Ketorolac (Toradol) for Acute Back Pain
Ketorolac is an effective option for acute low back pain in patients presenting to the emergency department, providing analgesia comparable to opioids with a superior adverse effect profile, but it must be limited to short-term use (≤5 days) and should be combined with other therapies for optimal pain control. 1, 2
Evidence for Ketorolac in Acute Back Pain
A randomized controlled trial directly comparing ketorolac to acetaminophen-codeine in 123 ED patients with acute low back pain found equivalent analgesic efficacy between the two agents, but ketorolac had significantly fewer adverse events and no withdrawals due to drug side effects (compared to 7 withdrawals in the acetaminophen-codeine group). 2
Ketorolac provides analgesia equivalent to standard doses of morphine and meperidine for moderate-to-severe pain, though onset of action is delayed (30-60 minutes) and approximately 25% of patients may exhibit little or no response. 3, 4
The FDA label explicitly restricts ketorolac to short-term management (≤5 days) of moderately severe acute pain requiring opioid-level analgesia, typically in postoperative settings, with oral formulations used only as continuation therapy after initial IV/IM dosing. 1
Clinical Algorithm for the "Hunched Over" Back Pain Patient
Start with ketorolac 60 mg IM as initial therapy in the ED for rapid pain control, recognizing that maximal effect occurs approximately 2.2 hours after dosing. 5, 2
Consider adding a muscle relaxant (such as cyclobenzaprine) for short-term use (≤1-2 weeks) if severe pain persists, as combination therapy targeting both inflammatory and muscle spasm components may provide enhanced relief. 6, 7
Transition to oral NSAIDs (such as ibuprofen 400-800 mg every 6 hours, maximum 2.4 g/day) after initial ED treatment rather than continuing oral ketorolac, as guidelines recommend NSAIDs as first-line therapy for acute low back pain. 5
If radicular symptoms (sciatica) are present, add gabapentin titrated to 1200-3600 mg/day for the neuropathic component, as this addresses radiculopathy more effectively than NSAIDs alone. 6, 8
Critical Limitations and Pitfalls
Do not prescribe ketorolac for more than 5 days total (combined IV/IM and oral), as prolonged use significantly increases risk of gastrointestinal bleeding, operative site bleeding, and acute renal failure, particularly in elderly patients. 1, 4
Avoid ketorolac in patients with aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, or significant renal impairment. 5
Do not use ketorolac as monotherapy expecting complete pain resolution—approximately 25% of patients fail to obtain adequate relief, and it works best when supplementing other analgesics or as part of multimodal pain management. 3
In older adults (>60 years), exercise particular caution due to increased risk of renal, gastrointestinal, and cardiac toxicity; consider lower doses and shorter duration. 8, 9
Comparative Context
Guidelines from the American College of Physicians and American Pain Society recommend against opioids as first-line therapy for acute low back pain, positioning NSAIDs (including ketorolac) as preferred initial agents. 5
The Cochrane review found NSAIDs slightly effective for short-term symptomatic relief in acute low back pain without sciatica, with fewer adverse effects than opioids or muscle relaxants. 5
For the "hunched over" presentation suggesting severe acute pain, ketorolac provides opioid-equivalent analgesia without the sedation, respiratory depression, or abuse potential of narcotics, making it preferable for initial ED management. 2, 4