Comparative Effectiveness of Treatments for Chronic Low Back Pain: A Multiple Treatment Comparison Analysis.
METHODS
A systematic review and network meta-analysis.


OBJECTIVE
To determine current treatment options of chronic low back pain (LBP) as defined by randomized controlled trials (RCTs) and to compare effectiveness of those treatments using a mixed-treatment comparison (MTC).


BACKGROUND
It is important to provide an evidence-based assessment of the treatment options that exist for LBP.


METHODS
A systematic search of RCTs was conducted in MEDLINE and the Cochrane Collaboration Library from 1990 to 2014. From the selected studies, we extracted preoperative and postoperative ODI and VAS back pain scores, additional surgeries, and complications. Standard and network meta-analytic techniques were used.


RESULTS
Twelve RCTs were included in the analysis: 5 total disk replacement (TDR) versus fusion; 1 TDR versus exercise and cognitive behavioral therapy (CBT); 5 fusion versus exercise and CBT; and 1 fusion versus physical therapy (PT). On the basis of MTC, with respect to ODI change scores, the pooled mean difference favoring fusion over exercise and CBT was 2.0 points (95% CI, -1.2 to 4.8). The pooled mean difference favoring TDR over exercise and CBT was 6.4 points (95% CI, 3.2-9.3). The pooled mean difference favoring fusion over PT was 8.8 points (95% CI, 4.1-13.6). The pooled mean differences favoring TDR over fusion was 4.4 points (95% CI, 2.37-6.63). For PT versus structured exercise with CBT, the pooled mean difference favoring exercise with CBT over PT was 6.8 points (95% CI, 1.5-12.8). For TDR versus PT, the pooled mean difference favoring TDR over PT was 13.2 points (95% CI, 8.0-18.4). Additional surgery rates were similar between treatment options.


CONCLUSIONS
All 4 treatments provided some benefit to patients with chronic LBP. According to the MTC analysis, TDR may be the most effective treatment and PT the least effective treatment for chronic LBP. This review is based on a limited number of RCT studies and does not support any 1 treatment modality for all patients.
*Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA †Spectrum Research Inc., Tacoma, WA ‡Midwest Orthopeadics at Rush, Chicago, IL §Scripps Clinic Torrey Pines, La Jolla, CA ∥Department of Internal Medicine, University of Michigan, Ann Arbor, MI ¶Physical Medicine and Rehabilitation, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA.
Jeffrey A
JA
Rihn
Kristen
K
Radcliff
Daniel C
DC
Norvell
Robert
R
Eastlack
Frank M
FM
Phillips
Daniel
D
Berland
Ned
N
Sherry
Mitchell
M
Freedman
Alexander R
AR
Vaccaro
D059350:Chronic Pain / Q000628:therapy*; D015928:Cognitive Behavioral Therapy; D004185:Disability Evaluation; D005081:Exercise Therapy; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D026741:Physical Therapy Modalities; D013123:Spinal Fusion; D059145:Total Disc Replacement; D064232:Visual Analog Scale