A new systemic multi-center and multi-continent review of both randomized controlled studies and trial registries found that we—as surgeons and industry—are still on the journey to successfully treating chronic non-specific low back pain without radiculopathy.
The study, “Benefits and Harms of Treatments for Chronic Non-Specific Low Back Pain Without Radiculopathy: Systematic Review and Meta-analysis,” was published online on November 15, 2022 in The Spine Journal.
The systematic review and meta-analysis compare the benefits (and harms) of treatments for the management of chronic low back pain without radiculopathy using the Benefit-Harm Scale: level 1 to 7. The team collected data from randomized controlled trials, including trial registries and from electronic databases up until May 23, 2022.
The outcome measures included comparison of pain at immediate-term (2 weeks or less) and short-term (greater than 2 weeks to less than or equal to 12 weeks) and serious adverse events using the Benefit-Harm Scale (level 1 to 7).
The interventions studied include non-pharmacological (acupuncture, spinal manipulation only), pharmacological, and invasive treatments compared to placebo.
Overall, 17,326 records were found. Only three studies provided data on the benefits of interventions and 30 provided data on harms. Studies included interventions of:
- acupuncture,
- manipulation,
- pharmacological therapies, including NSAIDS and opioid analgesics,
- surgery and
- epidural corticosteroid injections.
The researchers found:
- acupuncture (standardized mean difference (SMD) -0.51, 95%CI -0.88 to -0.14, n = 1 trial, moderate quality of evidence, benefit rating of 3) and
- manipulation (SMD -0.39 (96%CI -0.56 to -0.21, n = 2 trials, moderate quality of evidence, benefit rating of 5) effective reduced pain intensity compared to sham
- other treatments were scored as uncertain due to not being effective, statistical heterogeneity preventing pooling of effect sizes, or the absence of relevant trials.
The researchers reported that the harms level warnings were at the lowest for:
- acupuncture,
- spinal manipulation,
- NSAIDs,
- combination ingredient opioids, and
- steroid injections
Harms warnings were higher for single ingredient opioid analgesics and surgery.
“There is uncertainty about the benefits and harms of all the interventions reviewed due to the lack of trials conducted in patients with chronic non-specific low back pain without radiculopathy. From the limited trials conducted, non-pharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions.”
“However, more research is needed. There were high harms ratings for opioid and surgery.”
Study authors include Ronald J. Feise of Institute of Evidence-Based Chiropractic in Scottsdale, Arizona; Stephanie Mathieson of The University of Sydney, Sydney, Australia; Rodger S. Kessler of the University of Colorado Denver – Anschultz Medical Campus in Aurora, Colorado; Corey Witenko of New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, New York; Fabio Zaina of Italian Scientific Spine Institute in Asti, Italy and Benjamin T. Brown of Macquarie University, Macquarie Park, Australia.
This article only describes non radicular nonspecific low back pain without parsing out facet syndrome, sacroiliac sprain, discogenic pain. In my practice the aforementioned conditions represent around 40% of the back pains I see, and they are all treated very differently. Therefore the study is not as useful as it could be
there should no longer be a category titled “non specific beck pain without radiculopathy”. A careful history, PE and radiologic studies should allow an accurate identification of the pain generator . Only then can a specific treatment be applied, one that is directed to the diagnosis and has logical anatomic and medical sense.Non specific “therapies ” are little more than voodoo!
Well put, Andy!!
“One size fits all “ therapy should have gone out in the 70’s concomitant with the advent of more specific diagnostic studies and criteria !!
I agree. Non specific low back pain should not be a diagnosis anymore.
The etiology should be found and the pain treated accordingly. Most of the time could be a facet joint inflammation/osteoarthritis due to disc collapse etc. Surgery should never be done for low back pain. We know the results are bad.
Many of the back pain patients in this category are myofascial in nature. Unfortunately myofascial pain does not show up in any tests other than if you examine the muscles that could be the pain generators. This is present despite having x-ray, CT scan or MRI changes. The question I always ask is, is there an event that precipitated the pain. The changes in the imaging did not happen suddenly. They may be there for many months or years but the pain is acute. By questioning about the incident and examining the patient thoroughly, one would be able to come to true cause of pain and appropriate treatment. I have been a practicing Physiatrist for 45 years and teach in a residency program. I have been examining these patients in a electrodiagnostic laboratory and always think about how we can treat the “no” radiculopathy patients. Radiating pain to the legs does not always mean radiculopathy. My first lesson to the residents. Look at trigger points in gluteus minimus that radiates pain in the S1 distribution. Myofascitis of the quadratus lumborum or iliopsoas causing referred pattern of pain to the lower limbs in L2-L5 distribution is easily treated by muscle energy manipulation techniques. Remember, when I started practicing, there were no advanced imaging studies. We still appropriately diagnosed and treated the patients. I always teach and practice the dictum that the best test to examine back pain patients is you and you alone.
In addition to being diagnosis-nonspecific, differentiation between palliative and therapeutic interventions was not measured and daily core exercise with cognitive behavioral therapy for low back pain was not assessed. Short duration palliative intervention, i.e. massage, manipulation, injections, medication, that requires no patient effort or insight is often ineffective.
Agree strongly that myofascial cause is common; I found sitting slumped was cause in many patients, including myself–ligaments stretched for a few minutes are ok; longer time produces pain, sometimes reactive muscle spasm (try standing on the outside of your feet for 10 minutes). Attention to maintaining lumbar lordotic curve when sitting helps a lot. On other hand, in 40 years, I was never convinced I’d found symptoms due to lumbosacral sprain.