Recommendations for management of low-back pain misleading

We appreciate the dialogue initiated by Busse and colleagues1 surrounding the very complex and controversial field of low-back pain.

The definitions of pain resolution are critical. In the meta-analysis2 referenced by Busse and colleagues1 many of the included studies define resolution of pain as the complete absence of pain. Other studies define resolution of pain as a significant improvement that results in low levels of pain.3^,4 Chronic back pain is a serious concern and often does warrant long-term management strategies, as noted by Busse and colleagues.1 Although back pain often resolves (improves significantly) without treatment, it frequently persists with substantially lesser severity.

In our article,5 we refer only to analgesia, not to narcotics specifically. Analgesia, which includes nonsteroidal anti-inflammatory drugs, COX-2 inhibitors and acetaminophen, is most certainly a well-accepted and valid means to control chronic low-back pain. Busse and colleagues1 warn against the use of narcotics. In the appropriate clinical circumstances, narcotic use is indeed also indicated.6 Implying otherwise would be a great disservice to the large number of patients with intractable pain.

The American College of Radiology periodically releases appropriateness criteria for nearly every type of radiology exam, which describe the relevant indications for referral. These criteria include specific indications that warrant lumbar magnetic resonance imaging (MRI), one of which is pain that lasts more than six weeks. As Busse and colleagues1 note, this specific criterion is discordant with the American College of Physicians’ criteria for ordering lumbar MRI.7 Guidelines can be discordant with one another. We agree that lumbar MRIs are frequently ordered inappropriately. Although inappropriate use of lumbar MRIs may not alter outcomes, MRI must be used for the appropriate indication of complicated back pain.

We make no reference to the utilization of lumbar MRI to indiscriminately screen patients with low-back pain as Busse and colleagues1 suggest. We do not recommend load-bearing MRI for clinical use in the investigation of low-back pain. We clearly state “evidence is insufficient to support widespread adoption.”5

Busse and colleagues1 refer to two randomized controlled trials that compare vertebroplasty to a sham procedure.8^,9 Both of these trials have been criticized as deeply flawed by many,10 including an author of one of the trials.11 The authors1 ignore the larger and better designed VERTOS II trial,12 consensus statements from the major societies and organizations representing those who actually perform the procedure, as well as the great preponderance of evidence in its favour.

Busse and colleagues1 note the substantial controversy over the utility of selective nerve-root blocks and radiofrequency denervation for back pain. When evaluating the literature, one must be conscious of the significant heterogeneity that is inherent in terms of patient back-pain etiology. Interventional procedures likely will not be efficacious when indiscriminately applied to nonspecific back pain. Rather, a better understanding of the types of back pain may lead to the ability to selectively choose those who will benefit the most from particular procedures.