Review: evidence for the effectiveness of non-surgical interventions for low back pain and radiculopathy is limited

Question Are nonsurgical treatments effective for low back pain and radiculopathy? Review scope Included studies evaluated target injections or other nonsurgical treatments in patients >18 years of age who had low (lumbar or sacral) back pain. Studies reported 1 of the following outcomes: back-specific function, general health status, pain, work disability, and patient satisfaction. Exclusion criteria included pregnancy and low back pain associated with acute major trauma, cancer, infection, the cauda equina syndrome, fibromyalgia, spondyloarthropathy, osteoporosis, and vertebral compression fracture. Review methods MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (all to Jul 2008) and reference lists were searched for randomized controlled trials (RCTs) published in English or included in English-language systematic reviews and English-language systematic reviews published after 1999. Experts were contacted. 97 RCTs, including 75 reported in 26 systematic reviews, met the inclusion criteria. Main results The main results are in the Table. Conclusion Evidence supporting the effectiveness of nonsurgical interventions for low back pain and radiculopathy is limited. Nonsurgical interventions for low back pain* Intervention Selected findings Local injection Subacute/chronic pain: Local anesthetic was better than placebo at 2 wk in 3 RCTs (2 lower quality) but did not differ from dry needlestick or acupressure in 1 RCT. Prolotherapy Chronic nonspecific pain: Prolotherapy and saline or local anesthetic did not differ for pain and disability at 24 mo in 3 (1 lower quality) of 4 RCTs. Epidural steroid injection Pain with radiculopathy: Epidural steroid was better than nonepidural placebo in 5 of 6 RCTs (2 of 3 lower quality) and epidural placebo in 2 of 11 RCTs (1 of 7 lower quality) for pain/function at 1 mo; epidural steroid was no better than placebo at >3 mo in 11 of 17 RCTs (5 of 8 lower quality). Chemonucleolysis Lumbar disc prolapse: Chemonucleolysis was better than placebo for treatment success in 4 (1 lower quality) of 5 RCTs. FJSI or medial branch block Chronic pain: FJSI was better than saline at 6 mo but not earlier in 1 RCT; treatments did not differ in 1 lower-quality RCT. FJSI and medial branch block did not differ in 2 RCTs (1 lower quality). Intradiscal steroid injection Degenerative disc disease: Intradiscal steroids did not improve pain/function when added to discography in 1 lower-qualty RCT or compared with saline or local anesthetic in responders to discography in 2 RCTs (1 lower quality). Back pain with sciatica: Intradiscal steroids and chemonucleolysis did not differ in 3 RCTs (2 lower quality). Radiofrequency denervation Presumed facet joint pain: Inconsistent results. Radiofrequency denervation was better than sham treatment for some measures of pain at 4 wk to 12 mo in 4 (1 lower quality) of 5 RCTs. IDET Chronic pain: Inconsistent results. IDET was better than sham IDET on some measures of pain in responders to discography in 1 of 2 RCTs. PIRFT Presumed discogenic pain: PIRFT and sham PIRFT did not differ for pain relief or treatment success in 1 RCT; PIRFT of lower or higher intensity resulted in minimal improvement in 1 RCT. Spinal cord stimulation Failed back surgery syndrome and persistent radiculopathy: SCS was better for pain relief than reoperation at 2.9 y in 1 RCT or conventional medical management at 6 mo in 1 RCT. *FJSI = facet joint steroid injection; IDET = intradiscal electrothermal therapy; PIRFT = percutaneous intradiscal radiofrequency thermocoagulation; RCT = randomized controlled trial. Trials were rated high quality (6 of 11 criteria) unless otherwise noted. Commentary Chronic low back pain is recognized as an increasing medical challenge and, as discussed by Chou and colleagues, primary care physicians are often inadequately prepared for managing the condition (1). But is there an even more fundamental problem? Does diagnosis of low back pain imply failure to identify its etiology? In fact, the cause of low back pain is sometimes murky. We know, for example, that vertebral body osteophytes are not a source of back pain unless they are pressing on a nerve (2), and even if there appears to be nerve root impingement, the diagnosis is not always clear. Also, the referred pain patterns of fibromyalgia may mimic those of nerve root impingement (3). It is important to note that Chou and colleagues excluded studies of what are probably the major diagnosable sources of back pain (i.e., osteoporosis, vertebral fracture, fibromyalgia, and postural abnormalities). In my experience, adequately trained, educated, and experienced physicians can usually identify the etiology of back pain. Accurate diagnosis is essential, and it is recognized that treatments might differ depending on the etiology of a particular pattern of back pain. Light back extension exercise programs and avoidance of flexion activities (1) usually result in major reductions of pain related to inflammatory back disease, while aggravation of symptoms by extension activities would suggest facet disease; however, even that differentiation is not absolute (3). It is surprising that Chou and colleagues considered a >20% change on visual analogue pain scales to be a large improvement; many would consider <30% change to be a failure. A major challenge in assessing therapeutic efficacy is the invasiveness of some techniques and failure to use, or the ethical inappropriateness of, sham techniques. Thus, it is difficult to reliably establish efficacy of the very remunerative epidural and facet joint injections even if placebo effects of the procedures are ignored. Chou and colleagues found that the results of surgical studies were inconsistent (even without considering placebo effects). They did not adequately address potential contributions of physical therapy in those studies, although they appropriately emphasize surgical complications. They note problems with intention-to-treat analyses in this setting, appropriately challenging their statistical and clinical validity. As almost 50% of patients did not adhere to assigned treatments in 2 large studies comparing laminectomy with nonsurgical treatment, one wonders why these protocol violations were not considered sufficiently important to preclude publication, especially in a prestigious medical journal (4, 5). The major issue in studies of back pain treatment appears to be lack of significant long-term benefits (even at the 20% level) and some side effects of these approaches. Chou and colleagues examined treatment modalities that are typically well-reimbursed rather than those that are not, such as education of patients in home exercise programs. Their analysis of surgical studies found that intensive rehabilitation with cognitive behavioral therapy was of equal value to fusion surgery for chronic nonradicular low back pain.