Interventional|Non-Interventional treatments|Low back pain

Saturday, May 16, 2009 

These are the recommendations from the American Pain Society based on a systematic review that focused on evidence from randomized controlled trials on interventional treatments for low back pain: 

1. Provocative discography is not recommended for diagnosis in patients with chronic, nonradicular low-back pain.
2. Intensive interdisciplinary rehabilitation, which incorporates psychological interventions and exercise therapy, with cognitive/behavioral emphasis should be considered for patients with nonradicular low-back pain who do not respond to conventional, noninterdisciplinary therapies.
3. Facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections should not be used for patients with persistent nonradicular low-back pain.
4. The risks and benefits of surgery should be discussed, and shared decision-making that includes a discussion of interdisciplinary rehabilitation as an option should be used for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms.
5. There is not enough evidence to guide the use of vertebral disc replacement in patients with nonradicular low back pain, common degenerative spinal changes, and persistent and disabling symptoms.
6. The risks and benefits of epidural steroid injections should be discussed, and shared decision-making that includes a specific review of evidence of lack of long-term benefit should be used for patients with persistent radiculopathy due to herniated lumbar disc. Evidence for epidural steroid injection in spinal stenosis cases is sparse and shows no clear benefit, athough more trials are needed.
7. The risks and benefits of surgery should be discussed, and shared decision-making that includes a specific discussion about moderate benefits that decrease over time should be used for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis.
8. The risks and benefits of spinal cord stimulation should be discussed, and shared decision making that includes a reference to the high rate of complications following stimulator placement should be used for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.

Chou, Roger MD; Loeser, John D. MD; Owens, Douglas K. MD, MS; Rosenquist, Richard W. MD; Atlas, Steven J. MD, MPH; Baisden, Jamie MD, FACS; Carragee, Eugene J. MD; Grabois, Martin MD; Murphy, Donald R. DC, DACAN; Resnick, Daniel K. MD; Stanos, Steven P. DO; Shaffer, William O. MD; Wall, Eric M. MD, MPH; For the American Pain Society Low Back Pain Guideline Panel:Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society.   Spine: 1 May 2009 - Volume 34 - Issue 10 - pp 1066-1077

A study in 2006 had shown that for non-intervential treatments show:

1. Acute Low Back Pain: NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief and long-term improvement of function.

2.   Chronic Low Back Pain: Interventions effective for short-term pain relief include antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. 

However, many trials showed methodological weaknesses and the effects were compared to placebo, no treatment or waiting list controls, and do not have adequate sample size. (van Tulder MW, Koes B, Malmivaara A: Outcome of non-invasive treatment modalities on back pain: an evidence-based review.   European Spine Journal. 15 Suppl 1:S64-81, 2006).

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