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5 Articles in this Series
Introduction
A Worldwide Take on Opioid Prescribing and Access
Evolution of the Neuropathic State and Evidence-Based Treatment
Incidence and Causes of Persistent Chronic Pain After Major Surgeries
Notable Industry Surveys
Putting a Stop to Guideline Warfare: Lower Back Pain

Putting a Stop to Guideline Warfare: Lower Back Pain

With presentation by Jan Van Zundert, MD, PhD

It is interesting to see how far the medical community has come with regard to lower back pain, both in treatment and how research has evolved since its first major appearances in literature. Jan Van Zundert, MD, PhD, an anesthesiologist at the Multidisciplinary Pain Center of the Ziekenhuis Oost-Limburg in Genk, Belgium, spoke on the epidemiology and guidelines for lower back pain at the 2018 World Congress for Regional Anesthesia and Pain Medicine .1

Pointing to the first major articles published on lower back pain in Europe in the 1980s,2 and its first incidence as a major concern in the 1990s,3 these articles aligned with a time when anesthesiologists first became involved in pain therapy. In the early science, researchers believed that lower back pain was not considered a long-term problem and merely an acute pain. Now, years later, articles have been published that challenge early neglect of lower back pain as a serious issue among sufferers. Dr. Zundert pointed to a study by Hestbaek et al,4 published in 2003, that challenged the reported 90% of spontaneous episodes of lower back pain healing after one month, finding that, on average, 62% of patients have recurrent pain after 12 months. “Either [lower back pain] wasn’t measured accurately 30 years ago, or the problem seems to be increasing,” Dr. Zundert said.

In addition, rankings published in 20155 regarding the global evaluation of disabilities by collaborators at the Global Burden of Disease (GBD) study released every five years, found that surprisingly, in both the first evaluation in 1990 and the last study reviewed in 2013, lower back pain was at the top of the list. “It is now 2018,” Dr. Zundert declared. “We have 20 or 30 years of more imaging, better scanners, better operations, better stimulators, more opioids and more interventions.”

The Case for Evidence-Based Medicine

Dr. Zundert made a strong case for the use of evidence-based medicine, focusing on its second edition definition, “integrating clinical expertise with the best available clinical evidence,” to give better and more dedicated treatment according to the literature already in place. While a quite new approach and discipline, Dr. Zundert says that it is “influencing our healthcare tremendously.”

Dr. Zundert pointed to some favorable guidelines6 that focused on the evidence-based medicine approach. “If you look in the literature, I think there are about 100 guidelines on low back pain up until now. This one is the best.” These guidelines “went back into the definition of evidence-based medicine, what’s available in the literature, to see what was clear and what was translated wrong,” he said. These guidelines involved a number of healthcare stakeholders, alleviating some bias. Among other benefits:

  • the replacement of previous NICE guidelines on early management of low back pain in adults (2009)
  • its basis on systematic reviews of the best available evidence and explicit consideration of cost-effectiveness
  • when minimal evidence was available, recommendations were based on the Guideline Development Group’s experience and opinion of what constitutes good practice.

This bias was featured prominently in the release of an article7 that put many of the already established guidelines of lower back pain under scrutiny. “Close to 20 years after the initial starting point of evidence-based medicine, a discussion over guidelines took place of how to go about interventional therapies for lower back pain,” Dr. Zundert said. The American Pain Society (APS) claimed that none of the interventional treatments for lower back pain were effective, while the American Society of Interventional Pain Physicians (ASIPP) said that all interventional treatments were appropriate for low back pain. “More papers [were released] from one side to the other,” Dr. Zundert said, later mentioning that “when one society says one thing and another society says another, it only creates problems, instead of helping everyone.”

What Not to Do

From the NICE guidance6 many “do nots” come into play. Some of these include:

  • Do not offer opioids for acute pain or chronic pain.
  • Do not offer selective inhibitors.
  • Do not offer spinal fusion for people with low back pain unless as part of a randomized controlled trial.
  • Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.
  • Do not offer imaging for people with low back pain with specific facet joint pain as a prerequisite for radiofrequency denervation.
  • Consider epidural injections of local anesthetic and steroids in people with acute and severe sciatica.
  • Do not use epidural injections for neurogenic claudication in people who have central spinal canal stenosis.
  • Do not offer disc replacement in people with low back pain.

Perspective

These guidelines featured “almost no pharmacological therapy anymore, [and] radiofrequency and epidurals in very select cases,” Dr. Zundert said, guidelines that he agrees with, especially for the United States.

In conclusion, Dr. Zundert reflected on how far the healthcare community has come with the treatment and overall awareness of lower back pain. “It’s a very important evolution. After 20 years of evidence-based medicine, we have to come at a certain level where at least we can say that clinical physicians know what to do, know what not to do, and what we might be able to do.”

Sources

1. Zundert JV. Low back pain advances in treatment/update on interventional treatment strategies. Presented at the World Congress on Regional Anesthesia & Pain Medicine. April 19-21, 2018, in New York, New York.

2. Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians. Spine. 1987;12:1-59.

3. Waddell G. Low back pain: a twentieth century health care enigma. Spine. 1996;21(24):2820-2825.

4. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003;12(2):149-165.

5. Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800.

6. Bernstein IA, Malik Q, Carville S, et al. Low back pain and sciatica: summary of NICE guidance. BMJ. 2017;356:i6748.

7. Chou R, Atlas SJ, Loeser JD, et al. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? J Pain. 2011;12(8):833-839.

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