American Pain Society's Low Back Guideline Expanded To Cover Interventional Procedures

The second part of the APS guideline is based on a multidisciplinary panel's review and analysis of volumes of evidence related to diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries, according to Roger Chou, MD, director of the American Pain Society's Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University.

Chou noted that in addition to the multidisciplinary panel that formulated the guideline for evaluation and management of low back pain in primary care settings, additional experts with expertise on interventional therapies and surgeries for low back pain were recruited to review the evidence and formulate the expanded recommendations.

"Prior to finalizing the guideline, APS conducts extensive peer review, and has sent the guideline to more than 20 experts in surgery, interventional pain medicine, primary care, and other disciplines for comments and feedback," Chou said.

Low-back pain is the fifth most common reason for doctor¡¦s office visits and one in four adults report having it last a least a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.

"The evidence is much better than even five or 10 years ago and both the primary care and interventional recommendations will help physicians be more confident when evaluating possible therapies for low back pain," said Chou. "As always, physicians and patients should discuss possible options proven by the evidence and choose the ones that make sense for their situation," he added.

During the symposium, Chou and two panel co-chairs, Richard Rosenquist, MD, assistant professor of anesthesiology, University of Iowa, and John Loeser, MD, professor, Department of Neurological Surgery, University of Washington, reported that for many interventional procedures the evidence from randomized controlled trials is mixed, sparse, not available or showed no benefits. Accordingly, the expanded, evidence-based APS guideline will report:

• Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.
• Epidural stenois injections are an option for short-term pain relief for persistent radiculopathy (radiating low back pain caused by a herniated disc). Other interventional therapies, such as local injections, prolotherapy, botulinum toxin (botox) injection, facet joint injection, sacroliliac joint injection, radiofrequency denervation and intradiscal electrothermal therapy are not supported by convincing, consistent evidence of benefits from randomized trials.
• Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.
• Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation. In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery.

The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou.

Recommendations from the first APS Clinical Practice Guideline on Low Back Pain were intended for primary care physicians and appeared in the Oct, 2, 2007 issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of x-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders.

In addressing treatment options, it recommended that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them. Also for various non-pharmacological treatments supported by the evidence, from spinal manipulation to massage therapy, the first guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications.