EMJ Podcast January 2021

Author: Graham Johnson, Andrew Tabner / Codes: / Published: 26/01/2021


Tabner A, Johnson G

Paper Title

Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials

Paper Authors

Crystian B Oliveira Hugo E Amorim, Danielle M Coombs Bethan Richards Marco Reedyk Chris G Maher Gustavo C Machado

Link to Paper

What is already known on this subject

Hundreds of trials have investigated interventions in people with low back pain or sciatica, although most have limited applicability to emergency care.

There are few trials that enrol participants, provide treatment and measure outcomes in the emergency department.

What this study adds

Ketoprofen gel for low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence between different treatment options.

The results derived from single trials, thus, additional trials measuring patient-reported outcomes and those relevant to the emergency department are needed.

Study Design

Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (18 years) with nonspecific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence.


Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30min (mean difference (MD) 15.0, 95% confidence interval (CI) 21.0 to 9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD 15.7, 95%CI 19.8 to 11.6) and intravenous morphine (MD 11.4, 95%CI 21.6 to 1.2) were both superior to placebo at 30min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95%CI 0.71 to 18.7) or sciatica (MD 6.8, 95%CI 24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating nonpharmacological treatments (low quality evidence).

Authors Conclusion

Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving nonpharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.


Many therapies not relevant to the UK.

By design, focussed purely on ED outcomes and did not examine representation rates.

Our Take Home

Nothing particularly surprising with this study, even considering that many therapies are not standard for UK practice.

A multimodal approach with paracetamol, an NSAID and an opiate +/- physical therapy is likely to be effective.

Topical NSAID is not something that we typically use, but looks to be effective from this study and may be worth using.

Online Learning

www.rcemlearning.co.uk lower back pain

www.rcemlearning.co.uk back pain advice know say

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