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病例漫谈103:腰椎间盘突出诱发严重疼痛的治疗 [复制链接]

Lumbar intervertebral disk protrusion can cause excruciating pain in severe cases, which can be exacerbated by activity such as sitting down and straining at stool. Acute sciatica due to disk rupture will improve within 1 to 3 months. The efficacy of drugs used for the management of sciatica in primary care is unclear. Severe cases can require opioid analgesia, however people taking opioids for pain relief frequently present with opioid-induced bowel dysfunction. The use of transforaminal steroid injections is a controversial issue and repeat steroid injections should be considered in light of the risk-benefit profile of the individual patient.

This article describes a case where strong opioid medication was required to relieve pain and where prolonged release oral oxycodone/naloxone presented the advantage of limiting situations where opioid-induced constipation would cause exacerbation of existing pain.

This case illustrates that many patients with lumbar disk protrusion complain of a significant exacerbation of their back and radicular pain as a consequence of coughing, straining at stool and so on. Many of these patients require opioid medication to control their pain; however, the ever-present problem of opioid-induced constipation can exacerbate their pain. The use of prolonged release oral oxycodone/naloxone in this situation could therefore be beneficial.


A 40-year-old male sales representative was referred acutely to the pain clinic by his family doctor. He had been previously diagnosed with type 2 diabetes mellitus. He had severe right-sided low back pain radiating to his right buttock and down the lateral aspect of his right thigh and calf. This pain occurred suddenly 2 weeks prior to review. His family doctor had prescribed diclofenac 50 mg three times daily and pregabalin 75 mg 12 hourly. The pain did not settle, so his doctor had prescribed prolonged release oxycodone 10 mg twice daily and this was increased to 10 mg three times daily 2 days later, in addition to immediate release oxycodone 10 mg 2-4 hourly for acute exacerbations of pain.
一例40岁男性患者,其工作是销售代表,因急性疼痛由其家庭医生送到了疼痛门诊部。  之前,患者已被诊断出患有II型糖尿病。患者右侧下腰背疼痛已经放射到右臀部,以及右大腿和小腿的外侧。此疼痛于就诊检查前2周突发。患者的家庭医生开具的处方为双氯芬酸50 mg(每日三次),普瑞巴林75 mg(每12h一次)。但该处方没有减轻疼痛,随后医生让其服用口服缓释羟考酮,每次10 mg,每日两次,2天后服药剂量增加到每次10 mg,每日三次,同时服用速释羟考酮以避免急性疼痛加重,每次10 mg,每2 - 4 h服用一次。

The patient complained that sitting down and, in particular, straining at stool exacerbated his pain.He stated that this exertion increased his pain score to “20/10” on the visual analog scale. He did not have any symptoms associated with cauda equine syndrome, or other “red flag” symptoms.

An MRI of the lumbar spine confirmed the presence of an annular tear at L4-5 and a broad-based right posterolateral disk protrusion at L5-S1, with impingement of the exiting L5 spinal nerve. Because of difficulties arranging a day case admission for a therapeutic right-sided transforaminal epidural injection of steroid, the patient was commenced on prolonged release oxycodone 20 mg/naloxone 10 mg combined tablet twice daily in conjunction with a fecal softener/stimulant, two capsules at night.

There was a 4 day delay in gaining admission to hospital for treatment, however the treatment regimen described above was successful in controlling the patient’s pain and there were no exacerbations of pain due to straining at stool.

The patient underwent a successful transforaminal injection under radiological screening and he was referred for neurosurgical opinion. As his pain was well controlled and there were no further complications, surgery was deferred and the patient was scheduled for a repeat transforaminal injection of steroid. His oxycodone/naloxone dosage was decreased to 10/5 mg twice daily immediately post-procedure and this achieved adequate pain control. It is envisaged to discontinue the oxycodone/naloxone immediately following the repeat injection.

Annica Rhodin

This patient has a few weeks history of severe pain due to right posterolateral disk protrusion with impingement on the L5 spinal nerve but no signs of cauda equina impact. He also has type 2 diabetes. His pain mechanism, as described, would be mixed nociceptive-neuropathic. There is inadequate pain relief with diclofenac 50 mg three times daily and pregabalin 75 mg twice daily. Prolonged release oxycodone 10 mg three times daily and immediate release oxycodone 10-40 mg as needed is added. However, constipation and straining at stool increases the pain.
Annica Rhodin
该患者因右后侧椎间盘突出对L5脊神经的撞击,造成剧烈疼痛持续了数周,但马尾神经未受影响。患者同时患有II型糖尿病。此痛苦机制为混合型疼痛(伤害性疼痛联合神经性疼痛)。双氯芬酸(50 mg,每日三次)联合普瑞巴林(75 mg,每12h一次)没有达到止痛的效果。然而,缓释羟考酮(10mg,每日三次)联合速释羟考酮(根据需要在处方中增加,10-40mg),便秘和用力大便会使疼痛加剧。

In the case described, oxycodone is switched to prolonged release oxycodone 20 mg/naloxone 10 mg together with a fecal stool softener/stimulant, relieving the problem with constipation contributing to the pain experience. This certainly improves the situation for the patient. However, the invasive procedure of transforaminal injection of steroid in a patient with acute pain is a controversial issue. Even if there is a low risk of complications as cited in many reviews, there are cases of neuronal damage, bleeding and infection. Repeat steroid injections should be carefully considered in respect of the risk-benefit profile of this patient with diabetes. Also, this procedure is not easily accessible in most hospitals.

An alternative conservative treatment would be to try a different anti-inflammatory drug to diclofenac, as individual patients may respond differently to different NSAIDs. Furthermore, amitriptyline 10-50 mg could be started at night together with physiotherapy and TENS. Most cases of acute sciatica resolve within 1-3 months.

Elon Eisenberg

This case raises three important issues: first, the majority of patients with acute sciatica due to disk rupture will improve within 1-3 months; only a small proportion of patients, typically those with intractable pain or with significant neurological deficits, require surgery. 1 This means that the majority of the patients with sciatica should be managed in the primary care/pain clinic setting, rather than being referred to spine surgeons. Primary care practitioners should therefore be capable of diagnosing and managing patients with uncomplicated acute sciatica.
Elon Eisenberg

Second, although sciatica is the most common form of neuropathic pain, a recent systematic review on drugs for the relief of sciatic pain concluded that “ the efficacy and tolerability of drugs commonly prescribed for the management of sciatica in primary care is unclear.” 2 No wonder therefore that the selection of analgesics prescribed for this condition is often arbitrary. Nonetheless, if pain is severe and image-guided steroid injections are not readily available, the use of a “strong” opioid in combination with an adjuvant drug (anticonvulsants, antidepressants or steroids) or an anti-inflammatory drug may make sense.

Third, studies show that, on average, approximately 40% of patients who consume opioids are constipated. Reduced mobility associated with the acute or subacute phases of severe sciatic pain may also be expected to cause constipation. Constipation, in turn, often exacerbates sciatic pain around strained bowel movements, as seen in the presented patient. Hence, the use of oxycodone/naloxone combination for acute sciatica (and perhaps for additional forms of acute exacerbations of chronic pain) seems reasonable.

由Medicool医库软件 王露黔 编译

原文来自 Journal of Pain &Palliative Care Pharmacotherapy

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