Keep low back pain patients out of surgery

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Pharmacotherapy has a limited role in low back pain management, generally in conjunction with self-care. The demonstrated benefits of diverse classes of medications have been, on the whole, modest and short-term.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the mainstay of drug treatment, with a time-limited course of opioid analgesics or tramadol to be considered when pain is severe and disabling.

Muscle-relaxant medications are another option for short-term pain relief, and while there is little evidence of overall differences in efficacy or safety among agents, the risks associated with certain drugs (e.g., hepatotoxicity with dantrolene) should be taken into account.

Among novel treatments, the anticonvulsive drug gabapentin has been shown to have modest, short-term benefits for radiculopathy. There is limited evidence demonstrating small-to-moderate benefits with herbal therapies (e.g., devil's claw, capsicum), and they seem to be safe, the authors say.

Nonpharmacologic interventions

A number of modalities with proven benefits should be considered for patients who do not improve with self-care. During the acute phase (pain of less than four weeks), spinal manipulation has been associated with small-to-moderate benefits, while exercise, whether supervised or done at home, has not been shown effective.
For pain of longer duration, interventions with evidence of moderate efficacy include acupuncture, exercise therapy, cognitive behavior therapy, progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation. Exercise programs that are supervised, tailored to the individual, and involve muscle stretching and strengthening appear to have the best outcomes.

Few trials have evaluated nonpharmacologic strategies specifically in patients with radicular pain or symptoms of spinal stenosis.

“A bunch of things seem to work, but there is no clear-cut first-line choice,” Dr. Chou says of nonpharmacologic interventions. Most have similar benefits—10-20 points on a 100-point pain scale. “Clinicians need to talk to patients about their preferences,” he says. “Studies show that if an individual believes acupuncture works, he or she will do better with it than with massage.” Cost and convenience are factors warranting consideration.

Specialty care

The Guideline suggests consultation with a back specialist when nonspecific low back pain doesn't respond adequately to noninvasive treatments but concedes that there are few data on timing or indications for referral. Although specialty interventions are not the province of this document, other guidelines suggest a three- to 24-month trial of nonsurgical interventions before considering surgery and note that participants in trials of surgery have generally had pain for at least one year.

Diagnosis and Treatment of Low Back Pain: a Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society was published in Annals of Internal Medicine (2007;147:478-491). Reviews of evidence for medications and nonpharmacologic therapies for low back pain were published in the same issue (pages 505-514 and 492-504, respectively) (all electronic documents were accessed September 21, 2009).

Mr. Sherman is a medical writer in New York City.

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