Use of Skeletal Muscle Relaxants and Gabapentinoids in Cervical Spondylosis

Evidence Base for Muscle Relaxants

No high‑quality trials directly evaluate muscle relaxants for cervical spondylosis; current evidence is extrapolated from acute low‑back‑pain studies. 1
Skeletal muscle relaxants provide modest short‑term benefit for acute musculoskeletal pain (2–4 days), increasing the chance of ≥30 % pain reduction (relative risk 1.25–1.72 vs placebo). 1

Cyclobenzaprine is the most studied agent for acute musculoskeletal conditions and shows moderate superiority to placebo for short‑term pain relief. 2
No single muscle relaxant has demonstrated superiority over others; selection should be based on side‑effect profile and patient comorbidities. 3
Clinical trials evaluated only 2‑week courses; treatment duration should not exceed 7–14 days. 3

All skeletal muscle relaxants double the risk of central‑nervous‑system adverse events (RR 2.04 vs placebo), mainly sedation and dizziness, raising fall risk in patients with limited mobility (e.g., cervical myelopathy or severe radiculopathy). [1][3]
Cyclobenzaprine has anticholinergic properties and does not produce true muscle relaxation despite its name. 2
Carisoprodol should be avoided because of abuse potential and lack of advantage over cyclobenzaprine. 3
Benzodiazepines are not recommended for cervical spondylosis due to higher abuse potential, tolerance development, and absence of FDA approval for this indication. 3
Combining muscle relaxants with benzodiazepines or opioids markedly increases sedation and respiratory‑depression risk; such combinations should be avoided. 3

Gabapentin or pregabalin are recommended as first‑line agents for cervical radiculopathy (arm pain, numbness, weakness). 3
An adequate therapeutic trial of gabapentin requires 3–8 weeks of titration plus an additional 2 weeks at the target dose (total 5–10 weeks). 3
Renal function must be assessed before initiating or titrating gabapentinoids, with dose adjustments for renal insufficiency. 3
Muscle relaxants should not be used as monotherapy for chronic radicular pain; gabapentinoids have stronger supporting evidence. 3

Baclofen (a GABA‑B agonist) may be considered for spasticity secondary to cervical myelopathy, but it does not address the underlying spinal‑cord compression. 2