Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = -0.20 [95% CI: -0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: -0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = -0.04 [95% CI: -0.36, 0.29]) and at follow-up (standardized mean difference = -0.05 [95% CI: -0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):1-11. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962.

The Effect of Massage Force on Relieving Nonspecific Low Back Pain: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of force applied during massage on relieving nonspecific low back pain (LBP). METHODS: This single-blinded, randomized controlled trial enrolled 56 female patients with nonspecific LBP at a single medical center. For each participant, the therapist performed a 30 min massage session (20 min general massage and 10 min focal massage) using a special instrument with a force sensor inserted, for a total of six sessions in 3 weeks. During the 10 min focal massage, HF and LF groups received high force (HF, ≥2 kg) and low force (LF, ≤1 kg) massage, respectively. The primary outcome was pain intensity (i.e., visual analog scale (VAS), 0-10), and secondary outcomes comprised pain pressure threshold, trunk mobility, LBP-associated disability, and quality of life. RESULTS: No significant between-group differences were observed in baseline characteristics. The HF group exhibited significantly lower VAS than did the LF group, with a mean difference of -1.33 points (95% CI: -2.17 to -0.5) at the end of the intervention, but no significant difference was noted at the end of the follow-up. A significant time effect (p < 0.05) was detected in all secondary outcomes except the pain pressure threshold and trunk mobility. A significant time × group interaction (p < 0.05) was found only for the VAS and pain pressure threshold. CONCLUSIONS: Compared with LF massage, HF massage exerted superior effects on pain relief in female patients with nonspecific LBP at the end of intervention. Applying different levels of force showed no effects on LBP-associated disabilities and quality of life.

Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial.

Importance: The use of spinal cord stimulation for chronic pain after lumbar spine surgery is increasing, yet rigorous evidence of its efficacy is lacking. Objective: To investigate the efficacy of spinal cord burst stimulation, which involves the placement of an implantable pulse generator connected to electrodes with leads that travel into the epidural space posterior to the spinal cord dorsal columns, in patients with chronic radiculopathy after surgery for degenerative lumbar spine disorders. Design, Setting, and Participants: This placebo-controlled, crossover, randomized clinical trial in 50 patients was conducted at St Olavs University Hospital in Norway, with study enrollment from September 5, 2018, through April 28, 2021. The date of final follow-up was May 20, 2022. Interventions: Patients underwent two 3-month periods with spinal cord burst stimulation and two 3-month periods with placebo stimulation in a randomized order. Burst stimulation consisted of closely spaced, high-frequency electrical stimuli delivered to the spinal cord. The stimulus consisted of a 40-Hz burst mode of constant-current stimuli with 4 spikes per burst and an amplitude corresponding to 50% to 70% of the paresthesia perception threshold. Main Outcomes and Measures: The primary outcome was difference in change from baseline in the self-reported Oswestry Disability Index (ODI; range, 0 points [no disability] to 100 points [maximum disability]; the minimal clinically important difference was 10 points) score between periods with burst stimulation and placebo stimulation. The secondary outcomes were leg and back pain, quality of life, physical activity levels, and adverse events. Results: Among 50 patients who were randomized (mean age, 52.2 [SD, 9.9] years; 27 [54%] were women), 47 (94%) had at least 1 follow-up ODI score and 42 (84%) completed all stimulation randomization periods and ODI measurements. The mean ODI score at baseline was 44.7 points and the mean changes in ODI score were -10.6 points for the burst stimulation periods and -9.3 points for the placebo stimulation periods, resulting in a mean between-group difference of -1.3 points (95% CI, -3.9 to 1.3 points; P = .32). None of the prespecified secondary outcomes showed a significant difference. Nine patients (18%) experienced adverse events, including 4 (8%) who required surgical revision of the implanted system. Conclusions and Relevance: Among patients with chronic radicular pain after lumbar spine surgery, spinal cord burst stimulation, compared with placebo stimulation, after placement of a spinal cord stimulator resulted in no significant difference in the change from baseline in self-reported back pain-related disability. Trial Registration: ClinicalTrials.gov Identifier: NCT03546738.

Clinical decision-making for spinal manipulation for persistent spinal pain following lumbar surgery: a protocol for a systematic review and meta-analysis of individual participant data.

INTRODUCTION: There are limited available research and guidance regarding the use of spinal manipulative therapy (SMT) in patients with low back-related symptoms following lumbar spine surgery, a condition called persistent spinal pain syndrome type 2 (PSPS-2). This publication outlines a review protocol to identify and synthesise individual participant data (IPD) to examine associations between patient, clinical and surgical variables and SMT application in adults with PSPS-2. METHODS AND ANALYSIS: PubMed, OVID, Web of Science, Scopus, PEDro, Index to Chiropractic Literature and KoreaMed will be searched from inception to 1 January 2022 without language restrictions. Case reports, series, observational studies and cases from grey literature of adults receiving SMT for PSPS-2 will be included. Two investigators will independently screen citations, abstracts and full-text articles. A risk-of-bias assessment will be performed in duplicate to rate cases according to exposure and outcome ascertainment and data completeness. Data extraction will be performed in duplicate and missing IPD will be requested from corresponding authors. Multiple binary logistic regression will be used to identify independent predictors of the use of lumbar-SMT, lumbar-manual-thrust SMT and SMT within 1-year postsurgery. Patient, clinical and surgical variables will be summarised using descriptive statistics, while SMT-related outcomes (lumbar-SMT, lumbar-manual-thrust SMT and 1-year surgery-to-SMT interval) will be described using adjusted ORs with 95% CIs. ETHICS AND DISSEMINATION: This study was deemed not human subjects research by the University Hospitals' institutional review board. The results of this review will be disseminated at conferences and/or published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42021250039.

Trigger point injections for axial back pain in adolescents.

Adolescents who participate in athletics or have abnormal musculoskeletal anatomy have higher incidences of back pain than non-athletic peers with normal anatomy. Significant time and money spent in diagnostic evaluations for axial back pain can result in treatment delay causing a subsequent decrease in quality of life. Myofascial trigger points are a commonly overlooked reason for axial back pain. They develop due to an abnormal myoneural connection in the setting of muscle overuse. Trigger point injections are a technically simple intervention that is both diagnostic and therapeutic in alleviating trigger point-mediated back pain. There are few complications from these injections, and they should be considered prior to surgical referral or fluoroscopic-guided interventions.

How I treat pain in hematologic malignancies safely with opioid therapy.

The field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.

Efficacy of Electrical Stimulation for Spinal Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Spinal fusion is one of the most common procedures performed in spine surgery. As rates of spinal fusion continue to increase, rates of complications such as nonunions continue to increase as well. Current evidence supporting the use of electrical stimulation to promote fusion is inconclusive. This review aimed to determine if postoperative electrical stimulation is more efficacious than no stimulation or placebo in promoting radiographic fusion in patients undergoing spinal fusion. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL and MEDLINE from date of inception to current. Ongoing clinical trials were also identified and reference lists of included studies were manually searched for relevant articles. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Data were pooled using the Mantel-Haenszel method. Trialists were contacted for any missing or incomplete data. Of 1184 articles screened, 7 studies were eligible for final inclusion (n = 941). A total of 487 patients received postoperative electrical stimulation and 454 patients received control or sham stimulation. All evidence was of moderate quality. Electrical stimulation (pulsed electromagnetic fields, direct current, and capacitive coupling) increased the odds of a successful fusion by 2.5-fold relative to control (OR = 2.53, 95% CI 1.86 to 3.43, p < 0.00001). A test for subgroup interaction by stimulation type, smoking status, and number of levels fused was not significant (p = 0.93, p = 0.82 and p = 0.65, respectively). This systematic review and meta-analysis found moderate-quality evidence supporting the use of postoperative electrical stimulation as an adjunct to spinal fusion surgery. Patients treated with electrical stimulation have significantly greater rates of successful fusion. The level of evidence for this study is therapeutic level I.

Physiotherapeutic management of a patient with spinal Schwannoma: A case report.

INTRODUCTION: Tumors are generally considered as red flags to manual therapy. The purpose of this report is to describe the clinical course of a patient diagnosed with spinal Schwannoma at L2-L3 level, who was referred to physiotherapy (PT) for the treatment of low back pain radiating to the left lower limb. CASE DESCRIPTION: A 30-year old man previously diagnosed with L2-L3 Schwannoma was referred for physiotherapy for the treatment of radiating pain. The patient had not responded favorably to symptomatic management. As the patient's history and physical examination were consistent with a mechanical dysfunction, it was decided to manage the patient along similar lines. The patient was treated with McKenzie extension and central postero-anterior mobilization over T4-T6 vertebrae. This intervention was followed up with strengthening and aerobic exercises. RESULTS: The outcomes were measured by the numerical rating scale (NRS), Oswestry Disability Index (ODI) and the Global rate of Change (GRC) scale. The patient responded well to McKenzie extension exercises and Thoracic mobilization. The NRS (7 at rest; 10 on activity) at the time of referral reduced to (2 on activity) at the time of discharge. The outcomes were maintained after 7 months. CONCLUSION: This case suggests that there is a need to undertake a detailed musculoskeletal examination and mobilization may be safely performed in patients diagnosed with spinal schwannomas. An individualized tailored approach may be beneficial in these patients.

Effect of Mulligan spinal mobilization with arm movement along with neurodynamics and manual traction in cervical radiculopathy patients: A randomized controlled trial.

OBJECTIVE: To determine the effect of Mulligan Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction on pain, disablity and cervical range of motion in cervical radiculopathy patients. METHODS: The randomised controlled trial (RCT) was conducted from August to December 2017 at the Railway General Hospital, Rawalpindi, Pakistan, and comprised cervical radiculopathy patients of either gender aged 20-60 years. They were randomised into two groups, with the experimental Group A getting treated with Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction, while the control group B only getting treated with neurodynamics and manual traction. The pain, disability and cervical range of motion were assessed before and after treatment of 3 weeks using Numeric Pain Rating Scale, Neck Disability Index and Goniometry. Data was analyzed using SPSS 21. RESULTS: Of the 31 patients, 19(61.3%) were females and 12(38.7%) were males. The overall mean age was 41.65±9.714 years. There were 15(48.4%) patients in Group A, and 16(51.6%) in Group B. Group A showed significantly better results in terms of pain, disability and cervical range of motion (p<0.05 each). CONCLUSIONS: Patients treated with Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction had better outcome compared to those who only got neurodynamics and manual traction.

Dietary polyphenols as a safe and novel intervention for modulating pain associated with intervertebral disc degeneration in an in-vivo rat model.

Developing effective therapies for back pain associated with intervertebral disc (IVD) degeneration is a research priority since it is a major socioeconomic burden and current conservative and surgical treatments have limited success. Polyphenols are naturally occurring compounds in plant-derived foods and beverages, and evidence suggests dietary supplementation with select polyphenol preparations can modulate diverse neurological and painful disorders. This study tested whether supplementation with a select standardized Bioactive-Dietary-Polyphenol-Preparation (BDPP) may alleviate pain symptoms associated with IVD degeneration. Painful IVD degeneration was surgically induced in skeletally-mature rats by intradiscal saline injection into three consecutive lumbar IVDs. Injured rats were given normal or BDPP-supplemented drinking water. In-vivo hindpaw mechanical allodynia and IVD height were assessed weekly for 6 weeks following injury. Spinal column, dorsal-root-ganglion (DRG) and serum were collected at 1 and 6 weeks post-operative (post-op) for analyses of IVD-related mechanical and biological pathogenic processes. Dietary BDPP significantly alleviated the typical behavioral sensitivity associated with surgical procedures and IVD degeneration, but did not modulate IVD degeneration nor changes of pro-inflammatory cytokine levels in IVD. Gene expression analyses suggested BDPP might have an immunomodulatory effect in attenuating the expression of pro-inflammatory cytokines in DRGs. This study supports the idea that dietary supplementation with BDPP has potential to alleviate IVD degeneration-related pain, and further investigations are warranted to identify the mechanisms of action of dietary BDPP.

Spa therapy induces clinical improvement and protein changes in patients with chronic back pain.

This study is primarily aimed at assessing serum changes on a large panel of proteins in patients with chronic back pain following spa therapy, as well as evaluating different spa therapy regimens as a preliminary exploratory clinical study. Sixty-six patients with chronic back pain secondary to osteoarthritis were randomly enrolled and treated with daily mud packs and bicarbonate-alkaline mineral water baths, or a thermal hydrotherapy rehabilitation scheme, the combination of the two regimens or usual medication only (control group), for two weeks. Clinical variables were evaluated at baseline, after 2 and 12 weeks. One thousand serum proteins were tested before and after a two-week mud bath therapy. All spa treatment groups showed clinical benefit as determined by improvements in VAS pain, Roland Morris disability questionnaire and neck disability index at both time points. The following serum proteins were found greatly increased (≥2.5 fold) after spa treatment: inhibin beta A subunit (INHBA), activin A receptor type 2B (ACVR2B), angiopoietin-1 (ANGPT1), beta-2-microglobulin (B2M), growth differentiation factor 10 (GDF10), C-X-C motif chemokine ligand 5 (CXCL5), fibroblast growth factor 2 (FGF2), fibroblast growth factor 12 (FGF12), oxidized low density lipoprotein receptor 1 (OLR1), matrix metallopeptidase 13 (MMP13). Three proteins were found greatly decreased (≤0.65 fold): apolipoprotein C-III (Apoc3), interleukin 23 alpha subunit p19 (IL23A) and syndecan-1 (SDC1). Spa therapy was confirmed as beneficial for chronic back pain and proved to induce changes in proteins involved in functions such as gene expression modulation, differentiation, angiogenesis, tissue repair, acute and chronic inflammatory response.

Causes of Residual Back Pain at Early Stage After Percutaneous Vertebroplasty: A Retrospective Analysis of 1,316 Cases.

BACKGROUND: Percutaneous vertebroplasty (PVP) is now well accepted in the treatment of painful osteopathic vertebral compression fractures (OVCF), providing early pain relief and strengthening of the bone of the vertebrae. However, some patients still experienced severe back pain after PVP. OBJECTIVES: To analyze the possible reason for unsatisfactory back pain relief (UBPR) after PVP at early stage. STUDY DESIGN: Retrospective analysis. SETTING: Hong-Hui Hospital in Xi'an. METHODS: Between March 2013 and January 2015, a total of 1,316 patients with OVCF were treated by PVP at our Hospital. Demographics, clinical data, and surgical data were collected to analyze the factors associated with UBPR after PVP. RESULTS: Sixty cases complained of UBPR, and the prevalence was 4.6%. Univariate analyses showed that preoperative bone mineral density (BMD), number of fractures, cement distribution and volume injected per level, lumbodorsal fascia contusion, and depression were associated with UBPR after PVP (P < 0.001). Multivariate analysis revealed that preoperative BMD (odds ratio [OR], 3.577; P = 0.029), lumbodorsal fascia contusion (OR, 3.805; P = 0.002), number of fractures (OR, 3.440; P < 0.001), cement volume injected per level (OR, 0.079; P < 0.001), cement distribution (OR, 3.009; P = 0.013), and depression (OR, 3.426; P = 0.028) were independently associated with UBPR after PVP at the early postoperative stage. LIMITATIONS: A further prospective controlled study is needed to explore the association between the different degrees of the aforementioned factors and UBPR after PVP. CONCLUSIONS: Preoperative low BMD, lumbodorsal fascial injury, multiple segment PVP, insufficient cement injected volume, unsatisfactory cement distribution, and depression were strong risk factors associated with UBPR after PVP in patients with OVCF. KEY WORDS: Unsatisfactory back pain relief, residual back pain, percutaneous vertebroplasty.

Efficiency of pulsed electromagnetic fields on pain, disability, anxiety, depression, and quality of life in patients with cervical disc herniation: a randomized controlled study

Background/aim: In this study, it was aimed to investigate the effects ofpulsed electromagnetic field(PEMF) therapy on pain, disability, psychological state, and quality of life in cervical disc herniation. Materials and methods: Patients were randomly divided into two groups, including Group 1, which received a therapy consisting of transcutaneous electrical nerve stimulation (TENS), hot pack (HP), and PEMF, and Group 2, which received a magnetic field (sham magnetic field) without current flow in addition to TENS and HP therapy. Pain was assessed by a visual analog scale (VAS, 0­10 cm). The other outcome measures were function (Neck Pain and Disability Scale), anxiety-depressive mood (Hospital Anxiety and Depression Scale), and quality of life (Nottingham Health Profile). All evaluations were performed at baseline, in the 3rd week, and in the 12th week after treatment. Results: A significant improvement was found in the neck pain, disability, depression, anxiety, and quality of life scores of both groups after treatment when compared to those before treatment. However, in the comparison between changes within groups, significant improvements were determined only in the VAS and Nottingham Health Profile sleep subparameter in the 12th week after treatment compared to those before treatment. Conclusion: PEMF therapy in cervical disc herniation can be used safely in routine treatment in addition to conventional physical therapy modalities.

Abdominal decompression illness following repetitive diving: a case report and review of the literature.

The complete pathophysiology of decompression illness is not yet fully understood. What is known is that the longer a diver breathes pressurized air at depth, the more likely nitrogen bubbles are to form once the diver returns to surface [1]. These bubbles have varying mechanical, embolic and biochemical effects on the body. The symptoms produced can be as mild as joint pain or as significant as severe neurologic dysfunction, cardiopulmonary collapse or death. Once clinically diagnosed, decompression illness must be treated rapidly with recompression therapy in a hyperbaric chamber. This case report involves a middle-aged male foreign national who completed three dives, all of which incurred significant bottom time (defined as: "the total elapsed time from the time the diver leaves the surface to the time he/she leaves the bottom)" [2]. The patient began to develop severe abdominal and back pain within 15 minutes of surfacing from his final dive. This case is unique, as his presentation was very concerning for other medical catastrophes that had to be quickly ruled out, prior to establishing the diagnosis of severe decompression illness. After emergency department resuscitation, labs and imaging were obtained; abdominal decompression illness was confirmed by CT, revealing a significant abdominal venous gas burden.

Acute idiopathic spinal subdural hematoma: What to do in an emergency?

Acute spinal cord compression usually results from trauma, infection, or cancer. Spinal subdural hematoma is an uncommon cause of spinal cord compression that occurs after spine trauma or spinal invasive procedure, especially in context of coagulopathy. In the following reported case, an 82-year-old woman with a history of rapidly progressive paraparesis after a sudden middle back pain, with no previous trauma or coagulopathy, due to an acute spontaneous spinal subdural hematoma. In fact, the main difficulty was to determine, in an emergency situation, the right strategy to identify both the lesion and its cause to adapt therapeutics. This case not only provides an illustrative unusual condition in an emergency department but also a challenging discussion to choose the right treatment for a sudden neurological impairment. According to a literature review of the idiopathic cases of spinal subdural hematomas without coagulopathy, the clinical outcome depends on severity of neurological impairment. MRI is the main examination to perform in an emergency. Thus surgical evacuation should be performed in emergency in patients presenting with severe neurological impairment.

A Randomized Controlled Trial of Subcutaneous Nerve Stimulation for Back Pain Due to Failed Back Surgery Syndrome: The SubQStim Study.

OBJECTIVES: To compare the effectiveness of peripheral nerve stimulation utilizing a subcutaneous lead implant technique-subcutaneous nerve stimulation (SQS) plus optimized medical management (SQS + OMM arm) vs. optimized medical management alone (OMM arm) in patients with back pain due to failed back surgery syndrome. PATIENTS AND METHODS: Patients were recruited from 21 centers, in Europe, Israel, and Australia. Eligible patients were randomized (1:1) to SQS + OMM or OMM arms. Those in the SQS arm were implanted with a neurostimulator and up to two subcutaneous percutaneous cylindrical leads in the area of pain. Patients were evaluated pre-randomization and at one, three, six, and nine months post-randomization. The primary endpoint was the proportion of subjects with a ≥50% reduction in back pain intensity ("responder") from baseline to nine months. Secondary outcomes included proportion of responders with a ≥50% reduction in back pain intensity at six months and ≥30% reduction at nine months, and the mean change from baseline in back pain intensity at six and nine months between the two arms. RESULTS: Due to the slow rate of recruitment, the study was terminated early with 116 subjects randomized. A total of 33.9% (19/56, missing: n = 20 [36%]) of subjects in the SQS + OMM arm and 1.7% (1/60, missing: n = 24 [40%]) in the OMM arm were responders at Month 9 (p < 0.0001). Secondary objectives showed a significant difference in favor of SQS + OMM arm. CONCLUSION: The results indicate that the addition of SQS to OMM is more effective than OMM alone in relieving low back pain at up to nine months.

Effectiveness and safety of acupotomy for treating back and/or leg pain in patients with lumbar disc herniation: A study protocol for a multicenter, randomized, controlled, clinical trial.

BACKGROUND: As the number of patients suffering from back and/or leg pain due to lumbar disc herniation (LDH) is increasing in Korea, conservative treatments for patients with LDH have been spotlighted. Although several studies have been published on the use of acupotomy for the treatment of such patients, most of them are only case studies. Therefore, the purpose of this study is to compare the effectiveness and safety of acupotomy to those for manual acupuncture for the treatment of patients with LDH. METHODS/DESIGN: This study is planned as a multicenter, parallel design, randomized, controlled, clinical study. One hundred forty-six patients diagnosed with LDH will be randomly assigned to either the acupotomy group or the manual acupuncture group at a 1:1 ratio. Participants in both groups will receive a total of 4 interventions over 2 weeks. An effectiveness assessment based on the outcomes on the visual analog scale (VAS), Roland Morris Disability Questionnaire (RMDQ), Modified-Modified Schober Test (MMST), EuroQol Five Dimensions (EQ-5D), and Patient Global Impression of Change (PGIC) will be conducted at baseline and at 2, 4, and 6 weeks postrandomization. The primary outcome will be the mean change in the VAS for back and/or leg pain 4 weeks postrandomization. Adverse events will be recorded at every visit. DISCUSSION: The results of this study will provide evidence for the effectiveness and safety of acupotomy treatment for patients with LDH. TRIAL REGISTRATION: Clinical Research Information Service of South Korea (CRIS- KCT0002824), April 24, 2018.