1. Use of Benzodiazepines in Lower Back Pain Problem Based Learning, Oct 2008

2. Cochrane Systematic Review - 2003 Muscle relaxants for non-specific low-back pain: Thirty trials met the inclusion criteria 23 trials (77%) were of high quality 24 trials (80%) were on acute low back pain 4 studied benzodiazepines 11 non-benzodiazepines 2 antispasticity muscle relaxants – in comparison with placebo

3. Cochrane Systematic Review Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute LBP on short-term pain relief. The various muscle relaxants were found to be similar in performance.

4. Cochrane Systematic Review Authors' conclusions “Muscle relaxants are effective in the management of non-specific LBP, but adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or NSAIDs.”

5. BestBets - 2005 Use of muscle relaxants in acute LBP. Also benzodiazepines & non- benzodiazepines. Following comment: – Many cope well with simple analgesics – But many c/o spasmodic pain and stiffness – Therefore logical argument for use of relaxants.

6. BestBets The systematic review demonstrates that in RCTs and CCTs does appear to be a real benefit from use of muscle relaxants in acute and chronic settings. However, incidence of S/Es is considerable and their blanket use cannot be advocated. Remains up to treating physician to assess need for and potential risks in individual patients

7. BestBets Clinical bottom line: – Muscle relaxants are effective in management of acute and chronic back pain. – However, the incidence of side effects means that they must be used with caution.”

8. CKS (formerly PRODIGY) Discuss muscle relaxants in their guideline on lower back pain, this includes the following passage: – “If analgesics fail to provide adequate relief, consider a short course of a muscle relaxant, on its own or together with an NSAID. – Several muscle relaxants have been studied in relation to lower back pain. Diazepam is usually first- line choice. – Due to risk of dependency, recommended only for short courses”