Ketorolac Injection for Bulging Disc Pain and Narrowing Facets
Ketorolac (Toradol) injection is not recommended for chronic low back pain from bulging discs and narrowing facets as it lacks evidence for long-term benefit and is only indicated for short-term (≤5 days) management of moderately severe acute pain. 1
Mechanism of Pain in Disc Bulging and Facet Narrowing
- Disc space narrowing significantly increases pressure between facet joints, which may be a source of pain in patients with reduced disc spaces 2
- Facet-mediated pain requires specific diagnostic criteria and is best confirmed through double-injection technique with an improvement threshold of 80% or greater 3, 4
- Imaging findings alone (such as bulging discs or facet narrowing) are insufficient to justify specific interventional treatments 4
Limitations of Ketorolac for This Condition
- Ketorolac is FDA-approved only for short-term (≤5 days) management of moderately severe acute pain, usually in a postoperative setting 1
- The analgesic effect of ketorolac begins in approximately 30 minutes with maximum effect in 1-2 hours and duration of 4-6 hours, making it unsuitable for chronic pain management 1
- While ketorolac has shown comparable single-dose analgesic efficacy to moderate doses of opioids for acute musculoskeletal low back pain in emergency settings, it is not indicated for chronic conditions 5, 6
Evidence-Based Recommendations for Facet-Mediated Pain
- Conservative treatment should be attempted for at least 6 weeks before considering interventional procedures 4
- For facet-mediated chronic low back pain, there is only moderate evidence (Level II) that facet medial nerve ablation produces short-term decrease (3-6 months) of pain 7
- Trigger point injections performed as dry needling, with anesthetics alone or with steroids, are not recommended for chronic low-back pain without radiculopathy from degenerative disease of the lumbar spine 3
Appropriate Diagnostic and Treatment Approach
- Advanced imaging (MRI or CT) is essential before initiating treatment to confirm facet joint pathology and exclude alternative diagnoses 4
- The double-block technique using anesthetics with different durations of action on two separate occasions is the most reliable means of identifying facet-mediated pain 4
- Only one invasive modality or procedure should be considered at a time for the treatment of back pain 8
Potential Treatment Options with Better Evidence
- Facet joint nerve blocks have moderate-quality evidence for both short-term and long-term treatment of facet-mediated low back pain 4
- Radiofrequency ablation (RFA) of facet medial nerves has Level II-III evidence with a strong recommendation for use in patients who respond to diagnostic blocks 4
- Epidural steroid injections may provide only short-term relief (<2 weeks) for chronic back pain 4, 9
Important Caveats
- Relying solely on imaging findings of facet arthropathy to justify interventional treatment is not recommended 4
- Performing facet joint procedures without proper imaging can lead to misdiagnosis of the pain generator 4
- Documented evidence of pain reduction is critical for determining the appropriateness of repeat procedures 4
- There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain overall 10