New Guidelines for Treating Lower Back Pain

May 19, 2009

New guidelines issued by the American Pain Society address clinical practices for use in treating lower back pain.

New guidelines issued by the American Pain Society (APS) address clinical practices for use in treating lower back pain that “emphasize the use of noninvasive treatments over interventional procedures, as well as shared decision making between provider and patient.”

The eight new suggestions are based on reviews of extensive research that should help physicians determine the best course of treatment for patients with lower back pain. These guidelines expand on the APS’s current and past recommendations for evaluation and treatment.

“These recommendations are based on an even more complete body of evidence than was available just a few years ago,” said Roger Chou, MD, director of the APS Clinical Practice Guideline Program and associate professor of medicine in the Oregon Evidence-based Practice Center of Oregon Health & Science University, whose research review prompted the issuing of the new guidelines.

According to the National Institute of Neurological Disorders and Stroke, Americans spend at least $50 billion every year on lower back pain, which is also the second most common neurological ailment in the United States. Though several tests for lower back pain do exist, and there are a number of therapies, including surgery, available for those who suffer from lower back pain, Chou said that the true nature of their effectiveness is still not entirely known.

A multidisciplinary APS panel examined 3,348 abstracts and looked at 161 clinical trials relevant to the research. With the help of “experts on interventional therapies,” the APS panel found that “evidence for the use of these interventions was mixed, sparse or not available.”

“Unfortunately, randomized trials for a number of commonly used interventional procedures are still too limited to generate evidence-based recommendations, and our review also highlights the need for more research,” said Chou.

The APS now recommends:

1. 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.

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, non-interdisciplinary therapies.

3. Against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with persistent nonradicular low-back pain, and insufficient evidence to guide use of other interventional therapies.

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. Insufficient evidence to guide recommendations for vertebral disc replacement.

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 radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.

To access the full findings of the study, please click here.