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Letters

Recommendations for management of low-back pain misleading

Sean A. Kennedy and Mark O. Baerlocher
CMAJ June 10, 2014 186 (9) 696-697; DOI: https://doi.org/10.1503/cmaj.114-0041
Sean A. Kennedy
School of Medicine (Kennedy), McMaster University, Hamilton, Ont.; Department of Radiology (Baerlocher), Royal Victoria Hospital, Barrie, Ont.
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Mark O. Baerlocher
School of Medicine (Kennedy), McMaster University, Hamilton, Ont.; Department of Radiology (Baerlocher), Royal Victoria Hospital, Barrie, Ont.
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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.

References

  1. ↵
    1. Busse JW,
    2. Rampersaud R,
    3. White LM,
    4. et al
    . Recommendations for management of low-back pain misleading. CMAJ 2014;186:696.
    OpenUrlFREE Full Text
  2. ↵
    1. Itz CJ,
    2. Geurts JW,
    3. van Kleef M,
    4. et al
    . Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain 2013;17:5–15.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Pengel LH,
    2. Herbert RD,
    3. Maher CG,
    4. et al
    . Acute low back pain: systematic review of its prognosis. BMJ 2003;327:323.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Heuch I,
    2. Foss IS
    . Acute low back usually resolves quickly but persistent low back pain often persists. J Physiother 2013;59:127.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Kennedy SA,
    2. Baerlocher MO
    . New and experimental approaches to back pain. CMAJ 2014; Feb. 10 [Epub ahead of print].
  6. ↵
    1. Chaparro LE,
    2. Furlan AD,
    3. Deshpande A,
    4. et al
    . Opioids compared to placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine (Phila Pa 1976) 2014;39: 556–63.
    OpenUrlCrossRef
  7. ↵
    1. Chou R,
    2. Qaseem A,
    3. Owens DK,
    4. et al.
    Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154: 181–9.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Kallmes DF,
    2. Comstock BA,
    3. Heagerty PJ,
    4. et al
    . A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361:569–79.
    OpenUrlCrossRefPubMed
  9. ↵
    1. Buchbinder R,
    2. Osborne RH,
    3. Ebeling PR,
    4. et al
    . A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009;361: 557–68.
    OpenUrlCrossRefPubMed
  10. ↵
    1. Baerlocher MO,
    2. Munk PL,
    3. Liu DM
    . Trials of vertebroplasty for vertebral fractures. N Engl J Med 2009; 361:2098; author reply 2099–100.
    OpenUrlPubMed
  11. ↵
    1. Kallmes DF,
    2. Jarvik JG,
    3. Osborne RH,
    4. et al
    . Clinical utility of vertebroplasty: elevating the evidence. Radiology 2010;255:675–80.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Klazen CA,
    2. Lohle PN,
    3. de Vries J,
    4. et al
    . Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet 2010; 376: 1085–92.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 186 (9)
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Vol. 186, Issue 9
10 Jun 2014
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Recommendations for management of low-back pain misleading
Sean A. Kennedy, Mark O. Baerlocher
CMAJ Jun 2014, 186 (9) 696-697; DOI: 10.1503/cmaj.114-0041

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Recommendations for management of low-back pain misleading
Sean A. Kennedy, Mark O. Baerlocher
CMAJ Jun 2014, 186 (9) 696-697; DOI: 10.1503/cmaj.114-0041
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