Muscle Relaxers for Back and Neck Pain

Back and neck pain are very common symptom in group of adult and senior citizens.¹ The muscles of the lower back and neck controls the movement of the head like flexion, extension, sideways bending, and rotation. Muscles end into tendon at both ends. The tendons and ligaments are attached to the bones of vertebra and fan out towards the shoulder blades. Several paravertebral muscles attached to vertebral column helps to achieve movements like forward, backward and side bending as well as twisting, turning and rotational movements. The most common cause of back and neck pain is muscle sprain, spasm and fatigue. Less common causes are muscle injury, bulge disc, herniated disc, pinched nerve, facet joint arthritis and nerve injury. The domestic fall, work injury and auto accident often results in back and neck pain secondary to muscle, ligament, tendon or disc injury resulting in tear or fracture. In such cases muscle spasm and muscle fatigue are treated with muscle relaxants and back and neck pain is treated with NSAIDs or opioids. Opioids are often avoided to prevent possible addiction and instead muscle relaxants are used with NSAIDs to treat back and neck pain.

Back and neck pain may range from mild to severe depending on the cause of pain.

• Acute Back and Neck Pain – Last for less than 3 to 6 months. Pain occurs suddenly and will heal within several days to weeks. This type of back and neck pain is usually due to problems originating in the muscles, ligaments, joints or discs.²
• Chronic Back and Neck Pain – The chronic pain in the back and neck usually lasts for more than 3 to 6 months. It may worsen with certain activities. Contributing factors include injury of muscles, ligament, tendon and nerve as well as bulge or herniation of disc.

Skeletal muscle relaxants are often prescribed for low back and neck pain when caused by muscle spasm or fatigue.³ The muscle relaxers are also prescribed when back or neck pain is caused by cerebral palsy or multiple sclerosis.

Below is a list of antispasmodic drugs given for relieving neck, mid back and lumbar pain. The description also includes dosages and adverse effects if relaxants is used for long-term.

• Carisoprodol: Dosage 350 mg 4 times a day. Carisoprodol is contraindicated in children below 12 years for reducing any pain. Adverse effects include dizziness, drowsiness, headache, anaphylactic shock, idiosyncratic reactions.
• Chlorzoxazone: Dosage 250 to 750 mg three times a day to reduce back and neck pain. Children 20 mg per kg daily thrice daily. Adverse effects are dizziness, drowsiness, red/orange urine, GI irritation, hepatoxicity.
• Cyclobenzaprine: 5 mg thrice a day up to 10 mg. The adverse effects of cyclobenzaprine are anticholinergic effects, arrhythmias, myocardial infarction, seizures.
• Diazepam: Diazepam is given as 2 to 10 mg 3-4 times a day to treat back and neck pain. For children the dosages are 0.12 to 0.80 mg per kg daily thrice or four times a day. Adverse effects – dizziness, drowsiness, confusion.
• Metaxalone: 800 mg 3-4 times a day to reduce back and neck pain. This medicine is contraindicated in children below 12 years. Adverse effects include dizziness, drowsiness, headache, nervousness, leukopenia, LFT elevation, nausea, vomiting, diarrhea, paradoxical muscle cramps.
• Methocarbamol: 1500 mg 4 times a day for 2 days followed by 750 mg 4 times a day to reduce back and neck pain. Adverse effects are black, brown or green urine, mental impairment, exacerbation of myasthenia gravis symptoms.
• Orphenadrine: 100 mg 2 times a day. Anticholinergic effects, aplastic anemia, GI irritation, confusion, tachycardia, hypersensitivity reaction are the adverse effects of this drug due to prolonged intake.
• Tizanidine: 4 mg initially may increase to 2 to 4 mg every six hours till one gets relief from the pain; however, the dosage must not exceed 36 mg daily. Adverse effects are dose related hypotension, sedation, dry mouth. Hepatoxicity, withdrawal and rebound hypertension are also the side effects that are experienced due to prolonged intake of the drug.

The evidence for effectiveness of these medicines for back and neck pain caused by musculoskeletal disease or disorder is limited however their side effects are well documented. The specific relaxants should be selected depending on condition, which may be causing acute or chronic back and neck pain. Dosage depends on severity and the cause of pain in the back and neck. Consult your Primary Care physician, Physical Rehab or Pain Specialist prior to taking any of these muscle relaxers to treat back and neck pain.

Following are other treatment options available for acute or chronic pain of back and neck :

• Conservative Measures: Rest, ice pack, heat, massage, exercise ⁴, physical therapy often provide a considerable amount of relief from back and neck pain.
• Medications: NSAIDS such as ibuprofen, paracetamol, and naproxen provide relief to the majority of patients. Muscle relaxants help in case of muscle spasms. If the pain is severe, combinations of NSAIDs with muscle relaxants or analgesics may be used. Steroids may be given in case of swelling or inflammation.
• Surgery: Surgery is rarely advised unless there is disc herniation, fracture, spinal cord compression, and severe pain with all other treatments being failed.

Back and neck pain can be a debilitating condition. With proper care low back and neck pain could be prevented or at least reduce the recurrence and intensity of pain. Prevention depends on conditioning of the disc, facet joint and paravertebral muscles. The published scientific data suggests muscle and joint of vertebral column are protected by stretching and regular exercises. The muscle spasm and inflammation of muscle, tendon and ligament are prevented by maintaining normal anatomical posture of vertebral column while sitting, bending and standing at work or during traveling. The key points are to keep the back and neck and low back skeletal system in good condition. The neck and low back skeletal system includes vertebral bones, facet joint, disc, paravertebral muscle, tendon and ligament. The skeletal system of neck and lower back is maintained in good condition by maintaining good posture, regular exercise, stress management practicing relaxation techniques, good nutrition, avoiding smoking and regular massage if advised by physician.

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