Category: Orthopedics
Keywords: lower back pain, analgesia, NSAIDs (PubMed Search)
Posted: 4/8/2023 by Brian Corwell, MD
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Acute lower back pain is a very common emergency department presenting complaint. Over the last several years there has been impetus to move away from opioids in the management of lower back pain.
A recent systematic review investigated the pharmacologic management of acute low back pain. This review looked at RCTs investigating the efficacy of muscle relaxants, NSAIDs, and acetaminophen for the treatment of acute nonspecific lower back pain of fewer than 12 weeks duration in patients > 18 years of age. Studies that investigated the use of opioids were not considered.
18 RCTs, totaling 3478 patients were included. 54% were women. The mean patient age was 42.5 ± 7.3 years. The mean length of follow-up was 8.0 ± 5.6 days. The mean duration of symptoms before treatment was 15.1 ± 10.3 days.
Results: Muscle relaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately 1 week.
The combination of NSAIDs and acetaminophen was associated with a greater improvement than the sole administration of NSAIDs.
However, acetaminophen alone did not promote any significant improvement. Placebo administration was not effective.
Limitations: Most patients with acute LBP experience spontaneous recovery or at least reduction of symptoms, therefore, the real impact of most medications is uncertain. The present study wasn't able to distinguish among different classes of NSAIDs. A best practice treatment protocol cannot be extrapolated from this study.
Take home: In my practice, patients are treated with NSAIDs and Acetaminophen first line. I also include Licocaine patches for all patients. If there is a contraindication to NSAIDs, I treat with muscle relaxants alone.
This study highlights the lack of benefit of acetaminophen as mono therapy (which has been noted in other studies).
Baroncini A, et al. Nonopioid pharmacological management of acute low back pain: A level I of evidence systematic review. J Orthop Res. 2023 Feb 22. doi: 10.1002/jor.25508.
