Study design Clinical practice guideline Objective To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain Summary of background data Management of patients with persistent and disabling low back pain remains a clinical challenge A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain Methods A multidisciplinary panel was convened by the American Pain Society Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group Results Investigators reviewed 3348 abstracts A total of 161 randomized trials were deemed relevant to the recommendations in this guideline The panel developed a total of 8 recommendations Conclusion Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy.

Study design: Systematic review. 

Objective: To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. 

Summary of background data: Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions. 

Methods: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. 

Results: For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms. 

Conclusion: Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline

Study Design. A Cochrane review of randomized controlled trials. Objectives. To collate the scientific evidence on surgical management for lumbar disc prolapse and degenerative lumbar spondylosis. Summary of Background Data. Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures still is unclear. Methods. A highly sensitive search strategy identified all published randomized controlled trials. Cochrane methodology was used for meta-analysis of the results. Results. Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions. There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not improve clinical outcomes. Conclusions. There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other trials become available.

The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis.

Background. Failed back surgery syndrome (FBSS) is a chronic pain condition that has considerable impact on the patient and health care system. Despite advances in surgical technology, the rates of failed back surgery have not declined. The factors contributing to the development of this entity may occur in the preoperative, intraoperative, and postoperative periods. Due to the severe pain and disability this syndrome may cause, more radical treatments have been utilized. Recent trials have been published that evaluate the efficacy and cost-effectiveness of therapeutic modalities such as spinal cord stimulation for the management of patients with failed back surgery.

Review Summary. This article will describe the epidemiology and etiology of FBSS. The importance of prevention will be emphasized. In those patients with established FBSS, a guide to interdisciplinary evaluation and management will be outlined. Special attention will focus on recent trials that have studied the efficacy of more invasive procedures such as spinal cord stimulation. Finally, a suggested management pathway is presented.

Conclusion. FBSS is a challenging clinical entity with significant impact on the individual and society. To better prevent and manage this condition, knowledge of the factors contributing to its development is necessary. While research on FBSS has increased in recent years, perhaps the best strategy to reduce incidence and morbidity is to focus on prevention. Patients diagnosed with FBSS should be managed in an interdisciplinary environment. More radical treatments for FBSS have now been extensively studied providing clinicians with much needed evidence on their efficacy. Incorporating these results into our current knowledge provides a basis on which to construct an evidence-based guide on how best to manage patients who suffer from FBSS.

/pdf/failed-back-surgery-syndrome-1aya1yrm91.pdf

Failed Back Surgery Syndrome

The purpose of the study was to evaluate whether a microsurgical discectomy (MS), compared with a standard lumbar discectomy (SD), could reduce the stay at the hospital or the postoperative morbidity. The study was prospective and of 79 patients with "virgin' lumbar radiculopathy from only one nerve root, 39 were randomized to MS and 40 to SD. All patients had positive myelography or CT findings. The fascia incision was 31 and 70 mm (p < 0.0001), respectively, but the skin incision was of the same length in both groups to blind the study. For the MS and SD group of patients, the median operation time was 48 and 35 min (p < 0.0001), and the stay at the hospital was 5.2 and 4.6 days, respectively. The two groups were not different in sex, age, localization or type of herniated discs. Use of analgesic medicine and the presence of pain in the back or legs pre- and postoperative was the same. We conclude that in a controlled and prospective study, reducing the fascia incision and the muscular dissection from a median of 70-31 mm, does not shorten the length of a stay at a hospital and it has no influence on postoperative morbidity.

A controlled study of microsurgical versus standard lumbar discectomy

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A controlled study of microsurgical versus standard lumbar discectomy