Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline

Problem areas identified as important to older adults with lumbar spinal stenosis

BACKGROUND CONTEXT

There is growing concern that patient-reported outcomes (PROs) commonly used in clinical research evaluating treatments such as epidural steroid injections (ESIs) for lumbar spinal stenosis may not adequately capture outcomes of greatest importance to older adults.

PURPOSE

The purpose of the study was to determine what outcomes are most important to older adults with spinal stenosis, how well commonly used PROs reflect what is most important to these participants, and which outcomes older adults with spinal stenosis would want improved to consider having ESI.

STUDY DESIGN/SETTING

This is an outcome prioritization study.

PATIENT SAMPLE

Community sample of 33 older adults with spinal stenosis were included.

OUTCOME MEASURES

The outcome measures were Swiss Spinal Stenosis Questionnaire and Roland-Morris Disability Questionnaire.

METHODS

The methods involve individual sorting and ranking exercises followed by facilitated focus groups.

RESULTS

Highest rated problem areas were "experiencing pain/discomfort" (88% of participants), "problems with physical function" (85%), "difficulty exercising" (73%), "difficulty participating in hobbies and leisure activities" (55%), and "problems with weakness" (52%). Only 10 of the 24 Roland-Morris Disability Questionnaire items were rated by 50% or more of participants experiencing them as important enough to warrant ESI treatment.

CONCLUSIONS

Older adults with spinal stenosis rated problems related to pain and physical function as the most important outcomes to them. However, difficulty exercising and difficulty participating in hobbies and leisure activities were also among the most highly rated and were two areas not typically assessed in treatment studies. Commonly used PROs in spinal stenosis treatment studies may be insufficient to comprehensively assess outcomes from the patient perspective.

Report of the NIH Task Force on research standards for chronic low back pain

OBJECTIVE

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus.

DESIGN

Expert panel and preliminary evaluation of key recommendations.

METHODS

The NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting.

RESULTS

The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals.

CONCLUSION

The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document, and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

WITHDRAWN: Botulinum toxin for subacute/chronic neck pain

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

[Profile of the patient with failed back surgery syndrome in the National Institute of Rehabilitation. Comparative analysis]

BACKGROUND

Failed back surgery syndrome is a complication of spine surgery that leads to chronic pain and disability, often with disastrous emotional consequences to the patient.

AIM

To compare the profile of patients whose first surgery was performed in our hospital versus a group that underwent first spine surgery in a different centre.

METHODS

Retrospective study with 65 patients; 18 formed group I (first spine surgery performed in our institution), and 47 patients in group II (first surgery performed in another hospital). Background, demographic, clinical features and functional status were compared. In group I the majority of the cases had a previous diagnosis of lumbar stenosis (group I 44.4% vs group II 25.5% p = 0.22), whereas disk herniation was the main diagnosis in group II (group I 22.2% vs group II 61.7% p = 0.001). The main cause of the syndrome in group I was technical error during surgery (61.1%), while in group II this cause represented only 6.3% (p=.001). Among the patients of this latter group, misdiagnosis was highly prevalent (57.4%), against no cases in group I (p=.001). The preoperative functional status between both groups and their recovery in the immediate postoperative period was similar (p = 0.68).

CONCLUSIONS

This study suggests that the diagnostic and treatment standards are different between healthcare centres, specifically between academic centres vs. private practice.

Ageism, negative attitudes, and competing co-morbidities--why older adults may not seek care for restricting back pain: a qualitative study

Background

Back pain, the most common type of pain reported by older adults, is often undertreated for reasons that are poorly understood, especially in minority populations. The objective of this study was to understand older adults’ beliefs and perspectives regarding care-seeking for restricting back pain (back pain that restricts activity).

Methods

We used data from a diverse sample of 93 older adults (median age 83) who reported restricting back pain during the past 3 months. A semi-structured discussion guide was used in 23 individual interviews and 16 focus groups to prompt participants to share experiences, beliefs, and attitudes about managing restricting back pain. Transcripts were analyzed in an iterative process to develop thematic categories.

Results

Three themes for why older adults may not seek care for restricting back pain were identified: (1) beliefs about the age-related inevitability of restricting back pain, (2) negative attitudes toward medication and/or surgery, and (3) perceived importance of restricting back pain relative to other comorbidities. No new themes emerged in the more diverse focus groups.

Conclusions

Illness perceptions (including pain-related beliefs), and interactions with providers may influence older adults’ willingness to seek care for restricting back pain. These results highlight opportunities to improve the care for older adults with restricting back pain.

Effectiveness and economic evaluation of chiropractic care for the treatment of low back pain: a systematic review protocol

BACKGROUND

Chiropractic care is a common treatment for low back pain (LBP). Previous studies have failed to clarify the relative cost-effectiveness of chiropractic care in comparison with other commonly used approaches because previous attempts to synthetize the economic literature has only included partial economic evaluations. The objective of this project is to estimate the clinical effectiveness and cost-effectiveness of chiropractic care compared to other commonly used care approaches among adult patients with non-specific LBP.

METHODS/DESIGN

Two systematic reviews will be conducted to identify 1) randomized controlled trials and 2) full economic evaluations of chiropractic care for low back pain compared to standard care provided by other healthcare providers. We will conduct searches in specialized electronic databases for randomized controlled trials and full economic evaluations published between 1990 and 2014 using a combination of keywords and MeSH terms. This will be supplemented by a search of the gray literature. Citations, abstracts, and relevant papers will be screened for eligibility by two reviewers independently. Studies will be critically appraised using 1) the Cochrane risk of bias tool and 2) the Drummond (BMJ) checklist. Results will be summarized using Slavin's qualitative best-evidence synthesis approach. Data relating to the primary outcomes of the effectiveness study will be evaluated for inclusion in meta-analyses. The costs will be standardized to the same currency (USD) and adjusted to the same year for inflation. The incremental cost-effectiveness, incremental net benefit, and relevant confidant intervals will be recalculated in order to facilitate comparison between studies.

DISCUSSION

Our review will evaluate both the clinical effectiveness and the cost-effectiveness associated with chiropractic care for LBP. A more precise estimate of the cost-effectiveness of chiropractic care for LBP relative to other forms of conservative care is needed for decision-makers and third-party payers to offer best care options for LBP. Our results will facilitate evidence-based management of patients with LBP and identify key areas for future research.

SYSTEMATIC REVIEW REGISTRATION

The protocol is registered on PROSPERO ( CRD42014008746 ).

Comparison of the efficacy of transforaminal and interlaminar radicular block techniques for treating lumbar disk hernia

Objective

To compare the interlaminar and transforaminal block techniques with regard to the state of pain and presence or absence of complications.

Method

This was a randomized double-blind prospective study of descriptive and comparative nature, on 40 patients of both sexes who presented lumbar sciatic pain due to central-lateral or foraminal disk hernias. The patients had failed to respond to 20 physiotherapy sessions, but did not present instability, as diagnosed in dynamic radiographic examinations. The type of block to be used was determined by means of a draw: transforaminal (group 1; 20 patients) or interlaminar (group 2; 20 patients).

Results

Forty patients were evaluated (17 males), with a mean age of 49 years. There was a significant improvement in the state of pain in all patients who underwent radicular block using both techniques, although the transforaminal technique presented better results than the interlaminar technique.

Conclusion

Both techniques were effective for pain relief and presented low complication rates, but the transforaminal technique was more effective than the interlaminar technique.

Patient-reported outcomes associated with use of physical therapist services by older adults with a new visit for back pain

BACKGROUND

Among older adults, it is not clear how different types or amounts of physical therapy may be associated with improvements in back pain and function.

OBJECTIVE

The study objective was to investigate the association between types or amounts of physical therapist services and 1-year outcomes among older adults with back pain.

DESIGN

This was a prospective cohort study.

METHODS

A total of 3,771 older adults who were enrolled in a cohort study and who had a new primary care visit for back pain participated. Physical therapy use was ascertained from electronic health records. The following patient-reported outcomes were collected over 12 months: back-related disability (Roland-Morris Disability Questionnaire) and back and leg pain intensity (11-point numerical rating scale). Marginal structural models were used to estimate average effects of different amounts of physical therapy use on disability and pain for all types of physical therapy and for active, passive, and manual physical therapy.

RESULTS

A total of 1,285 participants (34.1%) received some physical therapy. There was no statistically significant gradient in relationships between physical therapy use and back-related disability score. The use of passive or manual therapy was not consistently associated with pain outcomes. Higher amounts of active physical therapy were associated with decreased back and leg pain and increased odds of clinically meaningful improvements in back and leg pain relative to results obtained with no active physical therapy.

LIMITATIONS

The fact that few participants had high amounts of physical therapy use limited precision and the ability to test for nonlinear relationships for the amount of use.

CONCLUSIONS

Higher amounts of active physical therapy were most consistently related to the greatest improvements in pain intensity; however, as with all observational studies, the results must be interpreted with caution.

Report of the NIH Task Force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration

Chronic low back pain accompanied by intervertebral disk degeneration is a common musculoskeletal disorder. Physical exercise, which is clinically recommended by international guidelines, has proven to be effective for degenerative disc disease (DDD) patients. However, the mechanism underlying the analgesic effects of physical exercise on DDD remains largely unclear. The results of the present study showed that mechanical withdrawal thresholds of bilateral hindpaw were significantly decreased beginning on day three after intradiscal complete Freund's adjuvant (CFA) injection and daily running exercise remarkably reduced allodynia in the CFA exercise group beginning at day 28 compared to the spontaneous recovery group (controls). The hindpaw withdrawal thresholds of the exercise group returned nearly to baseline at the end of experiment, but severe pain persisted in the control group. Histological examinations performed on day 70 revealed that running exercise restored the degenerative discs and increased the cell densities of the annulus fibrosus (AF) and nucleus pulposus (NP). Furthermore, immunofluorescence labeling revealed significantly higher numbers of 5-bromo-2-deoxyuridine (BrdU)-positive cells in the exercise group on days 28, 42, 56 and 70, which indicated more rapid proliferation compared to the control at the corresponding time points. Taken together, these results suggest that running exercise might alleviate the mechanical allodynia induced by intradiscal CFA injection via disc repair and cell proliferation, which provides new evidence for future clinical use.

Epidural steroid injections for radicular lumbosacral pain: a systematic review

Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.

The failed back surgery syndrome: pitfalls surrounding evaluation and treatment

This article describes the costs and risk factors for failed back surgery syndrome and reviews the diagnosis and treatment strategies commonly used to address this syndrome. The purpose of this review is to describe some of the treatment pitfalls associated with these approaches from a physiatric perspective.

Protective effects of cannabidiol on lesion-induced intervertebral disc degeneration

Disc degeneration is a multifactorial process that involves hypoxia, inflammation, neoinnervation, accelerated catabolism, and reduction in water and glycosaminoglycan content. Cannabidiol is the main non-psychotropic component of the Cannabis sativa with protective and anti-inflammatory properties. However, possible therapeutic effects of cannabidiol on intervertebral disc degeneration have not been investigated yet. The present study investigated the effects of cannabidiol intradiscal injection in the coccygeal intervertebral disc degeneration induced by the needle puncture model using magnetic resonance imaging (MRI) and histological analyses. Disc injury was induced in the tail of male Wistar rats via a single needle puncture. The discs selected for injury were punctured percutaneously using a 21-gauge needle. MRI and histological evaluation were employed to assess the results. The effects of intradiscal injection of cannabidiol (30, 60 or 120 nmol) injected immediately after lesion were analyzed acutely (2 days) by MRI. The experimental group that received cannabidiol 120 nmol was resubmitted to MRI examination and then to histological analyses 15 days after lesion/cannabidiol injection. The needle puncture produced a significant disc injury detected both by MRI and histological analyses. Cannabidiol significantly attenuated the effects of disc injury induced by the needle puncture. Considering that cannabidiol presents an extremely safe profile and is currently being used clinically, these results suggest that this compound could be useful in the treatment of intervertebral disc degeneration.

Focus article: report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study

BACKGROUND

Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy.

METHODS

A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month.

RESULTS

One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of -3.1 (95% CI, -3.8 to -2.3) in average arm pain at 1 month versus -1.8 (CI, -2.5 to -1.2) in the conservative group and -2.0 (CI, -2.7 to -1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of -2.2 (95% CI, -3.0 to -1.5) was noted in combination patients versus -1.2 (CI, -1.9 to -0.5) in conservative group patients and -1.1 (CI, -1.8 to -0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006).

CONCLUSIONS

For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.

Indications for lumbar total disc replacement: selecting the right patient with the right indication for the right total disc

Summary of Background Data

As with any surgery, care should be taken to determine patient selection criteria for lumbar TDR based on safety and optimizing outcome. These goals may initially be addressed by analyzing biomechanical implant function and early clinical experience, ongoing evaluation is needed to refine indications.

Objective

The purpose of this work was to synthesize information published on general indications for lumbar TDR. A secondary objective was to determine if indications vary for different TDR designs.

Methods

A comprehensive literature search was conducted to identify lumbar TDR articles. Articles were reviewed and patient selection criteria and indications were synthesized.

Results

With respect to safety, there was good agreement in the literature to exclude patients with osteopenia/osteoporosis or fracture. Risk of injury to vascular structures due to the anterior approach was often addressed by excluding patients with previous abdominal surgery in the area of disc pathology or increased age. The literature was very consistent on the primary indication for TDR being painful disc degeneration unresponsive to at least 6 months of nonoperative care. Literature investigating the impact of previous spine surgery was mixed; however, prior surgery was not necessarily a contra-indication, provided the patient otherwise met selection criteria. The literature was mixed on setting a minimum preoperative disc height as a selection criterion. There were no publications investigating whether some patients are better/worse candidates for specific TDR designs. Based on the literature a proposal for patient selection criteria is offered.

Conclusions

Several TDR indications and contra-indications are widely accepted. No literature addresses particular TDR design being preferable for some patients. As with any spine surgery, ongoing evaluation of TDR outcomes will likely lead to more detailed general and device design specific indications.

Practical considerations and patient selection for intrathecal drug delivery in the management of chronic pain

Chronic pain continues to pose substantial and growing challenges for patients, caregivers, health care professionals, and health care systems. By the time a patient with severe refractory pain sees a pain specialist for evaluation and management, that patient has likely tried and failed several nonpharmacologic and pharmacologic approaches to pain treatment. Although relegated to one of the interventions of "last resort", intrathecal drug delivery can be useful for improving pain control, optimizing patient functionality, and minimizing the use of systemic pain medications in appropriately selected patients. Due to its clinical and logistical requirements, however, intrathecal drug delivery may fit poorly into the classic pain clinic/interventional model and may be perceived as a "critical mass" intervention that is feasible only for large practices that have specialized staff and appropriate office resources. Potentially, intrathecal drug delivery may be more readily adopted into larger practices that can commit the necessary staff and resources to support patients' needs through the trialing, initiation, monitoring, maintenance, and troubleshooting phases of this therapy. Currently, two agents - morphine and ziconotide - are approved by the United States Food and Drug Administration for long-term intrathecal delivery. The efficacy and safety profiles of morphine have been assessed in long-term, open-label, and retrospective studies of >400 patients with chronic cancer and noncancer pain types. The efficacy and safety profiles of ziconotide have been assessed in three double-blind, placebo-controlled trials of 457 patients, and safety has been assessed in 1,254 patients overall, with severe chronic cancer, noncancer, and acquired immunodeficiency syndrome pain types. Both agents are highlighted as first-line intrathecal therapy for the management of neuropathic or nociceptive pain. The purpose of this review is to discuss practical considerations for intrathecal drug delivery, delineate criteria for the identification and selection of candidates for intrathecal drug delivery, and consider which agent may be more appropriate for individual patients.

Tri-length laser therapy associated to tecar therapy in the treatment of low-back pain in adults: a preliminary report of a prospective case series

Low-back pain is very frequent, especially in active adult population. There are several different orthopaedic condition that can cause low-back pain, and the pain worsen the quality of life significantly. The treatments vary from drugs, physical therapies, kinesiology, local infiltrations, and so on. Laser therapy has an important role in the treatment of the inflammatory causes of pain, with several studies that demonstrate the efficacy of low and high energy laser therapy in the treatment of low-back pain. Sixty-six consecutive patients with low-back pain with or without leg pain were treated using a combination of Tri-length laser I-Triax® (Mectronic Medicale, Bergamo, Italy) and Pharon® tecar therapy (Mectronic Medicale, Bergamo, Italy). The patients were treated three times a week, every other day, for a total of 10 sessions. Clinical results were evaluated using visual analogic scale for individual pain (0 to 10) and the Oswestry disability scale (ODS). Tests started before the beginning of therapies and 8 weeks after the end of the therapies. Visual analogic scale (VAS) score significantly improved from an average value of 8.1 ± 1.58 pre-treatment to an average value 8-weeks post-treatment of 2.63 ± 2.74 (P < .01). ODS values start from a pre-treatment average value of 53.0 ± 13.0 to a post-treatment average value of 23.5 ± 19.8 (P < .01). A higher improvement both in VAS and in ODS was denoted in the group of patient with low-back pain and leg pain (respectively, VAS from 8.66 ± 1.58 to 2.86 ± 2.94 and ODS from 57.8 ± 15.5 to 23.7 ± 19.5). Low-back pain, associated or not with leg pain, is a very common clinical situation. The treatments of this condition are different, and an important role can be given to the laser therapy. The conclusion of this study is that the association between laser therapy iLux-Triax® and tecar therapy Pharon® in the treatment of low-back pain, with or without leg pain, can significantly reduce pain and improve the quality of life in patients with degenerative and inflammatory problems.

Nuclear magnetic resonance therapy in lumbar disc herniation with lumbar radicular syndrome: effects of the intervention on pain intensity, health-related quality of life, disease-related disability, consumption of pain medication, duration of sick leave and MRI analysis

PURPOSE

The objective was to assess the effects of therapeutic nuclear magnetic resonance (tNMR) as a conservative treatment for lumbar radicular syndrome (LRS) in patients with lumbar disc herniation.

METHODS

The prospective, randomised, double-blind, placebo-controlled trial included 94 patients, aged 20-60 years (44.79 ± 8.83), with LRS caused by lumbar disc herniation confirmed by MRI scans and with clinical signs of a radicular lesion without indication for surgical intervention. Treatment group (TG) and control group (CG) received standard non-surgical therapy. Additionally, the TG had seven sessions with the tNMR device with a magnetic flux density of 2.3 mT and a frequency of 85 kHz; the CG received 7 sham treatments. Outcome parameters were the treatment effect on pain intensity (Visual Analogue Scale-VAS), health-related quality of life (36-item Short Form Health Survey-SF-36), disease-related disability (Roland Morris Disability Questionnaire-RMDQ), pain medication intake, duration of sick leave and morphological changes assessed by MRI scan analysis.

RESULTS

VAS scores improved significantly in both groups (p < 0.000). Only in week 4, improvement in the TG significantly surpassed that of the CG (morning pain p = 0.011, evening pain = 0.001). In both groups, SF-36 scores reflected a significant amendment in the physical component score (p < 0.000) and a significant deterioration in the mental component score (p < 0.000). SF-36 scores did not differ significantly between groups. RMDQ showed a significant amelioration in both groups (TG and CG p < 0.000), with a tendency to a superior benefit in the TG (p = 0.083). Patients in the TG recorded significantly fewer days of sick leave in month 3 after treatment (p = 0.026). MRI scan summary scores improved significantly in both groups (L4/5 p < 0.000, L5/S1 p < 0.001) and did not differ significantly between the groups.

CONCLUSIONS

This trial was the first to investigate the effects of tNMR as an additional treatment of lumbar disc herniation with LRS. The application of tNMR did not meet MCID criteria. It rendered few statistically significant differences between patient groups. The overall results of this trial make a clinical implementation of tNMR in the treatment of lumbar disc herniation with LRS appear premature. Further research is needed to better understand the mode of action of tNMR on compressed neural tissue and to elucidate the issue of the cost/benefit ratio.

Hypertonic dextrose versus corticosteroid local injection for the treatment of osteoarthritis in the first carpometacarpal joint: a double-blind randomized clinical trial

PURPOSE

To compare the advantages of prolotherapy in the treatment of first carpometacarpal osteoarthritis (OA) with those of corticosteroid local injection in the short and long term.

METHODS

We performed a randomized controlled trial from March 2010 to March 2011 in an outpatient clinic at a university hospital. Sixty participants (60 hands) with OA of the first carpometacarpal joint were assigned equally to two groups. For the corticosteroid group, after 2 monthly saline placebo injections, a single dose of 40 mg methylprednisolone acetate (0.5 ml) mixed with 0.5 ml of 2% lidocaine was injected. For the dextrose (DX) group, 0.5 ml of 20% DX was mixed with 0.5 ml of 2% lidocaine and the injection was repeated monthly for 3 months. Pain intensity, hand function and the strength of lateral pinch grip were measured at the baseline and at 1, 2, and 6 months after the treatment.

RESULTS

Mean age (STD) was 63.6 (9.7) years, and mean (STD) visual analog scale (VAS) was 6 (2). The two groups were comparable at 2 months, but significantly different at 1 month, with better results for corticosteroid, and at 6 months with apparently more favorable outcome for DX [mean difference (95% CI) in VAS = 1.1 (0.2, 2.0), p = 0.02]. After 6 months of treatment, both DX and corticosteroid injection increased functional level, but DX seemed to be more effective [mean difference (95% CI) in total function score = 1.0 (0.2, 1.8), p = 0.01].

DISCUSSION

For the long term, DX seems to be more advantageous, while the two treatments were comparable in the short term. Because of the satisfactory pain relief and restoring of function, we would prefer DX prolotherapy for the treatment of patients with OA.

LEVEL OF EVIDENCE

Therapeutic studies--investigating the results of treatment; level I.

Minimally invasive surgery with spotlight work channel system in the treatment of lumbar disc herniation: a retrospective study of 21 cases

A group of lumbar discherniation cases was treated with posterior discectomy and decompression with Spotlight working channel. We retrospectively studied these patients. To study and analyze the clinical efficacy and technical features of discectomy which is carried out with the Spotlight channel technology. The development of the minimally invasive spine surgery technology promotes new instruments and materials. For minimally invasive spine surgery in channel technology, the newly launched Depuy(Spine) working channel-Spotlight, which is a new generation of wide viewing angle, single-hole device for minimally invasive spine operations, has good prospects for clinical application. From March 2011 to March 2012, 21 patients who were diagnosed with lumbar disc herniation were treated with posterior discectomy and decompression with Spotlight working channel, then the lumbar and leg pain visual analogue scale (VAS) scores of before and after surgery and that of the follow-ups and the Oswestry Disability Index were analyzed. All patients were successfully operated, and also they received follow-ups for more than 1 year. The postoperative lumbar and leg pain VAS scores improved significantly compared with the preoperative ones (P < 0.05) and can effectively maintain (P > 0.05). The three time points of lumbar pain VAS were 7.80 ± 0.49, 1.51 ± 0.52 and 1.47 ± 0.59. The leg pain VAS were 7.53 ± 0.50, 1.58 ± 0.58 and 1.49 ± 0.67. During the follow-ups of the cases in this group, no case of disc herniation relapsed. Patients were satisfied with that. The Spotlight channel system is one of the surgical approaches to "minimally invasive spine technology with direct vision". It has a good range of surgical indications. It can be carried out flexibly and used widely, which means it will be easier for the surgeons to master.

Report of the National Institutes of Health task force on research standards for chronic low back pain

OBJECTIVES

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The purpose of this article is to disseminate the report of the National Institutes of Health (NIH) task force on research standards for cLBP.

METHODS

The NIH Pain Consortium charged a research task force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting.

RESULTS

The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved these recommendations, which investigators should incorporate into NIH grant proposals.

CONCLUSIONS

The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of cLBP. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document and undergo continual improvement.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Diagnostic and therapeutic spinal interventions: Epidural injections

Epidural injections of local anesthetic or a corticosteroid are frequently given to diagnose and treat patients with radicular pain originating from any spinal level. The best-quality evidence supports a transforaminal approach in the lumbar spine. Many patients experience substantial benefit from a single therapeutic injection. Depending upon the benefit obtained, additional injections may be administered. Selective nerve blocks with local anesthetic alone can identify the spinal nerve mediating the patient's pain. Serious short-term risks are rare but occur; long-term risks are infrequent and can be due to systemic effects of multiple corticosteroid injections. Patients who have failed conservative therapy or are not candidates for surgical intervention can be considered for epidural steroid injections to relieve their radicular pain temporarily.

Report of the NIH task force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a research task force to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum data set to describe research participants (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The research task force believes that these recommendations will advance the field, help resolve controversies, and facilitate future research addressing the genomic, neurological, and other mechanistic substrates of cLBP. We expect that the research task force recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for cLBP. The results included recommendations for definitions, a minimum data set, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Report of the NIH Task Force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Low back pain

Low back pain is a common, frequently recurring condition that often has a nonspecific cause. Most nonspecific acute low back pain will improve within several weeks with or without treatment. The diagnostic workup should focus on evaluation for evidence of systemic or pathologic causes. Psychosocial distress, poor coping skills, and high initial disability increase the risk for a prolonged disability course. All patients with acute or chronic low back pain should be advised to remain active. The treatment of chronic nonspecific low back pain involves a multidisciplinary approach targeted at preserving function and preventing disability. Surgical referral is indicated in the presence of severe or progressive neurologic deficits or signs and symptoms of cauda equina syndrome.

Establishing the diagnosis of low back pain: patient selection for interventional pain medicine

SUMMARY Low back pain is one of the most prominent healthcare problems but there is no gold standard for its diagnosis. Aspecific low back pain can be subdivided into radicular and mechanical pain. The diagnosis mainly relies on a combination of elements, such as medical history, physical examination, medical imaging and other possible additional tests. Once a working diagnosis has been established, confirmation of the causative structure and level is sought by means of diagnostic blocks. The use of the different diagnostic tests and blocks should be guided by the balance between the potential benefit (mainly in terms of improved treatment outcome, the possible burden for the patient and the chances of withholding potential effective treatment to patients) with false-negative test results.

A systematic review to assess comparative effectiveness studies in epidural steroid injections for lumbar spinal stenosis and to estimate reimbursement amounts

OBJECTIVE

To systematically appraise published comparative effectiveness evidence (clinical and economic) of epidural steroid injections (ESI) for lumbar spinal stenosis and to estimate Medicare reimbursement amounts for ESI procedures. TYPE: Systematic review.

LITERATURE SURVEY

PubMed, Embase, and CINAHL were searched through August 2012 for key words that pertain to low back pain, spinal stenosis or sciatica, and epidural steroid injection. We used institutional and Medicare reimbursement amounts for our cost estimation. Articles published in English that assessed ESIs for adults with lumbar spinal stenosis versus a comparison intervention were included. Our search identified 146 unique articles, and 138 were excluded due to noncomparative study design, not having a study population with lumbar spinal stenosis, not having an appropriate outcome, or not being in English. We fully summarized 6 randomized controlled trials and 2 large observational studies.

METHODOLOGY

Randomized controlled trial articles were reviewed, and the study population, sample size, treatment groups, ESI dosage, ESI approaches, concomitant interventions, outcomes, and follow-up time were reported. Descriptive resource use estimates for ESIs were calculated with use of data from our institution during 2010 and Medicare-based reimbursement amounts.

SYNTHESIS

ESIs or anesthetic injections alone resulted in better short-term improvement in walking distance compared with control injections. However, there were no longer-term differences. No differences between ESIs versus anesthetic in self-reported improvement in pain were reported. Transforaminal approaches had better improvement in pain scores (≤4 months) compared with interlaminar injections. Two observational studies indicated increased rates of lumbar ESI in Medicare beneficiaries. Our sample included 279 patients who received at least 1 ESI during 2010, with an estimated mean total outpatient reimbursement for one ESI procedure "event" to be $637, based on 2010 Medicare reimbursement amounts ($505 technical and $132 professional payments).

CONCLUSION

This systematic review of ESI for treating lumbar spinal stenosis found a limited amount of data that suggest that ESI is effective in some patients for improving select short-term outcomes, but results differed depending on study design, outcome measures used, and comparison groups evaluated. Overall, there are relatively few comparative clinical or economic studies for ESI procedures for lumbar spinal stenosis in adults, which indicated a need for additional evidence.

Managing acute back pain patients to avoid the transition to chronic pain

Chronic back pain is a major source of disability, decreased quality of life and healthcare costs. Treating chronic back pain is difficult, with even effective therapies only being modestly effective. Helping patients avoid the transition from acute to chronic low back pain is a promising strategy for preventing suffering and reducing healthcare utilization. The biopsychosocial model provides a useful framework for understanding factors that contribute to chronicity in low back pain, and are important targets for interventions. This article reviews recent research on predictors of chronicity and treatment strategies in higher risk patients that may be helpful for preventing chronicity.

What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review

PURPOSE

To investigate what interventions can improve walking ability in neurogenic claudication with lumbar spinal stenosis.

METHODS

We searched CENTRAL, Medline, EMBASE, CINAHL and ICL databases up to June 2012. Only randomized controlled trials published in English and measuring walking ability were included. Data extraction, risk of bias assessment, and quality of the evidence evaluation were performed using methods of the Cochrane Back Review Group.

RESULTS

We accepted 18 studies with 1,220 participants. There is very low quality evidence that calcitonin is no better than placebo or paracetamol regardless of mode of administration. There is low quality evidence that prostaglandins, and very low quality evidence that gabapentin or methylcobalamin, improves walking distance. There is low and very low quality evidence that physical therapy was no better in improving walking ability compared to no treatment, oral diclofenac plus home exercises, or combined manual therapy and exercise. There is very low quality evidence that epidural injections improve walking distance up to 2 weeks compared to placebo. There is low- and very low-quality evidence that various direct decompression surgical techniques show similar significant improvements in walking ability. There is low quality evidence that direct decompression is no better than non-operative treatment in improving walking ability. There is very low quality evidence that indirect decompression improves walking ability compared to non-operative treatment.

CONCLUSIONS

Current evidence for surgical and non-surgical treatment to improve walking ability is of low and very low quality and thus prohibits recommendations to guide clinical practice.

The effect of sedation on the accuracy and treatment outcomes for diagnostic injections: a randomized, controlled, crossover study

BACKGROUND AND OBJECTIVE

Diagnostic injections are used to diagnose myriad pain conditions, but are characterized by a high false-positive rate. One potential cause of inaccurate diagnostic blocks is the use of sedation. We sought to determine the effect of sedation on the validity of diagnostic injections.

DESIGN

Randomized, crossover study in which 73 patients were allocated to receive a diagnostic sacroiliac joint or sympathetic nerve block performed either with or without sedation using midazolam and fentanyl. Those who obtained equivocal relief, good relief lasting less than 3 months, or who were otherwise deemed good candidates for a repeat injection, received a subsequent crossover injection within 3 months (N = 46).

SETTING AND PATIENTS

A tertiary care teaching hospital and a military treatment facility.

RESULTS

In the primary crossover analysis, blocks performed with sedation resulted in a larger mean reduction in pain diary score than those done without sedation (1.2 [2.6]; P = 0.006), less procedure-related pain (difference in means 2.3 [2.5]; P < 0.0001), and a higher proportion of patients who obtained > 50% pain relief on their pain diaries (70% vs. 54%; P = 0.039). The increased pain reduction was not accompanied by increased satisfaction (sedation mean 3.9 [1.1] vs. 3.7 [1.3]; P = 0.26). Similar findings were observed for the parallel group (N = 73) and omnibus (all sedation vs. no sedation blocks, N = 110) analyses. No differences in outcomes were noted between the use and non-use of sedation at 1-month.

CONCLUSIONS

The use of sedation during diagnostic injections may increase the rate of false-positive blocks and lead to misdiagnoses and unnecessary procedures, but has no effect on satisfaction or outcomes at 1-month.

Update in pain medicine for primary care providers: a narrative review, 2010-2012

OBJECTIVE

This manuscript reviews peer-reviewed literature published from 2010-2012 relevant to the management of chronic pain in the primary care setting.

DESIGN

Narrative review of peer-reviewed literature.

METHODS

We searched MEDLINE, PubMed, and reference lists and queried expert contacts for English-language studies related to the management of chronic noncancer pain in adult patients in primary care settings. One investigator reviewed all eligible studies for relevance, and 47 studies were reviewed by all authors and rated according to their impact on 1) primary care clinical practice, 2) policy, 3) research, and 4) quality of study methods. Through iterative discussion, nine articles were selected for detailed review and discussion.

RESULTS

We present articles in six topic areas: interventional pain management; opioid dose and risk of overdose death; neuropathic pain; yoga for chronic low back pain; cognitive behavioral therapy; and systematic approaches to treating back pain. We discuss implications for pain management in primary care.

CONCLUSIONS

There is growing evidence for the risks, benefits, and limitations of the multiple modalities available to primary care providers for the management of chronic pain. The dissemination and implementation of the evidence from these studies as well as novel system-level interventions warrant additional study and support from clinicians, educators, and policy makers.

Effect of therapeutic infra-red in patients with non-specific low back pain: a pilot study

The purpose of this study was to investigate the effect of infra-red (IR) in patients with chronic non-specific low back pain (NSLBP). Ten patients with NSLBP (5 men and 5 women) and disease duration of 21.7 ± 11.50 months participated in this pilot study. Patients had a mean age of 36.40 ± 10.11 years (range = 25-55). Patients were treated with infra-red (IR) for 10 sessions, each for 15 min, 3 days per week, for a period of 4 weeks. Outcome measures were the Numerical Rating Scale (NRS), the Functional Rating Index (FRI), the Modified-Modified Schober Test (MMST), and the Biering-Sorensen test to assess pain severity, disability, lumbar flexion and extension range of motion (ROM), and back extensor endurance, respectively. Data were collected at: baseline - study entry (T0); end of 5th treatment session after 2 weeks (T1); and end of the treatment after 4 weeks (T2). The results of the ANOVA demonstrated a statistically significant main effect of IR on all outcomes of pain, function, lumbar flexion-extension ROM, and back extensor endurance. The treatment effect sizes ranged from large to small. IR was effective in improving pain, function, lumbar ROM, and back extensor endurance in a sample of patients with NSLBP. Treatment effect sizes ranged from large to small indicating clinically relevant improvements primarily in pain and function for patients with NSLBP.

Peripheral nerve field stimulation (PNFS) in chronic low back pain: a prospective multicenter study

OBJECTIVES

The goal of this study was to evaluate the long-term efficacy and safety of peripheral nerve field stimulation (PNFS) for chronic low back pain (cLBP).

MATERIALS AND METHODS

In this prospective, multicenter observational study, 118 patients were admitted to 11 centers throughout Austria and Switzerland. After a screening visit, all patients underwent a trial stimulation period of at least seven days before implantation of the permanent system. Leads were placed in the subcutaneous tissues of the lower back directly in the region of greatest pain. One hundred five patients were implanted with a permanent stimulating system. Patients' evaluation of pain and functional levels were completed before implantation and one, three, and six months after implantation. Adverse events, medication usage, and coverage of the painful area and predictive value of transcutaneous electrical nerve stimulation (TENS) were monitored.

RESULTS

All pain and quality-of-life measures showed statistically significant improvement during the treatment period. These included the average pain visual analog scale, the Oswestry Disability Questionnaire, the Becks Depression Inventory, and the Short Form-12 item Health survey. Additionally, medication usage with opioids, nonsteroidal anti-inflammatory drugs, and anti-convulsants showed a highly significant reduction. Complications requiring surgical intervention were reported in 9.6% of the patients. The degree of coverage of painful areas seems to be an important criterion for efficacy of PNFS, whereas TENS is presumably no predictor.

CONCLUSIONS

This prospective, multicenter study confirms that PNFS is an effective therapy for the management of cLBP. Significant improvements in many aspects of the pain condition were measured, and complications were minimal.

Local anesthetics injection therapy for musculoskeletal disorders: a systematic review and meta-analysis

OBJECTIVES

Therapeutic injections with local anesthetics (TLA) are widespread and are used for various symptoms of the musculoskeletal system. The aim of the present project was to evaluate the efficacy and safety of TLA in the treatment of musculoskeletal disorders.

METHODS

Systematic literature search for controlled clinical trials (Medline, Cochrane, CAMbase, hand search of references) without language limitation; independent screening of the search results (n=3200 hits), abstract reading, and full-text analysis by 2 reviewers. Two authors independently extracted the data and assessed study quality. Meta-analysis was calculated for studies using a continuous scale for pain assessment.

RESULTS

Twenty-four controlled trials were included in this review. In almost all studies no primary outcome measure was defined and the overall study quality was low. The qualitative data analysis revealed no clear trend for or against TLA. The meta-analysis of 12 studies showed no significant difference in pain reduction for TLA compared with control treatments consisting of saline injections or other substances, oral analgesics, or nonpharmacological interventions (standardized mean difference -0.31, 95% confidence interval, -0.75 to 0.14). Minor adverse side effects were reported in 7 studies in both the TLA and the control groups with no trend for one of the groups to be safer.

DISCUSSION

Despite the widespread use of TLA for musculoskeletal disorders in daily practice, available data are sparse and of low quality and, therefore, do not allow a final recommendation. High-quality studies are needed to close the gap between common practice and research.

In vivo discography in degenerate porcine spines revealed pressure transfer to adjacent discs

STUDY DESIGN

In vivo experimental porcine study.

OBJECTIVE

To investigate if discography induced pressure increase in adjacent degenerate discs.

SUMMARY OF BACKGROUND DATA

Despite refinements in the past 2 decades, the validity of discography is debated. Discography in healthy pigs has shown that the pressure increase during disc injection transmits to adjacent discs, a potential source for false positive responses.

METHODS

Degeneration in 1 lumbar disc was induced in 10 pigs by drilling a hole through the endplate. Intradiscal pressure was recorded using a 0.36-mm fiber-optic pressure transducer inserted into nucleus pulposus through a 22-gauge needle. The pressure was measured simultaneously in 2 adjacent discs during slow (0.03 mL/s) automated contrast injection into 1 of the discs up to 8 bar (116 psi). Ten adjacent discs were prefilled with contrast from previous discogram. A pressure increase 2 psi or more above baseline was defined as increased pressure in adjacent discs. Pressure was recorded until 15 minutes after injection.

RESULTS

A total of 28 discograms were successfully performed. A pressure increase during injection was detected in 57% (16) of the 28 adjacent discs with mean 3.2 psi (1.7-8.2; standard deviation, 1.8), corresponding to a mean increase above baseline of 11%. Of those 16 adjacent discs, 4 were nondegenerate and 12 degenerate, of which 7 were prefilled. Fifteen minutes after injection, 89% of adjacent discs displayed increase in pressure of mean 14% above baseline.

CONCLUSION

Discography induced pressure increase in adjacent discs in a degenerate disc model, something not reported earlier. If present, also in human spine pressure transmission, may be a potential cause for false positive discography responses.

One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study

BACKGROUND CONTEXT

The clinical entity "discogenic back pain" remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation.

PURPOSE

To compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels.

DESIGN

Prospective observational cohort study.

PATIENT SAMPLE

Patients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area.

OUTCOME MEASURES

Roland-Morris back disability score (primary outcome), current rating of overall pain severity on a numerical scale, back and leg pain bothersomeness measures, the physical function scale of the short-form 36 version 2 questionnaire, use of medications for pain, work status, emergency department visits, hospitalizations, and further surgery.

METHODS

Patients receiving spine surgery within 6 months of enrollment were designated as the "surgical treatment" group and the remainder as "nonsurgical treatment." Outcomes were assessed at 3, 6, 9, and 12 months after enrollment.

RESULTS

We enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons. Eighty-six patients (17%) had surgery within 6 months of enrollment. Surgery consisted of instrumented fusion (79%), disc replacement (12%), laminectomy, or discectomy (9%). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland disability questionnaire (primary outcome) 1 year after enrollment. Using a composite definition of success incorporating 30% improvement in the Roland score, 30% improvement in pain, no opioid pain medication use, and working (if relevant), the 1-year success rate was 33% for surgery and 15% for nonsurgical treatment. The rate of reoperation was 11% in the surgical group; the rate of surgery after treatment designation in the nonsurgical group was 6% at 12 months after enrollment.

CONCLUSIONS

The surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.