Musculoskeletal

Backache (including Sciatica)

کمر درد

A common complaint of females and the middle-aged group. Differentiate vitamin D deficiency (SLR negative, no tenderness), muscle strain (tender, SLR negative) and sciatica from disc herniation (SLR positive).

ICD-10: —
Source: OPD handbook pp.85–92
Status: Draft

Not yet reviewed by a clinician. Check doses and brands against current national guidelines before use.

Symptoms

Backache, off and on, relieved by medicine
Severe backache radiating to the leg (sciatica)

Diagnosis

Differential: vitamin D deficiency (83% of the population per the book), SLR negative
Differential: strain (history of injury), SLR negative
Differential: sciatica due to disc herniation, SLR positive
Tenderness positive: strain; SLR positive: disc herniation; no tenderness and no SLR: vitamin D deficiency

Treatment

Step 1 of 4

A. Vitamin D deficiency

Loading dose of vitamin D: Inj D3 200,000 IU/mL, one ampoule in milk once a week for 4 weeks (per the Urdu note)
NSAIDs for temporary relief: Tab Pytex 20 mg 1+1 (piroxicam), Tab Voren 50 mg 1+1 (diclofenac), Tab Neoprox 500 mg 1+1 (naproxen)
Counselling: sit in sunlight; increase eggs, milk, fish; use olive oil as needed

Prescription

Vitamin D3 injectionSupplement

Dose1 ampoule in milk once a week

Brand Inj D3 200,000 IU/mL 4 weeks

Also sold as D3 (200,000 IU), D3 200,000 IU/mL

PiroxicamNSAID

Dose1+1

Brand Tab Pytex 20 mg 5 days (sample)

Also sold as Brysk, Pytex, Brexin, Feldene

Diclofenac sodiumNSAID

Dose1+1

Brand Tab Voren 50 mg

Also sold as Voren, Diclo, Dicloran

NaproxenNSAID

Dose1+1

Brand Tab Neoprox 500 mg

Also sold as Neoprox, Neopron, Flexin, Synflex

Step 2 of 4

B. Backache due to strain

NSAID: piroxicam or naproxen for 5 days
Muscle relaxant: Tab Duragesic Forte (orphenadrine + paracetamol), 1 at night; alternate brands Proval N-Forte, Nuberol Forte
Antioxidant vitamin E: Cap Evion 600 IU, 1 daily

Prescription

PiroxicamNSAID

Dose1+1

Brand Tab Pytex 20 mg 5 days

Also sold as Brysk, Pytex, Brexin, Feldene

NaproxenNSAID

Dose1+1

Brand Tab Neoprox 500 mg 5 days

Also sold as Neoprox, Neopron, Flexin, Synflex

Alternative to piroxicam

Orphenadrine + ParacetamolMuscle relaxant + analgesic

Dose1 at night

Brand Tab Duragesic Forte / Proval N-Forte / Nuberol Forte 5 days

Also sold as Duragesic Forte, Proval N-Forte, Nuberol Forte, Wilgesic

Vitamin E (antioxidant)Antioxidant

Dose1 daily

Brand Cap Evion 600 IU 5 days

Step 3 of 4

C. Sciatica

NSAID: Tab Pytex 20 mg 1+1 or Tab Neoprox 500 mg 1+1
Muscle relaxant: tizanidine, Tab Movax 2 mg 1+1
Pregabalin: indicated in nerve-origin pain such as sciatica, trigeminal neuralgia, post-herpetic neuralgia and shingles; Tab Gabica 50 mg 1+0 at night
B12 (nervine tonic): indications Bell's palsy, shingles, sciatica, megaloblastic anaemia; Tab Neuromet 500 mcg 1+0 daily (or Mexamine, cobalamin)
PPI low dose: Cap Ruling 20 mg OD
Refer to a consultant for further management

Prescription

PiroxicamNSAID

Dose1+1

Brand Tab Pytex 20 mg

Also sold as Brysk, Pytex, Brexin, Feldene

NaproxenNSAID

Dose1+1

Brand Tab Neoprox 500 mg

Also sold as Neoprox, Neopron, Flexin, Synflex

TizanidineMuscle relaxant

Dose1+1

Brand Tab Movax 2 mg

Also sold as Movax, Termelin

PregabalinNeuropathic pain agent

Dose1+0 at night

Brand Tab Gabica 50 mg

Methylcobalamin (vitamin B12)Nervine tonic / B12

Dose1+0 daily

Brand Tab Neuromet 500 mcg / Mexamine / cobalamin

Also sold as Neuromet, Mexamine, Cobalamin, Mexamin, Methycobal

OmeprazoleProton pump inhibitor

DoseOD

Brand Cap Ruling 20 mg

Also sold as Risek, Teph, Ruling, Ruling sachet, Omega

Step 4 of 4

D. Counselling and referral (Urdu notes)

Pray on a chair
Avoid climbing stairs
Sleep on a hard, flat surface
Avoid travelling, heavy work, continuous standing and prolonged bending
Use a western commode in the washroom
Avoid the advice of relatives
Refer to a consultant when needed

Sample prescriptions from the book (patient details removed)

Female, 40 y, backache off and on, relieved with medicine for 2 months; SLR negative; vitamin D deficiency: Inj D3 200,000 IU/mL, one ampoule in milk once a week for 4 weeks; Tab Pytex 20 mg 1+1 for 5 days; sit in the sunlight; increase eggs, milk, fish; use olive oil as needed.
Male, 26 y, severe backache radiating to the left leg, sharp, very severe; muscle pull and SLR positive; sciatica: Inj Mexamine 500 mcg IM stat (B12); Inj Toradol IM stat. Rx: Tab Movax 2 mg 1+1; Tab Gabica 50 mg 1+0 at night; Tab Neoprox 500 mg 1+1; Cap Mexamine 500 mcg 1 daily; Cap Ruling 20 mg 1+0; refer to a consultant.
Male, 35 y, backache 2 days, moderate to severe, after lifting 40 kg; tender, pain on bending forward, SLR negative; strain: Tab Pytex 20 mg 1+1 for 5 days; Tab Duragesic Forte 1 at night for 5 days; Cap Evion 600 IU 1 daily for 5 days; avoid lifting weight, unnecessary travel, bending work and prolonged sitting; sleep on a hard bed; pray sitting on a chair.