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Neck and back pain – radicular syndromes
ADAM LEVINE AND STEPHEN H. THOMAS
n Agents
n NSAIDs
n Opioids
n Steroids
n Evidence
True radiculopathy is usually caused by intervertebral disk compression and
subsequent irritation of a spinal nerve root. The etiologic differences between
radiating spine pain (RSP) and other causes of neck and back pain translate
into differences in therapeutic approach. This chapter focuses on pharmacologic
treatment modalities for RSP. Drug treatment remains the mainstay of
RSP analgesia, since studies of most nonpharmacologic approaches find
them ineffective or impractical for ED use. 1,2
The NSAIDs have been studied extensively for pain relief in undifferentiated
low-back pain, but there are fewer data addressing their use in RSP.
Several early studies, each with methodological limitations, failed to show
consistent benefit (over placebo) for use of NSAIDs (e.g. indomethacin,
phenylbutazone, ketoprofen) in acute RSP based in the lower back. 3–8 Two
larger trials have reported conflicting results with regard to piroxicam’s
efficacy. 9,10 A multicenter RCT found IM dipyrone outperformed both diclofenac
PO and placebo in reducing RSP pain at 1, 6, and 48 h, but dipyrone
cannot be recommended owing to its hematologic side effects (which
resulted in its removal from the US market). 11–13
Two recent multicenter RCTs (comprising over 1000 patients) were
designed with more methodological rigor than earlier studies. 14 The first of
these RCTs compared oral meloxicam (a COX-2 selective NSAID), at doses of
7.5 mg and 15 mg PO QD, with placebo; the second compared the same
doses of meloxicam with diclofenac (50 mg PO TID). There was similar