What’s new in the literature: Nonspecific low back pain

Issue: BCMJ, vol. 51, No. 8, October 2009, Page 359 WorkSafeBC
By: Craig Martin, MD, Kukuh Noertjojo, MD,

Nonspecific low back pain (LBP) is a common,[1,2] costly,[3-5] and debilitating condition, and to date, management of this disorder remains a challenge.[6,7] While the most recent medical evidence supports moderate physical activity as a valid and durable intervention for LBP, many conventional treatments appear to provide a lack of efficacy or durability. Indeed, for some treatments, including surgery, the risks might outweigh the benefits.

Recently, the American Pain Society published clinical guidelines based on high-quality, systematic reviews on the management of LBP.[8-10] Their key findings and recommendations are as follows:

• Provocative discography is not recommended for diagnosing discogenic LBP in patients with chronic, nonradicular LBP.

• Current evidence is insufficient to evaluate the validity or utility of diagnostic selective nerve root block, intra-articular facet joint block, medial branch block, or sacro-iliac joint block as diagnostic procedures for LBP, with or without radiculopathy.

• Intensive, interdisciplinary rehabilitation with a cognitive/behavioral emphasis should be considered for patients with nonradicular LBP who do not respond to the usual non-interdisciplinary interventions, including patients with persistent, disabling back pain.

• Facet joint injection, prolotherapy, and intradiscal steroid therapy should not be recommended for patients with persistent, nonradicular LBP. At present, insufficient evidence is available to evaluate the benefits of local injection, botulinum toxin injection, epidural steroid injection, intradiscal electrothermal therapy, therapeutic medial branch block, radiofrequency denervation, sacro-iliac joint steroid injection, or intrathecal therapy with opioids or other medications for nonradicular LBP.

• For patients with nonradicular LBP, common degenerative spinal changes, and persistent and disabling symptoms, the risks and benefits of surgery as a treatment option should be discussed. In addition, patients should be aware of the similarly effective benefits of intensive interdisciplinary rehabilitation, the small-to-moderate benefits gained from surgery over the use of non-interdisciplinary, nonsurgical therapy, and the less-than-optimal outcome for the majority of patients who undergo such surgery (an “optimal outcome” is defined as the presence of minimal or no pain, the ability to discontinue or occasionally use pain medication, and the return of high-level functioning).

• Patients with persistent and disabling radiculopathy caused by a herniated disc, or persistent and disabling leg pain associated with spinal stenosis, should know that the benefits of surgery for these conditions are moderate at best, and appear to decrease over time.

• At present, insufficient evidence exists to determine whether the long-term benefits outweigh the harm of vertebral disc replacement.

• Patients with persistent radiculopathy caused by a herniated lumbar disc should know about inconsistent evidence showing moderate, short-term benefits and lack of long-term benefits associated with epidural steroid injection. At present, insufficient evidence exists to evaluate the benefits and harms of epidural steroid injection for spinal stenosis.

• Patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root should know that spinal cord stimulation is associated with a high rate of complications following the placement of a spinal cord stimulator.

A high-quality, systematic review on the role of imaging in LBP11 found that lumbar imaging for LBP, without indications of serious underlying conditions, does not improve clinical outcomes. It is recommended that clinicians refrain from providing immediate or routine lumbar imaging for patients with acute or subacute LBP who don’t appear to have serious underlying conditions, such as cauda equina, cancer, or infections.

Another high-quality, systematic review12 concluded that physical exercise might be the only effective intervention to prevent episodes of LBP among working-age adults. To date, other interventions, including stress management, shoe inserts, back supports, ergonomic or back education, and reduced lifting programs have been found to be ineffective in preventing episodes of LBP.

—Craig Martin, MD, MHSc
—Kukuh Noertjojo, MD, MHSc, MSc 

WorkSafeBC Evidence Based Practice and Outcome Research Group
www.worksafebc.com/evidence

References

If you wish to read the referenced articles, please contact Kukuh Noertjojo, at kukuh.noertjojo@worksafebc.com or 604 232-5883.
1. Manek NJ, MacGregor AJ. Epidemiology of back disorders: Prevalence, risk factors and prognosis. Current Opinion Rheumatol 2005;17:134-140.
2. Hogg-Johnson S, van der Velde G, Carroll LJ, et al. The burden and determinants of neck pain in the general population. Spine 2008;33(4S):S39-S51.
3. Dagenaies S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine 2008;8:8-20.
4. Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain. Who seeks care? Who goes where? Med Care 2001;39:956-967.
5. Lavis JN, Malter A, Anderson GM, et al. Trends in hospital use for mechanical neck and back problems in Ontario and the United States: Discretionary care in different health care systems. CMAJ 1998;158:29–36.
6. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine 2008;8:1-7.
7. Indahl A. Low back pain: Diagnosis, treatment, and prognosis. Scandinavian Rheumatol 2004;33:199-209.
8. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine 2009;34:1066-1077.
9. Chou R, Atlas SJ, Stanos P, et al. Nonsurgical interventional therapies for low back pain. Spine 2009;34:1078-1093.
10. Chou R, Bisden J, Carragee EJ, et al. Surgery for low back pain. Spine 2009;34:1094-1109.
11. Chou R, Fu R, Carinno JA, et al. Imaging strategies for low back pain: Systematic review and meta-analysis. Lancet 7 Feb 2009;373:463-472.
12. Bigos SJ, Holland J, Holland C, et al. High-quality controlled trials on preventing episodes of back problems: Systematic literature review in working-age adults. Spine 2009;9:147-168.

Craig Martin, MD,, Kukuh Noertjojo, MD,. What’s new in the literature: Nonspecific low back pain. BCMJ, Vol. 51, No. 8, October, 2009, Page(s) 359 - WorkSafeBC.


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