Mechanical Back Pain Date Last Search Run: Aug 01, 2024 Table last updated: Oct 25, 2021 Data last added: Sep 29, 2021

Recommendation		RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION		SUPPORTIVE (Green)	NEUTRAL (Yellow)	AGAINST (Red)	NOT YET GRADED (White)
	1 (strong evidence exists)	Ketamine Morphine	Benzodiazepines
	2 (fair evidence exists)	NSAIDs
	3 (weak evidence exists)	Fentanyl Nitrous Oxide

Interventions

Benzodiazepines

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
I	Neutral (Yellow)	Pain relief at 7 days	Patient	ED-MD	Friedman BW, Irizarry E, Solorzano C, Khankel N, Zapata J, Zias E, et al. Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain. Ann Emerg Med 2017; 70(2) 169-76.e1. Medline

Fentanyl

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
III	Supportive (Green)	Analgesia	Patient	PH-Paramedic	Rickard C., et al. A RCT of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 2007; 25:911-7. Medline

Ketamine

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
I	Supportive (Green)	Pain relief	Patient	ED-MD	Miller JP., Schauer SG., Ganem VJ., Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: A randomized controlled trial. Am J Emerg Med 2015; 33(3):402-8. Medline
III	Supportive (Green)	Reduction in pain	Patient	ED-MD	Goltser A., Soleyman-Zomalan E., Kresch F., Motov S. Short (low-dose) ketamine infusion for managing acute pain in the ED: Case-report series. Am J Emerg Med 2015; 33(4):e5-7. Medline

Morphine

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
I	Supportive (Green)	Pain Scale	Patient	ED-MD	Birnbaum A., Esses D., Bijur PE., Holden L., Gallagher EJ. Randomized double-blind placebo-controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med 2007; 49(4):445-53. Medline
I	Supportive (Green)	Pain relief	Patient	ED-MD	Miller JP., Schauer SG., Ganem VJ., Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: A randomized controlled trial. Am J Emerg Med 2015; 33(3):402-8. Medline
III	Supportive (Green)	Analgesia	Patient	PH-Paramedic	Rickard C., et al. A RCT of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 2007; 25:911-7. Medline

Nitrous Oxide

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
III	Supportive (Green)	Patient satisfaction	Patient	PH-Paramedic	Johnson JC., Atherton Gl. Effectiveness of Nitrous Oxide in a rural EMS System. The Journal of Emergency Medicine 1991; 9:45-53. Medline

NSAIDs

Level	Direction	Primary Outcome	Patient/Process	Setting	Reference
II	Supportive (Green)	Pain	Patient	ED-MD	Ashbrook J, Rogdakis N, Callaghan MJ, Yeowell G, Goodwin PC. The therapeutic management of back pain with and without sciatica in the emergency department: A systematic review. Physiotherapy 2020; 109:13-32. Medline