Letter to the Editor: Dexamethasone Works for Acute Back Pai …: Emergency Medicine News


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The title of the article by Dr. Michelle Johnston (REM. 2021; 43[6]: 15; https://bit.ly/3ju6o1d) should be: Does intravenous, intramuscular, oral or epidural dexamethasone have a place in the treatment of acute back pain? My answer is yes, an argument that I support with conversations with other emergency physicians who use it to treat acute back pain through anecdotal experience with patients and personal use.

I understand that one of the official back and spine advisory bodies has stated that steroids have no place in the treatment of back pain. In this time of caution about prescribing opioids, it would be tragic to lead doctors to believe that an effective drug does not work and is not worth trying.

I find that many seasoned emergency physicians consider it important for the treatment of acute back pain, but other emergency physicians either ignore its therapeutic use or, as the columnist stated, disagree with its use for back pain. treble.

Not all steroids are created equal, and prednisone and methylprednisolone are not the same as dexamethasone. I think the most obvious example of the differentiation is that dexamethasone is by far the predominant steroid treatment for preventing and improving acute mountain sickness. My belief is that dexamethasone is more energizing but produces less anxiety than prednisone. Of course, it also has the advantage of having a longer half-life, which is why it is more often used to treat pediatric asthma.

I have found it effective in treating chronic trigger point pain in the upper back, neck muscle spasms, and stiff necks. Unless otherwise indicated, I always treat lower back pain with dexamethasone. I almost always use it orally in the emergency department and will give 8-12 mg as a loading dose, although even 4 mg can be extremely helpful. In some cases, I will give a prescription for two or four dexamethasone 4 mg tablets to be taken every other day or if the pain goes away and comes back.

I find it paradoxical that epidural steroid injections are widely used and are generally considered effective, but other modes of administration are considered ineffective. Systemic steroids are used to treat rheumatological disorders so that they can obviously reach the inflamed joints in sufficient amounts to provide an anti-inflammatory effect.

Coming fully into anecdotal territory, my wife is extremely active but has already undergone spinal fusion for arthritis produced by spondylolisthesis. She doesn’t take dexamethasone often and only 4 mg at a time when she is straining too much on her back, but even 4 mg is extremely effective.

The only times I’ve missed a change in my 40-year career is when I’ve broken something and twice when my back has exploded. I was basically cured by an epidural steroid injection most of the time, and now I will take 4 mg of dexamethasone if I feel my back starting to have a severe spasm, and that almost always prevents it all. Does this mean that I take dexamethasone all the time? No, only about once or twice a month and rarely more than 4 mg for a single episode, although I rarely took 8 mg. A single dose is usually sufficient.

James M. Larson, MD

San Diego

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