A new excellent evidence-based review of invasive treatments for low back pain was published in the European Spine Journal last week (Dec 1st). [1]
Link

This was a thorough review of the best available trials in this area. They also published a review on non-invasive treatments which will be the subject of another QOH Update.

They commented that "compared to conservative treatments, less evidence is available for surgical and other invasive interventions for low back pain. However, there is an increasing acceptance among the orthopaedic community of the principles of evidence-based medicine."

Interestingly even now even the effectiveness of some spinal surgical procedures has not been evaluated in randomised controlled trials. Also most of the trials published compare one type of invasive treatment to another, not to conservative treatment or no treatment at all.

Some of the results are as follows (excluding the original citations):

"Prolotherapy (sclerosant injections) vs placebo The Cochrane review included one trial (N=110). No statistically significant differences were found on pain and disability between fortnightly injections (mean of seven injections) of lumbopelvic ligaments with glucose (20%) and lignocaine (0.2%), 10–30 ml, and injections with saline (0.9%) after 6, 12 and 24 months."

"Facet joint injections vs placebo One study did not find significant differences in proportions with pain improvement between corticosteroid and saline injections at 1 and 3 months after injection: short-term RR 0.89 (0.65–1.21), and long-term RR 0.90 (0.69–1.17). At 6 months, the percentage of patients with marked or very marked improvement was significantly higher in the group treated with methylprednisolone (46 vs 15%, P=0.002). Despite this latter finding, the authors concluded that the efficacy of facet joint injections was small, because 11 of the 22 patients in the steroid group, who reported substantial improvement at 6 months after injection, reported no benefit at earlier evaluations. Moreover, co-interventions were more frequent in the steroid group.
Another study reported that mean scores for pain relief with methylprednisolone and/or bupivacaine were not superior compared to placebo injections. This study did not report the proportions of patients with pain relief."

They concluded that:

• Facet joint, epidural, trigger point and prolotherapy (sclerosant) injections have not clearly been shown to be effective and can not be recommended.
• Fusion surgery for chronic low back pain may be considered only in carefully selected patients with severe pain after the active rehabilitation programmes over a two-year period has failed. Cognitive intervention combined with exercises is recommended when available. Demanding surgical techniques are not better than the traditional posterolateral fusion without internal fixation.
• Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc prolapses that fail to resolve with conservative management.
• There have been no randomised controlled trials on artificial disc replacement surgery and no conclusions can be drawn on its effectiveness. Suffice it so say that its effectiveness has not been demonstrated and this needs to be clearly explained to patients. Other authors have stated that artificial disc replacement should be regarded as an experimental procedure in the meantime [2]

This paper provides some interesting information. There is clearly a need to critically look at how patients with back pain are managed surgically. What we do know is that exercise and cognitive behavioural intervention do help. Surgery may have a role for selected patients.

There is a lot more in this article and we will send more details in future updates. Please let me know if you have any comments or questions by sending an email to david allen@qoh.com.au or calling me on 98977699.

References:
1. van Tulder, M.W., et al., Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J, 2005.
2. de Kleuver, M., F.C. Oner, and W.C. Jacobs, Total disc replacement for chronic low back pain: background and a systematic review of the literature. Eur Spine J, 2003. 12(2): p. 108-16.