Invasive Treatments for Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS: Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS: Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION: Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Non-Invasive and Minimally Invasive Management of Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Low Back Disorders Guideline reviews the evidence and recommendations developed for non-invasive and minimally invasive management of low back disorders. METHODS: Systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking. A total of 70 high-quality and 564 moderate-quality trials were identified for non-invasive low back disorders. Detailed algorithms were developed. RESULTS: Guidance has been developed for the management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 121 specific recommendations. CONCLUSION: Quality evidence should guide treatment for all phases of managing low back disorders.

Effects of Axial Torsion on Disc Height Distribution: An In Vivo Study.

OBJECTIVES: Axial rotation of the torso is commonly used during manipulation treatment of low back pain. Little is known about the effect of these positions on disc morphology. Rotation is a three-dimensional event that is inadequately represented with planar images in the clinic. True quantification of the intervertebral gap can be achieved with a disc height distribution. The objective of this study was to analyze disc height distribution patterns during torsion relevant to manipulation in vivo. METHODS: Eighty-one volunteers were computed tomography-scanned both in supine and in right 50° rotation positions. Virtual models of each intervertebral gap representing the disc were created with the inferior endplate of each "disc" set as the reference surface and separated into 5 anatomical zones: 4 peripheral and 1 central, corresponding to the footprint of the annulus fibrosus and nucleus pulposus, respectively. Whole-disc and individual anatomical zone disc height distributions were calculated in both positions and were compared against each other with analysis of variance, with significance set at P < .05. RESULTS: Mean neutral disc height was 7.32 mm (1.59 mm). With 50° rotation, a small but significant increase to 7.44 mm (1.52 mm) (P < .0002) was observed. The right side showed larger separation in most levels, except at L5/S1. The posterior and right zones increased in height upon axial rotation of the spine (P < .0001), whereas the left, anterior, and central decreased. CONCLUSIONS: This study quantified important tensile/compressive changes disc height during torsion. The implications of these mutually opposing changes on spinal manipulation are still unknown.

Management of degenerative disk disease and chronic low back pain.

Degenerative disk disease is a strong etiologic risk factor of chronic low back pain (LBP). A multidisciplinary approach to treatment is often warranted. Patient education, medication, and cognitive behavioral therapies are essential in the treatment of chronic LBP sufferers. Surgical intervention with a rehabilitation regime is sometimes advocated. Prognostic factors related to the outcome of different treatments include maladaptive pain coping and genetics. The identification of pain genes may assist in determining individuals susceptible to pain and in patient selection for appropriate therapy. Biologic therapies show promise, but clinical trials are needed before advocating their use in humans.

Intradiscal electrothermal therapy (IDET) for the treatment of discogenic low back pain: patient selection and indications for use.

Discogenic low back pain resulting from internal disc disruption can be severely disabling, clinically challenging, and expensive to treat. Previously, when conservative care had been exhausted, open surgical intervention such as spinal fusion or artificial disc replacement was the only treatment option for these patients. Intradiscal electrothermal therapy (IDET), a minimally-invasive technique performed in the outpatient setting, offers an intermediate intervention between conservative care and surgery. Specific selection criteria have been refined that identify patients for treatment with IDET, ensuring maximal clinical benefit and appropriate use of healthcare resources. Indications for use were developed from review of selection criteria from published clinical reports and review articles of IDET, and further refined by identifying components with the strongest positive predictive value and by direct physician feedback. Final indications for use consist of clinical and imaging criteria. There are 5 compulsory indications for use: 1) persistent axial low back pain +/- leg pain and non-responsive to > or = 6 weeks of conservative care; 2) history consistent with discogenic low back pain without marked lower extremity neurological deficit; 3) one to 3 desiccated discs with or without small, contained herniated nucleus pulposus by T2-weighted magnetic resonance imaging, with at least 50% remaining disc height; 4) concordant pain provocation by low pressure (< 50 psi above opening pressure) discography; and, 5) posterior annular disruption by post-discography computed tomography. Using these patient selection characteristics, approximately 3 of 4 IDET-treated patients should achieve a minimal clinically important improvement in pain and disability.

Nonsurgical management of acute and chronic low back pain.

A variety of nonsurgical treatment alternatives exists for acute and chronic low back pain. Patients should receive appropriate education about the favorable natural history of low back pain, basic body mechanics, and methods (eg, exercises, activity modification, behavioral modification) that can reduce symptoms. Nonprescription medication is efficacious for mild to moderate pain. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain. Exercise therapy has limited value for acute low back pain, but strong evidence supports exercise therapy in the management of chronic low back pain. Moderately strong evidence supports the use of manipulation in acute back pain. Evidence is weak for the use of epidural corticosteroid injections in patients with acute low back pain, strong for short-term relief of chronic low back pain, and limited for long-term relief of chronic low back pain. The use of facet injections in the management of acute low back pain is not supported by evidence, nor is the effectiveness of orthoses, traction, magnets, or acupuncture. Trigger point injections are not indicated for nonspecific acute or chronic low back pain, and sacroiliac joint injections are not indicated in the routine management of low back pain. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation.

Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET).

BACKGROUND: A growing number of patients suffer from severe low back pain of discogenic origin that is not responsive to conservative medical management. These patients must consider the option of surgical spinal fusion or minimally-invasive intradiscal electrothermal therapy (IDET). OBJECTIVE: To conduct a systematic review of clinical outcomes in patients undergoing spinal fusion or the intradiscal electrothermal therapy (IDET) procedure for intractable discogenic low back pain. DESIGN: Systematic literature review. METHODS: English-language journal articles published from January 1995 to December 2005 were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected if disc degeneration or disruption was the primary indication for spinal fusion or the IDET procedure and if follow-up outcome data included evaluations of back pain severity, condition-specific functional impairment and/or health-related quality of life. The literature reviewed encompassed 33 spinal fusion articles: 10 randomized controlled trials, 1 nonrandomized controlled trial, 9 before-after trials, and 13 case series. There were 18 IDET articles: 2 randomized controlled trial, 2 nonrandomized controlled trials, 11 before- after trials, and 3 case series. Data were extracted and summarized on patient characteristics, surgical methods, and clinical outcomes. RESULTS: Overall, there were similar median percentage improvements realized after spinal fusion and the IDET procedure, respectively, for 2 of the 3 outcomes evaluated: pain severity (50%, 51%), back function (42%, 14%) and quality of life (46%, 43%). There was an identifiable randomized controlled trials trend of both treatments reporting a smaller magnitude of improvement in all 3 primary outcomes (pain severity, back function, quality of life) compared to other types of trials. Perioperative complications were commonly associated with spinal fusion (median: 14%, range: 2% to 54%, n = 31 study groups) whereas adverse events were rarely experienced with the IDET procedure (median: 0%, range: 0% to 16%, n = 14 studies). Randomized controlled trials of spinal fusion, in particular, had important methodological limitations. CONCLUSION: The majority of patients reported improvement in symptoms following both spinal fusion and the IDET procedure. The IDET procedure appears to offer sufficiently similar symptom amelioration to spinal fusion without the attendant complications.