IV Dexamethasone for Back Pain and Radiculopathy in the ED
IV Dexamethasone for Back Pain and Radiculopathy in the ED
Objective To assess the effect of a single dose of intravenous dexamethasone in addition to routine treatment on visual analogue scale (VAS) pain scores at 24 h in emergency department (ED) patients with low back pain with radiculopathy (LBPR).
Methods Double-blind randomised controlled trial of 58 adult ED patients with LBPR, conducted in one tertiary and one urban ED. The intervention was 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. The primary outcome was the change in VAS pain scores between presentation and 24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay (EDLOS), straight leg raise (SLR) angles and Oswestry functional scores.
Results Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42, p=0.019) greater reduction in VAS pain scores at 24 h than placebo (dexamethasone: −2.63 (95% CI −3.63 to −1.63) versus placebo: −0.77 (95% CI −2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline. Patients receiving dexamethasone had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and improved SLR angle at discharge (14.7°, p=0.040). There was no difference in functional scores.
Conclusions In patients with LBPR, a single dose of intravenous dexamethasone in addition to routine management improved VAS pain scores at 24 h, but this effect was not statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be considered as a safe adjunct to standard treatment.
Each year, 15%–45% of adults suffer low back pain, and 1 in 20 people present to a healthcare professional with a new episode. Based on the 2004–2005 National Health Survey conducted in Australia, 15% of the population reported having back problems, leading to a total expenditure of $A567 million (US$ ~630 million) in the treatment of back pain. In the USA, back pain is the fifth most common reason for all physician visits. In 2006, total healthcare costs associated with low back pain in the USA exceeded US$100 billion per year.
Some causes of acute and chronic low back pain, such as lumbar stenosis or disc herniation causing nerve root compression, can be associated with radiculopathy. For these patients, the current mainstay of emergency department (ED) treatment includes appropriate analgesia and physiotherapy when available.
Although some studies have assessed systemic corticosteroid treatments in back pain, they were performed in settings outside the ED, used tapered dosing for at least 7 days or included patients without radiculopathy. Hence, there is little evidence that single-dose corticosteroids provide additional symptom relief for ED patients with low back pain with radiculopathy (LBPR).
Back pain meets the broad criteria for National Health Priority Area in Australia, in which outcomes can be improved with an effective treatment strategy. Among patients treated for back pain in the emergency setting, almost half still experienced symptoms at 3 months postdischarge, with another cohort study suggesting that nearly one-third of individuals did not achieve a full recovery at 12 months.
In 2010, back pain with radiculopathy accounted for approximately 1% of ED diagnoses in the health district where this study took place. Pain leading to the inability to mobilise appears to be the largest factor preventing discharge after initial management. This poses both a medical and logistical challenge. Thus, improving the management of low back pain has the potential to benefit both patients and the healthcare system. Despite the lack of high-quality evidence, it is not unusual for clinicians to prescribe single-dose parenteral steroids for patients with LBPR, highlighting the need for further data to bridge this evidence-practice gap.
We aimed to assess the effect of a single dose of 8 mg intravenous dexamethasone compared with placebo in addition to standard management (analgesia and physiotherapy referral) in ED patients with LBPR.
We hypothesised that this intervention (compared with placebo) would lead to a greater reduction in the primary outcome: visual analogue scale (VAS) pain scores at 24 h. We also hypothesised that the intervention would improve secondary outcomes including pain scores at 6 weeks, functional scores at 24 h and 6 weeks, ED length of stay (EDLOS) and straight leg raise (SLR) angle.
Abstract and Introduction
Abstract
Objective To assess the effect of a single dose of intravenous dexamethasone in addition to routine treatment on visual analogue scale (VAS) pain scores at 24 h in emergency department (ED) patients with low back pain with radiculopathy (LBPR).
Methods Double-blind randomised controlled trial of 58 adult ED patients with LBPR, conducted in one tertiary and one urban ED. The intervention was 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. The primary outcome was the change in VAS pain scores between presentation and 24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay (EDLOS), straight leg raise (SLR) angles and Oswestry functional scores.
Results Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42, p=0.019) greater reduction in VAS pain scores at 24 h than placebo (dexamethasone: −2.63 (95% CI −3.63 to −1.63) versus placebo: −0.77 (95% CI −2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline. Patients receiving dexamethasone had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and improved SLR angle at discharge (14.7°, p=0.040). There was no difference in functional scores.
Conclusions In patients with LBPR, a single dose of intravenous dexamethasone in addition to routine management improved VAS pain scores at 24 h, but this effect was not statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be considered as a safe adjunct to standard treatment.
Introduction
Each year, 15%–45% of adults suffer low back pain, and 1 in 20 people present to a healthcare professional with a new episode. Based on the 2004–2005 National Health Survey conducted in Australia, 15% of the population reported having back problems, leading to a total expenditure of $A567 million (US$ ~630 million) in the treatment of back pain. In the USA, back pain is the fifth most common reason for all physician visits. In 2006, total healthcare costs associated with low back pain in the USA exceeded US$100 billion per year.
Some causes of acute and chronic low back pain, such as lumbar stenosis or disc herniation causing nerve root compression, can be associated with radiculopathy. For these patients, the current mainstay of emergency department (ED) treatment includes appropriate analgesia and physiotherapy when available.
Although some studies have assessed systemic corticosteroid treatments in back pain, they were performed in settings outside the ED, used tapered dosing for at least 7 days or included patients without radiculopathy. Hence, there is little evidence that single-dose corticosteroids provide additional symptom relief for ED patients with low back pain with radiculopathy (LBPR).
Back pain meets the broad criteria for National Health Priority Area in Australia, in which outcomes can be improved with an effective treatment strategy. Among patients treated for back pain in the emergency setting, almost half still experienced symptoms at 3 months postdischarge, with another cohort study suggesting that nearly one-third of individuals did not achieve a full recovery at 12 months.
In 2010, back pain with radiculopathy accounted for approximately 1% of ED diagnoses in the health district where this study took place. Pain leading to the inability to mobilise appears to be the largest factor preventing discharge after initial management. This poses both a medical and logistical challenge. Thus, improving the management of low back pain has the potential to benefit both patients and the healthcare system. Despite the lack of high-quality evidence, it is not unusual for clinicians to prescribe single-dose parenteral steroids for patients with LBPR, highlighting the need for further data to bridge this evidence-practice gap.
We aimed to assess the effect of a single dose of 8 mg intravenous dexamethasone compared with placebo in addition to standard management (analgesia and physiotherapy referral) in ED patients with LBPR.
We hypothesised that this intervention (compared with placebo) would lead to a greater reduction in the primary outcome: visual analogue scale (VAS) pain scores at 24 h. We also hypothesised that the intervention would improve secondary outcomes including pain scores at 6 weeks, functional scores at 24 h and 6 weeks, ED length of stay (EDLOS) and straight leg raise (SLR) angle.