Recent Medical Literature Review On Current Medical Management of Chronic Back Pain

Article in Review-Deyo, A. et.al "Overtreating chronic back pain: time to back off?", Journal of the American Board of Family Medicine, March, 2009

Current medical management of chronic back pain, generally includes, prescriptive analgesics (pain killers), spinal injections, spinal surgery. A recent literature review (March, 2009) of the use and effectiveness of these modalities along with MRI imaging in the Journal of the American Board of Family Medicine found the following.

Imaging (MRI/CT)

In the US, medicare expenses for MRI imaging had increased by a mammoth 307%  between 1994 and 2004. Judged on the American College of Physician and American Pain Society guidelines 1/3-2/3 of spinal CT and MRI maybe inappropriate. Spinal imaging of this nature can lead to irrelevant findings such as herniated disc, which are common findings in asymptomatic patients. There was one paper reviewed which showed those who received an early spinal MRI were more likely to proceed to surgery sooner than those who just received an x-ray, with no better outcomes.

Prescriptive Opioid Analgesics 

Opioid analgesics include those such as Morphine, Codeine and Pethidine. The review found that between 1994 and 2004 the issuing of prescriptive opioid analgesics increased for spinal pain by 108%, even though the incidents of spinal pain based complaints has remained fairly stable since 1990. Many people with chronic back pain will endure it for years and even decades, resulting in long-term drug use with current research showing conflicting evidence as to the long-term cost/benefit risk. One Cochrane review of opioid analgesic use in patients with chronic back pain concluded that "despite concern surrounding the use of opioids for long term management of chronic back pain, there remains few high quality trials assessing their efficacy (effectiveness). Based on our results, the benefits of opioids in clinical practice for long term management of chronic back pain remains questionable."

Spinal Injections

Spinal injections generally include, corticosteroid and epidural injections. The research showing the effectiveness of spinal injections is limited. The reviewed revealed that epidural corticosteroid injections may offer temporary relief of sciatica, but European and American guidelines based on systematic reviews concluded they do not reduced the risk of subsequent surgery. The review found multiple randomised trials which showed that corticosteroid injections into the facet joints where no more effective than saline injections. Yet in the US facet joint injections have increased by 231% from 1994-2001 while epidural injections for spinal pain increased by 271%. To top this off, there is no evidence suggesting spinal injections for patients with spinal pain (without sciatica) provides any benefit, yet they still accounted for a high portion of spinal injections performed.

Spinal Surgery

Spinal surgery usually consists of fusing 2 or more vertebra together and usually involves the use of implants such as spinal fusion cages. Spinal fusion surgery is a long established way of treating fractures and deformities, but 4 randomised clinical trials showed its benefits are limited when treating degenerative discs with spinal pain (no sciatica). Between 1990-2001 there was a 220% increase in spinal surgery despite there being no changes, clarifications or improvements in the indications for surgery or improved effectiveness of spinal surgery. The review found that higher spinal surgery rates are sometimes associated with worse outcomes and the best surgical outcomes occurred where surgery rates where lower. It also found that use of surgical implants increased the risk of nerve injury, blood loss, overall complications, operating times and repeat surgery while only slightly improved solid bone fusion rates. There was no added improvement in pain levels or function. 

Conclusions

This review revealed that the current medical approaches to managing chronic back pain are not highly successful, with the current management system unlikely to change outcomes for patients with chronic back pain. 

There is no "magic bullet" for chronic back pain and expecting such a bullet is unrealistic and wishful thinking. Chronic pain falls into the same category as Diabetes and Asthma, one that has no instant cure, but one that can be treated. Emerging evidence shows that patient management strategies utilised by health care practitioners need to focus on patient involvement within the therapeutic decision making, self management and education, group based activity/exercise and realistic expectations.

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