Treatment of Low-Back Pain
Welcome back to the Strong Healthy Happy blog for the final article in our 4 part series on low-back pain (LBP). In case you missed it, we covered why LBP is such a big problem in part 1, the various causes of LBP in part 2, and preventative strategies in part 3.
Low-back pain will affect almost everyone at some point in their lives, and for some, the pain is severe, prolonged, recurrent, and debilitating. So when LBP interrupts life, what are the options? Treatment options for LBP can be categorized as noninvasive nonpharmacological, pharmacological, injections, and surgical (4).
Treating LBP can be a challenge because it’s so difficult to identify the disease or pathology that is causing the symptoms (4). Degenerative changes are commonly found in patients with and without LBP and can often times be non-symptomatic, so figuring out which pathology to treat is not trivial. The effectiveness of the various treatment options is dependent on each patient’s unique LBP etiology. Identifying the cause of the pain is key to effective treatment. In general, conservative and noninvasive treatment options should be considered before surgery.
Nonpharmacological Treatments of low-back pain
This includes psychological treatments (cognitive behavioral therapy), physical therapy & exercise, complementary & alternative therapies (massage, acupuncture), and orthoses (bracing). The preventative strategies described in part 3 fall into this category and can also be utilized as a treatment strategy for individuals experiencing pain. This can be an effective treatment for some because restoring normal spinal alignment can unload painful structures and improved strength and stability can help you maintain that pain free alignment. There is evidence that exercise, including yoga, cognitive behavioral therapy, multidisciplinary rehabilitation, acupuncture, and spinal manipulation can be effective treatments for chronic LBP (4,6). Determining the appropriate treatment is patient specific and depends on a number of factors, including patient preference, cost, convenience, and availability of skilled providers for specific therapies (6).
Pharmacological Treatments of low-back pain
Drugs play a large role in the treatment and management of LBP. Pharmacological treatments include NSAIDS, Acetaminophen, Opioids, Muscle Relaxants, Anti-Seizure Medication, Antidepressants, and Corticosteroids. There is some evidence supporting the effectiveness of these drugs for treating pain and improving function for individuals with LBP (4), although the effects may only be short-term (5).
Although the evidence suggests that benefits can be achieved through use of these medications, they each have a unique risk profile that must be considered (5). Considering specifically acetaminophen, NSAIDs, and opioids, varying levels of pain relief can be achieved with these drugs, but not without the risks for liver damage (acetaminophen), cardiovascular & gastrointestinal damage (NSAIDs), and addiction & respiratory depression (opioids), all of which can lead to death. Determining the appropriate medication is a complicated decision and risk factors for complications, concomitant medication use, severity and duration of pain, and costs must be considered relative to the benefits (5).
Injection Therapies for low-back pain
Common injection therapies include epidural steroid injection, spinal nerve root block, and prolotherapy, which are used to isolate and treat the pain generator, e.g., facet joint, disc, compressed nerve (2,10). There is very little evidence from randomized controlled trials to support the efficacy of injection therapies for the treatment of chronic and subacute LBP, especially for nonradicular pain (2,10). There is some evidence supporting the efficacy of epidural steroid injections and chemonucleolysis for radiculopathy caused by lumbar disc herniation, although the benefits are short-term and chemonucleolysis is relatively unavailable in the United States (2). This is not to say that injection therapies can not provide benefit to patients suffering from LBP, as anecdotal evidence is readily available, but that more well controlled trials are needed to understand the efficacy of these therapies.
Surgical Treatments for low-back pain
If the minimally- and non-invasive treatments fail to reduce pain and restore function, then a number of surgical treatments may be considered, including decompression (microdiscectomy, laminectomy), fusion, and disc replacement. The evidence on surgical treatments of LBP is mixed, with some trials reporting superior efficacy of surgical treatment compared to nonsurgical treatment (8,11), some reporting no difference (7), and some reporting that only a small proportion of patients do well from surgery (1). The efficacy of surgery also appears to be largely dependent on whether the patient is experiencing radicular pain (nerve root compression) or nonradicular pain, with surgical treatment reported to be beneficial for radicular LBP due to a herniated disc or spinal stenosis, but not for nonradicular LBP due to common degenerative changes (3).
the evidence for surgery
These studies can be difficult to interpret for a number of reasons. Treatment options are often reported as superior because a statistically significant difference between treatment groups was detected. However, statistical significance does not always translate to clinical significance (i.e., does the patient actually experience a noticeable improvement?). Furthermore, the nonsurgical treatment groups in these studies may not be well controlled beyond the fact that the patient did not receive surgery, and may not incorporate physical and/or cognitive therapy as part of that group’s treatment. This sets the bar pretty low for the surgical treatment group to outperform the nonsurgical group. Lastly, emphasis may be placed on results at favorable time points (often short-term in the case of lumbar fusion) but neglect the less favorable results. As one study reported, fusion was significantly superior to nonsurgical treatment for patients with chronic LBP and radiographic signs of disc degeneration and spondylosis (8). However, the authors go on to state that ‘there was still a considerable amount of both pain and disability reported 2 years after treatment start even in the surgical group...“only” 29% assessed themselves as “much better” in the surgical group compared with 14% in the nonsurgical group.’ Only 29% of patients that had surgery thought it made them much better? Only 15% more than patients that did not have surgery? Hmmm... Similarly, the diminished benefits of surgery over time have been reported (3), and another study found that spinal fusion was not more beneficial than intensive rehabilitation with cognitive behavior principles for the management of chronic LBP (7).
financial conflicts of interest
An additional factor to consider is financial conflicts of interest for physicians, which has received much more attention following introduction of The Physician Payments Sunshine Act in 2010. For example, a study which reported the benefits of surgery compared with nonoperative treatment for patients with spinal stenosis secondary to degenerative spondylolisthesis also disclosed that one or more of the authors or a member of his or her immediate family had received payments or benefits in excess of $10,000 from Medtronic, one of the largest spine device manufactures in the world (11). It’s concerning, not only that physicians are being paid by the medical device companies whose products are being implanted in patients, but also that these physicians are publishing evidence in the scientific literature which influences the clinical practice of countless other physicians. Consider the fact that, despite a paucity of evidence supporting the efficacy of fusion to treat LBP, the annual incidence of lumbar fusion procedures increased by 137% over a 10 year period, with 174,223 procedures performed in 1998 compared to 413,171 in 2008. I might need to get my TI-83 calculator out and graph this, but I’m pretty sure those numbers don’t make a lot of sense.
Are there patients who have had surgery when it was not indicated or needed? Probably. Can surgery help people with debilitating LBP that did not respond to less invasive treatments? Absolutely. The information presented here indicates that surgical treatment is often not as successful as one would expect, especially for nonradicular pain associated with degenerative changes of the spine. For those patients, intensive rehabilitation may be equally effective as surgery. But for patients with radiculopathy and an accurately identified pain mechanism, surgical treatment may provide pain relief and improved function when other treatment options could not.
Use this information to have an informed discussion with your physician about your LBP and determine the best treatment option for you.
Now get out there and live a Strong, Healthy, and Happy Life!
Bogduk N, Andersson G. Is spinal surgery effective for back pain?. F1000 medicine reports. 2009;1.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009 May 1;34(10):1078-93.
Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009 May 1;34(10):1094-109.
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Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. Bmj. 2005 May 26;330(7502):1233.
Fritzell P, Hägg O, Wessberg P, Nordwall A, Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine. 2001 Dec 1;26(23):2521-32.
Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine. 2012 Jan 1;37(1):67-76.
Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine. 2009 Jan 1;34(1):49-59.
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. The Journal of Bone & Joint Surgery. 2009 Jun 1;91(6):1295-304.