Last month, the American Pain Society added to its recommendations to health care providers regarding the diagnosis and treatment of low back pain.
In addition, the Society decided to discuss openly procedures that could be risky to sufferers of low back pain, including recommendations on surgery and other invasive therapies.
Unfortunately, there is not a significant body of good evidence to justify unquestioningly embracing these new recommendations. It is difficult to find well-done clinical studies which support the use of a number of the more invasive treatments used for chronic low back pain.
The initial set of guidelines for the management of chronic low back pain were published in “Annals of Internal Medicine” last October. However, these recommendations dealt more with the initial evaluation of a low back pain patient, and included thoughts on what type of x-rays to order in addition to more conservative treatments such as massage/manipulation and exercise.
Enter the latest round of recommendations: These are more geared toward the chronic low back pain patient who is not responding to such conservative measures. Unfortunately, some of these folks are the 5% (yes, five) of chronic back pain patients whose treatment requires 75% of the money spent on taking care of back pain.
But let us get to the meat of the new recommendations presented at the American Pain Society Annual Scientific Meeting this past May:
Invasive diagnostic tests such as facet joint block and sacroiliac joint block have NOT been proven to have accuracy in diagnosing spinal conditions.
Epidural steroid injections may give short-term pain relief of low back pain causing pain radiating into the leg. But other invasive treatments, such as botulinum toxin injections, prolotherapy, facet joint injections, sacroiliac injections and electrothermal therapy are not supported by good clinical studies.
Spinal cord stimulation in failed back surgery patients appears to have fairly good support, as clinical studies have shown benefit.
Diskectomy in patients with a herniated disk results in a better short-term outcome, but after about 6 months these patients who have had surgery do just as well as those patients who have been treated conservatively and without surgery. In other words, if you have a herniated disk problem, you will probably get better with or without surgery—but the improvement may be faster with surgery. Likewise, patients with spinal stenosis who have chosen surgery will look similar to patients who decided against surgery after about two years.
Surgery for nonspecific back pain is a little more tricky, compared to those patients with spinal stenosis or sciatica-type symptoms. There are studies that have shown no benefit of surgery when compared with aggressive physical therapy. And many nonspecific back pain patients who have had surgery often have persistent pain and/or decreased functional abilities after the surgery.
In conclusion, a patient with chronic low back pain must carefully consider the options. Surgery certainly does not mean an end to chronic low back pain, and like any invasive procedure, it has its risks. The various approaches to chronic low back pain treatment have advantages and disadvantages, but at this point it seems some treatments only have disadvantages.
Let the studies continue, as the experts in the pain field freely admit that they don’t yet know with certainty which treatment is best for many patients with chronic low back pain.
Discuss any discussion of surgery with your doctor.