Effectiveness of Injectable Ketorolac for Acute Exacerbations of Sciatic Pain With a History of Long-Term Adjuvant Piroxicam Therapy: A Case Report

Background: Acute pain exacerbations in chronic sciatica patients previously controlled with long-term oral NSAIDs present a unique clinical challenge, as they require rapid-acting analgesia while taking into account prior NSAID exposure. Ketorolac is a non-selective parenteral NSAID with analgesic potency comparable to opioids, frequently utilized as rescue therapy for moderate-to-severe acute pain in emergency and inpatient settings. Objective: This report aims to evaluate the effectiveness of ketorolac injection in an acute exacerbation of sciatic pain with a history of long-term piroxicam therapy. Methods: A 62-year-old female presented with sudden low back pain accompanied by tingling radiating down both legs, rendering her unable to walk properly, following a bending motion to lift heavy groceries. The patient had a 10-year history of chronic ischialgia/sciatica controlled with oral piroxicam. On examination, her blood pressure was 148/96 mmHg, and her heart rate was 107 bpm. The pain score upon arrival was 8–9/10 on the Numeric Rating Scale (NRS), accompanied by an antalgic gait requiring assistance to walk. The Straight Leg Raise (Lasegue) test, Patrick's test, and Contra-Patrick's test were positive bilaterally. AP/LAT lumbosacral X-rays revealed paravertebral muscle spasm and spondylosis with mild intervertebral space narrowing at the L5–S1 level. The patient received an injection of ketorolac along with supplemental oxygenation. Results: The patient showed improvement, with the NRS pain score decreasing to 4–5/10, blood pressure normalizing to 126/84 mmHg, and heart rate decreasing to 92 bpm. The improvement in hemodynamic parameters aligned with the reduction in subjective pain scores, objectively reflecting the resolution of sympathetic responses (hypertension and tachycardia) initially triggered by severe acute pain. Conclusion: Ketorolac injection provides rapid and significant pain relief in acute exacerbations of chronic sciatica.