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Title of Dr. Michelle Johnston’s article (Electromagnetic network. 2021;43:15; https://bit.ly/3ju6o1d) It should be, does intravenous, intramuscular, oral or epidural dexamethasone have a role in the treatment of acute back pain? My answer is yes. I support this argument in my conversations with other emergency doctors who treat acute back pain through anecdotal experience with patients and personal use.
I know that one of the official back and spine consulting agencies has declared that steroids have no place in the treatment of back pain. In this period of caution regarding prescription opioids, it would be tragic to convince doctors that an effective drug does not work and is not worth trying.
I have found that many experienced emergency doctors think it is important for the treatment of acute back pain, but other emergency doctors either do not know how to use it for treatment or, as the columnist pointed out, disagree with it for the treatment of acute back pain.
Not all steroids are created equal, prednisone and methylprednisolone are different from dexamethasone. I think the most obvious example of the difference is that dexamethasone is by far the main steroid treatment for preventing and improving acute mountain sickness. My belief is that dexamethasone is more energetic than prednisone, but it produces less anxiety. Of course, it also has the advantage of a longer half-life, which is why it is more commonly used to treat asthma in children.
I found it to be effective in treating chronic upper back trigger point pain, neck muscle spasms and neck twists. Unless there are contraindications, I always use dexamethasone to treat low back pain. I almost always take it by mouth in the emergency department and will give 8-12 mg as a loading dose, although even 4 mg will be very helpful. In some cases, I will prescribe two or four 4 mg dexamethasone tablets every other day, or if the pain disappears and recurs.
I found that epidural steroid injections are widely used and generally considered to be effective, but other methods of administration are considered ineffective, which is paradoxical. Systemic steroids are used to treat rheumatic diseases, so they can obviously reach the inflamed joints in sufficient amounts to provide anti-inflammatory effects.
Stepping into the realm of anecdotes completely, my wife is very active, but her arthritis caused by spondylolisthesis had undergone spinal fusion. She doesn’t take dexamethasone very often. When she is overworked, she only takes 4 mg at a time, but even 4 mg is very effective.
In my 40-year career, the only change I missed was something I broke and my back exploded twice. Most of the time I was basically cured by epidural steroid injections. Now if I feel that my back starts to cramp badly, I will take 4 mg of dexamethasone, which almost always stops everything. Does this mean I have been taking dexamethasone? No, only about once or twice a month, and a single episode rarely exceeds 4 mg, although I rarely take 8 mg. A single dose is usually sufficient.
James M. Larson, MD