adult dose: 50–150 mg PO three times daily after food; MedEx adult dose 50–150 mg TDS উল্লেখ করে।
  • Duration: 5–7 days; review if persistent।
  • Side effects: dizziness, weakness, GI upset, hypersensitivity rash; rare severe allergy।
  • Interaction: other muscle relaxants/CNS depressants; eperisone/methocarbamol combination avoid করা হয়।
  • Bangladesh available brand examples:
    • Myotol 50 mg
    • Myoxan 50 mg
    • Myoxant 50 mg
    • Tolson 50/100 mg
    • Tolus 50 mg
      MedEx lists tolperisone 50/100 mg brands including Myotol, Myoxan, Myoxant, Tolson and Tolus.

10) Generic name: Pregabalin

  • Therapeutic category: Neuropathic pain agent / anticonvulsant
  • Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
  • কেন used হয়: বাংলাদেশে burning/radicular neuropathic pain-এ commonly prescribed; তবে NICE sciatica-তে routine gabapentinoid avoid করতে বলে, কারণ benefit limited এবং harm আছে।
  • Adult dose: 25–75 mg at night initially; 75 mg BD or 50 mg TDS; titrate slowly. Renal impairment-এ dose adjust। MedEx PHN dosing 75–150 mg BD বা 50–100 mg TDS উল্লেখ করে।
  • Duration: 2–4 week trial; benefit না হলে taper and stop। Long-term avoid unless clear benefit।
  • Side effects: dizziness, somnolence, edema, weight gain, blurred vision, cognitive slowing, dependence/withdrawal risk।
  • Interaction: alcohol, benzodiazepine, opioid/tramadol → respiratory/CNS depression risk; renal impairment।
  • Bangladesh available brand examples:
    • GABA-P 25/75 mg; Gaba-P CR 82.5/165/330 mg — Renata
    • Nervalin 25/50/75 mg; Nervalin CR 82.5/165/330 mg — Beximco
    • Gabarol 100/150 mg; Gabarol CR 82.5/165/330 mg — ACI
    • Neugalin 25/50/75/150 mg; Neugalin XR 82.5/165 mg — ACME
    • Pregaver 25/50/75 mg — Veritas
      MedEx lists these pregabalin brands and strengths in Bangladesh.

11) Generic name: Gabapentin

  • Therapeutic category: Neuropathic pain agent / anticonvulsant
  • Pharmacological class: Gabapentinoid; α2δ calcium-channel ligand
  • কেন used হয়: neuropathic burning/radicular pain-এর trial হিসেবে; guideline-wise routine sciatica management নয়।
  • Adult dose: 300 mg at night day 1 → 300 mg BD day 2 → 300 mg TDS; usual 900–1800 mg/day in 3 divided doses. MedEx starting/effective dose 300 mg TDS and 900–1800 mg/day উল্লেখ করে।
  • Duration: 2–4 week trial; effective হলে review, ineffective হলে taper।
  • Side effects: dizziness, sedation, ataxia, edema, weight gain; renal adjustment needed।
  • Interaction: opioid/benzodiazepine/alcohol → CNS/respiratory depression; antacid absorption কমাতে পারে।
  • Bangladesh available brand examples:
    • Gabantin 100/300 mg — Sun Pharma Bangladesh
    • Gabapen 100/300 mg — Incepta
    • Gabastar 100/300 mg — Square
    • Gabatin 300 mg — UniMed UniHealth
      MedEx lists these gabapentin brands and strengths.

12) Generic name: Duloxetine Hydrochloride

  • Therapeutic category: Antidepressant / chronic pain modulator
  • Pharmacological class: SNRI
  • কেন used হয়: chronic pain with depression/anxiety, diabetic neuropathy বা central pain sensitization phenotype থাকলে; pure sciatica/low back pain-এ routine নয়—NICE SNRI/TCA low back pain-এ avoid করতে বলেছে।
  • Adult dose: 20–30 mg OD initially; target 60 mg/day depending indication/tolerability। MedEx MDD/GAD/DPNP dosing 40–60 mg/day target 60 mg/day উল্লেখ করে।
  • Duration: chronic pain/comorbidity থাকলে 4–6 week trial; response না হলে taper।
  • Side effects: nausea, dry mouth, insomnia/somnolence, sweating, BP rise, sexual dysfunction, withdrawal symptoms।
  • Interaction: MAOI contraindicated, SSRI/TCA/tramadol/linezolid → serotonin syndrome risk; anticoagulant/NSAID → bleeding risk।
  • Bangladesh available brand examples:
    • Deloxi 20/60 mg — Eskayef
    • Diliner DR 20/30/60 mg — Square
    • Dulox 20/30 mg — ACME
    • Duloxen 20/30/60 mg — Incepta
      MedEx lists these duloxetine brands and strengths in Bangladesh.

13) Generic name: Tramadol Hydrochloride

  • Therapeutic category: Analgesic
  • Pharmacological class: Weak opioid agonist + serotonin/norepinephrine reuptake inhibition
  • কেন used হয়: acute severe pain যখন NSAID contraindicated/ineffective; chronic sciatica/back pain-এ avoid। NICE acute low back pain-এ weak opioid only if NSAID contraindicated/not tolerated/ineffective এবং chronic sciatica/back pain-এ opioid avoid করতে বলে।
  • Adult dose: 50 mg PO 6–8 hourly PRN; severe acute painে 50–100 mg 4–6 hourly; max 400 mg/day. MedEx 50–100 mg every 4–6 hours and max 400 mg/day উল্লেখ করে।
  • Duration: 2–3 days, ideally ≤5 days; clear stop plan।
  • Side effects: nausea, vomiting, constipation, dizziness, sedation, seizure, dependence, respiratory depression।
  • Interaction: SSRI/SNRI/TCA/MAOI/linezolid → serotonin syndrome; benzodiazepine/alcohol/gabapentinoid → respiratory depression; seizure threshold-lowering drugs।
  • Bangladesh available brand examples:
    • Trado 50 mg capsule, 100 mg/2 ml injection — Pacific
    • Tranal 50 mg capsule, 100 mg/2 ml injection, 100 mg suppository — Opsonin
    • Utramal IR 50 mg; Utramal Retard 50/100 mg — UniMed UniHealth
    • Doloran 50 mg capsule, 100 mg suppository/PRT — Sandoz
    • Winpain 50 mg capsule, 100 mg/2 ml injection — Incepta
      MedEx lists these tramadol brands and strengths.

14) Generic name: Methylprednisolone

  • Therapeutic category: Corticosteroid / anti-inflammatory
  • Pharmacological class: Glucocorticoid
  • কেন used হয়: কিছু clinician acute radiculopathy-তে short oral steroid trial দেন; তবে NICE sciatica management-এ oral corticosteroid recommend করে না। Epidural steroid specialist setting-এ acute severe sciatica-তে consider করা যায়।
  • Adult dose: routine disc prolapse-এ standard recommended oral regimen নেই; যদি specialist trial দেন, commonly tapering short course ব্যবহার হয়।
  • Duration: short course only; diabetes, infection, PUD, psychosis, uncontrolled HTN থাকলে avoid/caution।
  • Side effects: hyperglycemia, dyspepsia/ulcer, mood change, insomnia, BP rise, fluid retention, infection risk।
  • Interaction: NSAID → GI bleed risk; anticoagulant, antidiabetic drug, live vaccine, CYP3A4 inhibitors/inducers।
  • Bangladesh available brand examples:
    • Depomed 2/4/8/16 mg — Drug International
    • Methigic 2/4/8/16 mg — Square
    • Methilon 2/4/8/16 mg — Opsonin
    • Methsolon 4/8/16 mg — Incepta
    • Predixa 4/8/16 mg — UniMed UniHealth
      MedEx lists these methylprednisolone tablet brands and strengths.

10. Bangladesh doctors’ common prescription drug groups — কেন দেন?

  • NSAID: Naproxen / Aceclofenac / Diclofenac / Etoricoxib — pain + inflammation কমাতে।
  • PPI: Esomeprazole — NSAID-induced gastritis/ulcer prevention।
  • Muscle relaxant: Tizanidine / Tolperisone — paraspinal spasm কমাতে।
  • Adjunct analgesic: Paracetamol — mild pain বা NSAID contraindication adjunct।
  • Neuropathic pain agent: Pregabalin / Gabapentin — burning radicular pain-এর trial; guideline caution।
  • Short-course opioid: Tramadol — severe acute pain only; chronic use avoid।
  • Steroid: Methylprednisolone — some local practice, but routine guideline-supported নয়; acute severe sciatica হলে epidural steroid specialist procedure হিসেবে consider।

11. Interventional / Surgical treatment

A. Epidural steroid injection

  • Acute severe sciatica, severe radicular pain, conservative treatmentে inadequate response হলে specialist setting-এ consider।
  • NICE acute severe sciatica-তে epidural local anaesthetic + steroid consider করতে বলেছে।

B. Surgery — microdiscectomy / endoscopic discectomy

Indication:

  • Cauda equina syndrome — emergency
  • Progressive motor deficit / foot drop
  • Persistent disabling sciatica > 6–12 weeks despite conservative treatment
  • MRI finding matches clinical level
  • Recurrent severe radicular pain with neurological deficit

NICE sciatica-তে non-surgical treatmentে pain/function improve না হলে এবং radiology symptom-এর সাথে consistent হলে spinal decompression consider করতে বলেছে। Early surgery faster sciatica relief দিতে পারে, তবে অনেক trial-এ 1-year outcome conservative care-এর সাথে কাছাকাছি।

12. Prevention — কীভাবে প্রতিরোধ করবেন

  • Proper lifting technique: কোমর না ভেঙে knee bend করে weight body-এর কাছে রাখুন।
  • Avoid flexion + twisting: বিশেষ করে ভারী জিনিস তোলার সময়।
  • Core strengthening: abdominal, multifidus, gluteal strengthening।
  • Regular walking/swimming: low-impact aerobic exercise।
  • Weight control: BMI high হলে lumbar load কমাতে weight reduction।
  • Stop smoking: disc nutrition ও healing-এর জন্য।
  • Ergonomic sitting: chair lumbar support, screen eye level, 30–45 min পরপর standing break।
  • Driving: long drive-এ lumbar roll, interval break।
  • Sleep posture: side lying with pillow between knees বা supine with pillow under knees।
  • Exercise + education: systematic review অনুযায়ী exercise alone বা educationসহ exercise low back pain prevention-এ effective হতে পারে।

Overview / Summary

Lumbar disc prolapse হলো lumbar disc material বের হয়ে nerve root compress/inflame করা। প্রধান লক্ষণ হলো low back pain + sciatica, dermatomal numbness, reflex change, weakness। Diagnosis primarily clinical, MRI দরকার হয় red flag, neurological deficit, persistent radicular pain বা intervention planning-এ। অধিকাংশ রোগী conservative treatment—activity, physiotherapy, NSAID-based pain control, education—দিয়ে ভালো হয়। Emergency signs: bladder/bowel dysfunction, saddle anaesthesia, progressive weakness/foot drop।

Actionable Plan / Steps

  1. Red flag screen করুন: bladder/bowel, saddle anaesthesia, progressive weakness, fever/cancer/trauma।
  2. Neurological chart করুন: L4/L5/S1 motor, sensory, reflex, SLR/crossed SLR।
  3. No red flag হলে: 2–6 সপ্তাহ conservative management—activity, physio, NSAID ± PPI, short muscle relaxant।
  4. Persistent radicular pain >6 weeks বা deficit থাকলে: MRI lumbosacral spine।
  5. Severe acute sciatica: specialist referral for epidural steroid consideration।
  6. Cauda equina/foot drop/progressive deficit: urgent MRI + emergency spine surgery referral।
  7. Prevention: core exercise, weight control, ergonomic correction, lifting technique, smoking cessation।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. McGraw-Hill; chapter: Back and Neck Pain.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Elsevier; chapter: Neurological disorders / back pain and radiculopathy.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Elsevier; musculoskeletal/spine degenerative disease principles.
  4. DeJong’s The Neurologic Examination, 8th ed.; radiculopathy clinical localization.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed.; NSAIDs, opioids, glucocorticoids, antidepressants/gabapentinoids.
  6. Katzung Basic & Clinical Pharmacology, 16th ed.; NSAIDs, opioids, muscle relaxants, anticonvulsants.

Guidelines

  1. NICE NG59. Low back pain and sciatica in over 16s: assessment and management. Last updated 11 Dec 2020.
  2. North American Spine Society / NASS. Evidence-based clinical guideline for diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014. DOI: 10.1016/j.spinee.2013.08.003.
  3. American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain. Ann Intern Med. 2017. DOI: 10.7326/M16-2367.

Peer-reviewed articles with DOI

  1. Kreiner DS, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–191. DOI: 10.1016/j.spinee.2013.08.003.
  2. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. Ann Intern Med. 2017. DOI: 10.7326/M16-2367.
  3. Steffens D, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199–208. DOI: 10.1001/jamainternmed.2015.7431.
  4. Peul WC, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245–2256. DOI: 10.1056/NEJMoa064039.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Wednesday,Time:-11-40-12 Am

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