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Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis
  1. Gustavo C Machado1,
  2. Chris G Maher1,
  3. Paulo H Ferreira2,
  4. Richard O Day3,
  5. Marina B Pinheiro2,
  6. Manuela L Ferreira1,4
  1. 1 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  2. 2 Arthritis and Musculoskeletal Research Group, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Department of Clinical Pharmacology, St Vincent's Hospital & University of New South Wales, Sydney, New South Wales, Australia
  4. 4 Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Gustavo C Machado, The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia; gmachado{at}


Background While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain.

Methods We searched MEDLINE, EMBASE, CINAHL, CENTRAL and LILACS for randomised controlled trials comparing the efficacy and safety of NSAIDs with placebo for spinal pain. Reviewers extracted data, assessed risk of bias and evaluated the quality of evidence using the Grade of Recommendations Assessment, Development and Evaluation approach. A between-group difference of 10 points (on a 0–100 scale) was used for pain and disability as the smallest worthwhile effect, as well as to calculate numbers needed to treat. Random-effects models were used to calculate mean differences or risk ratios with 95% CIs.

Results We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days.

Conclusions NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.

  • Low Back Pain
  • NSAIDs
  • Analgesics

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  • Handling editor Tore K Kvien

  • Twitter Follow Gustavo Machado @gustavocmachado

  • Contributors All authors made substantial contributions to the study conception and design or analysis and interpretation of data and were involved in drafting the manuscript and approved the final version.

  • Funding GCM and MBP are supported by an Australian Postgraduate Award from the Department of Education and Training of Australia. CGM is supported by a Principal Research Fellowship from the National Health and Medical Research Council. MLF holds a Sydney Medical Foundation Fellowship, Sydney Medical School.

  • Competing interests None declared.

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