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Neck and back pain – radicular syndromes 269
pain improvement (at 6 h, three days, and one week) with diclofenac and
either meloxicam dosage, with both drugs outperforming placebo.
Although there are studies of use of muscle relaxants (e.g. benzodiaze-
pines) for undifferentiated neck and back pain, no placebo-controlled trials
have examined their use in acute RSP. Furthermore, since RSP is not caused
by muscle spasm, there is little reason to suspect that muscle relaxants
should be of much therapeutic benefit in these patients.
Patients with refractory RSP often require opioid therapy, but available
evidence does not support specific recommendations. Some studies of undifferentiated
neck or back pain have included subjects with RSP, but no trials
have focused on opioid use in this population. The available data do provide
guidance as to which approaches are less likely to be useful. Studies suggest
no incremental benefit, compared with NSAIDs, for PO low-potency opioids
(e.g. codeine) or agonist–antagonist agents (e.g. meptazinol, ethoheptazine).
15–18 We believe the main role for low-potency opioids in RSP is for
use in patients who fail, or do not tolerate, other therapies such as NSAIDs.
Corticosteroids have been used for the treatment of acute RSP since the
1960s. Their use is rational, since RSP pain is caused by nerve root compression
and inflammation. Nonetheless, recent evidence has questioned
(though not ruled out) a role for corticosteroids in acute RSP.
The injection of corticosteroids into the epidural space is a commonly
used approach. A 2005 review of 11 RCTs assessing epidural corticosteroid
injection for acute (low back-centered) RSP concluded that, while data show
a few weeks’ benefit, pain tends to recur by the second post-treatment
month. 19 A subsequent trial confirmed these findings, reporting significant
improvement in pain scores (compared with placebo) at three weeks, but no
difference by 6–52 weeks. 20 In addition to its limitation of relatively short
analgesia duration, epidural corticosteroid injection requires resources and
expertise (e.g. fluoroscopic guidance) rarely available in the acute care
setting. 20
Corticosteroids have also been administered IV for RSP, with results
similar to those found for local injection: initial relief followed by pain
recurrence. An RCT illustrates that the IV route for corticosteroids is associated
with shorter analgesia duration than that achieved with epidural