New Guideline for Low-Back Pain Interventions

The American Pain Society (APS, Glenview, IL, USA) has issued a new clinical practice guideline for low back pain that emphasizes the use of noninvasive treatments over interventional procedures, as well as the importance of shared decision making between provider and patient.

An APS panel, augmented by experts on interventional therapies, reviewed 3,348 abstracts and analyzed 161 relevant clinical trials to provide clinicians with eight recommendations to help determine the best way to treat patients with low-back pain. It also expands its current and previously published guideline for initial evaluation and management of this chronic condition. Based on the data the panel gathered, the APS now recommends against the use of provocative discography (injection of fluid into the disc in order to determine if it is the source of back pain) for patients with chronic nonradicular low-back pain, and also against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with persistent nonradicular low-back pain. However, the panel found insufficient evidence to guide the use of other interventional therapies. The panel also recommends against consideration of intensive interdisciplinary rehabilitation with a cognitive and behavioral emphasis for patients with nonradicular low-back pain who do not respond to usual, non-interdisciplinary therapies.

The panel recommends discussion between clinician and patients of the risks and benefits of epidural steroid injections and shared decision making, including specific review of evidence of lack of long-term benefit, for patients with persistent radiculopathy due to herniated lumbar disc; a discussion of the risks and benefits of surgery and use of shared decision making that references moderate benefits that decrease over time for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain; a discussion of the risks and benefits of spinal cord stimulation and shared decision making, including reference to the high rate of complications following stimulator placement for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root; and a discussion of the risks and benefits of surgery and the use of shared decision making with reference to rehabilitation as a similarly effective option for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms. The panel further recommends discussion of the risks and benefits of epidural steroid injections and shared decision-making, including specific review of evidence of lack of long-term benefit for patients with persistent radiculopathy due to herniated lumbar disc. The new guideline was published in the May 1, 2009, issue of Spine.

"These recommendations are based on an even more complete body of evidence than was available just a few years ago. Consequently, we believe these recommendations will give physicians more confidence when treating patients with persistent back pain," said lead author Roger Chou, M.D., director of the APS clinical practice guideline program, and an associate professor of medicine at the Oregon Health & Science University (OHSU; Portland, USA).

"We have advocated strongly in many of our recommendations for physicians to use shared decision making because of the relatively close trade-offs between potential benefits relative to harms, as well as costs and burdens of these various treatment options," added Dr. Chou.

Related Links:
The American Pain Society
Oregon Health & Science University