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Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials
  1. Crystian B Oliveira1,2,
  2. Hugo E Amorim3,
  3. Danielle M Coombs3,4,
  4. Bethan Richards3,5,
  5. Marco Reedyk6,
  6. Chris G Maher3,4,
  7. Gustavo C Machado3,4
  1. 1Department of Physical Therapy, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, Sao Paulo, Brazil
  2. 2University of Western São Paulo (Unoeste), Presidente Prudente, Sao Paulo, Brazil
  3. 3Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
  4. 4School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  5. 5Rheumatology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
  6. 6Emergency Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
  1. Correspondence to Dr Crystian B Oliveira, Department of Physical Therapy, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, Sao Paulo, Brazil; crystianboliveira{at}


Background Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit.

Methods 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 non-specific 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.

Results 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 30 min (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 30 min. 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 non-pharmacological treatments (low quality evidence).

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 non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.

  • spine non trauma
  • emergency department management
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  • CBO and HEA are joint first authors.

  • Handling editor David Metcalfe

  • Twitter @crystianbso, @gustavocmachado

  • Presented at Poster presentation at the Musculoskeletal Network Forum, 28 February 2019, Sydney, Australia.

  • Contributors CBO, HEA, DMC, BR, MR, CGM and GCM were involved in the design of the review. CBO, HEA and DC developed the search strategy, and performed study selection, data extraction and risk of bias from included studies. CBO, CGM and GCM were involved in the data analysis. All authors were involved in interpretation and discussion of results, drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication.

  • Funding CBO was supported by São Paulo Research Foundation (FAPESP/grant number: 2018/10837-9). CGM is supported by an NHMRC Principal Research Fellowship. GCM is supported by an NHMRC Early Career Fellowship.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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