Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline.
METHODS
Systematic review.


OBJECTIVE
To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.


BACKGROUND
Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.


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 local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.


RESULTS
For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.


CONCLUSIONS
Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
Department of Medicine, Oregon Evidence-Based Practice Center, Oregon Health and Science University, Portland, OR, USA. chour@ohsu.edu
Roger
R
Chou
Steven J
SJ
Atlas
Steven P
SP
Stanos
Richard W
RW
Rosenquist
D017115:Catheter Ablation / Q000379:methods / Q000706:statistics & numerical data; D002986:Clinical Trials as Topic / Q000706:statistics & numerical data*; D004599:Electric Stimulation Therapy / Q000379:methods / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D006801:Humans; D007268:Injections, Epidural / Q000379:methods / Q000706:statistics & numerical data; D007404:Intervertebral Disc Chemolysis / Q000379:methods / Q000706:statistics & numerical data; D007405:Intervertebral Disc Displacement / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D017116:Low Back Pain / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D009407:Nerve Block / Q000379:methods / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011843:Radiculopathy / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome