Guideline for Interventional Procedures for Low Back Pain Published in Spine

After an extensive review of existing research, the American Pain Society (APS) has officially published its new clinical practice guideline for interventional procedures for low back pain. In a paper in the current (May 1, 2009) issue of the journal Spine, the APS presents physicians with eight recommendations to help determine the best way to treat patients with this chronic condition. It also expands its current and previously published guideline for non-invasive low back pain therapies.

“Because they are based on a more complete body of evidence than was available even just several years ago, we believe these recommendations should give physicians more confidence when treating patients,” said Roger Chou, MD, lead author of the review, director of the APS’ Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University.

“We also believe in and have advocated strongly in many of our recommendations for physicians to use shared decision-making (SDM) because of the trade-offs between potential benefits, harms, costs, and burdens of these various treatment options,” he added. Shared decision-making involves a patient’s full participation in medical choices after receiving comprehensive information about the impact of all options on his or her particular life situation.

Low-back pain is the fifth most common reason for doctor’s visits and accounts for more than $26 billion in direct health care costs nationwide each year. While a number of interventional diagnostic tests and therapies and surgery are available, and their use is increasing, in some cases their utility remains uncertain.

To develop the guideline in Spine, a multi-disciplinary APS panel, augmented by experts on interventional therapies, reviewed 3348 abstracts and analyzed 161 relevant clinical trials.

The panel found that the evidence for the use of these interventions was mixed, sparse, or not available.

As a result of the data they gathered, the panel, in their guideline now recommends:
1. Against the use of provocative discography (explain in short phrase for patients for patients with chronic nonradicular low back pain.
2. The consideration of intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis for patients with nonradicular low back pain who do not respond to usual, no interdisciplinary therapies.
3. Against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with patients with persistent nonradicular low back pain.
4. A discussion of 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.
5. Against vertebral disc replacement in patients with nonradicular low back pain, common degenerative spinal changes, and persistent and disabling symptoms.6. A 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.7. 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.8. Discussion of 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 ridiculer pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.