American Pain Society guidelines for low back pain

Clinical question What treatments for low back pain are effective?

Bottom line Patients with persistent nonradicular low back pain should be offered interdisciplinary rehabilitation, but no facet joint injections, prolotherapy, or intradiscal steroid injections. Patients with radicular symptoms do better in the short term with procedures, but long-term data are lacking. (Level of evidence = 1a)

Synopsis These authors used systematic reviews conducted by the Oregon Evidence-based Practice Center, funded by the Agency for Healthcare Research and Quality, to inform the guideline. All members of the panel were required to disclose conflicts of interest and recuse themselves from relevant votes. For therapeutic interventions, they used a grading scheme based on the United States Preventive Services Task Force (grade appears in brackets). The following is a summary of their key recommendations for patients with nonradicular back pain: (1) Do not perform a provocative discogram because of its poor diagnostic accuracy. The authors found insufficient evidence to recommend other diagnostic interventions, such as selective nerve blocks, facet blocks, and so forth, whether or not radicular symptoms are present (strong recommendation based on moderate quality evidence). (2) For patients with persisting symptoms after “usual care,” consider interdisciplinary rehabilitation (rehabilitation integrated with psychological and/or social/occupational evaluation) [B]. (3) Patients with persistent pain should not receive facet joint corticosteroid injections, prolotherapy, or intradiscal corticosteroid injections because these have not been found to be more effective than sham therapies [D]. (4) The authors found fair evidence that spinal fusion is more effective than usual nonsurgical care in patients with degenerative changes, but the surgery is no more effective than intensive rehabilitation [B]. (5) Patients with presumed facet-joint pain do not benefit from facet-joint injection with steroids [D]. (6) The authors found fair evidence that artificial disc replacement improves 2-year clinical outcomes in patients with single-level degenerative disc disease [B], but insufficient data for longer-term outcomes [I]. (7) The authors found insufficient data to com ment on botulinum toxin, local injections, epidural steroids, facet blocks, radiofrequency denervation, various intradiscal thermal treatments, spinal cord stimulation, or intrathecal therapy [I]. The following is a summary of the key recommendations for patients with radicular back pain or symptomatic spinal stenosis: (1) Discectomy (open or micro) is effective for the short-term (3 months) relief for patients with prolapsed disc [B]. (2) Laminectomy (with or without fusion) provides intermediate relief (1-2 years) in patients with symptomatic spinal stenosis [B]. (3) Chemonucleolysis is better than placebo but worse than surgery in patients with prolapsed discs [B]. (4) Epidural steroid injections provide short-term (3 months) relief in patients with prolapsed discs [B]. (5) Spinal cord stimulation is effective in patients with persistent radicular symptoms after surgery [B].

Grading scheme: A, Strongly recommended. The panel found good evidence that the intervention improves health outcomes and concludes that benefits substantially outweigh harms. B, Recommended. The panel found at least fair evidence that the intervention improves health outcomes and concludes that benefits moderately outweigh harms, or that benefits are small but there are no significant harms, costs, or burdens associated with the intervention. C, No recommendation for or against. The panel found at least fair evidence that the intervention can improve health outcomes but concludes that benefits only slightly outweigh harms, or the balance of benefits and harms is too close to justify a general recommendation. D, Recommendation against. The panel found at least fair evidence that the intervention is ineffective or that harms outweighs benefits. I, Insufficient evidence to recommend for or against. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.