New low back pain guideline features shared decision making

A new clinical practice guideline for low back pain (LBP) favors the use of noninvasive treatments over interventional procedures and suggests shared decision making between physicians and patients for better outcomes. Issued by the American Pain Society (APS), the guideline provides clinicians with several recommendations to help determine the best approaches to treating patients with LBP.

Key among the recommendations is the shared decision-making process, in which a patient is fully involved in medical choices after being provided with information about all the options. Such an approach is advocated in the APS guideline because the various options for LBP have several close trade-offs between potential advantages and disadvantages.

LBP is the fifth most common reason for physician visits and accounts for more than $26 billion in direct health care costs nationwide each year, the APS noted. The new guideline, which expands the current and previously published APS guideline for initial evaluation and management of LBP, is based on an extensive review of existing research. A multidisciplinary APS panel augmented by experts on interventional therapies looked at 3348 abstracts and analyzed 161 relevant clinical trials. Based on the data, the APS now makes the following recommendations:

•Avoid the use of provocative diskography (injection of fluid into the disk to determine whether it is the source of back pain) for patients with chronic nonradicular LBP.
•Consider intensive interdisciplinary rehabilitation with a cognitive-behavioral emphasis for patients with nonradicular LBP who do not respond to usual noninterdisciplinary therapies.
•Avoid facet joint corticosteroid injections, prolotherapy, and intradiskal corticosteroid injections for patients with persistent nonradicular LBP. (Evidence is insufficient to guide use of other interventional therapies.)
•Discuss the risks and benefits of surgery. Use shared decision making for consideration of rehabilitation as a similarly effective option for patients with nonradicular LBP, common degenerative spinal changes, or persistent and disabling symptoms. (Evidence is insufficient to guide recommendations for vertebral disk replacement.)
•Review the risks and benefits of epidural cortico-
steroid injections as part of the shared decision-making process. Specifically address the evidence of a lack of long-term benefit for patients who have persistent radiculopathy because of a herniated lumbar disk.
•In the discussion of the risks and benefits of surgery, reference the moderate benefits that decrease over time for patients with persistent and disabling radiculopathy resulting from a herniated lumbar disk or persistent and disabling leg pain.
•Discuss the risks and benefits of spinal cord stimulation. Refer to the high rate of complications after stimulator placement for patients who have persistent and disabling radicular pain after surgery for a herniated disk and show no evidence of a persistently compressed nerve root.

For more information about the guideline, visit the APS Web site at http://www.ampainsoc.org. Or, contact the APS at American Pain Society, 4700 W. Lake Avenue, Glenview, IL 60025; telephone: 847-375-4715; fax: 847-375-6479. For more on this topic, see "Applying shared decision making to low back pain," The Journal of Musculoskeletal Medicine, September 2008, page 421, or visit www.JMMLive.com.