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Spinal pain - Management - (3.3.18 - 3.3.24)

Updated: Mar 7, 2022



3.3.18 - Critically discuss the evidence base for management of acute low back pain with or without painful radiculopathy


Acute low back pain is the second most common symptom for a presentation to Australian General Practice (Britt, Miller & Henderson, 2016).


1% of patients with pain lasting up to 6 weeks will have a serious pathology, 5% will have radiculoatphy, and the remaining 94% are non-specific.


Imaging is not necessary.


The key of management is 'active' management.

This includes: self-management such as:

- Education

- Staying active as possible

- Reassurance that mild pain is ok - they are not doing harm

- Exercise is helpful particular aerobic, strengthening, or pilates.

- Heat can be effective (2006 systematic review showed some benefit at 3 mths)

- Massage may be considered but the evidence is lacking benefit, patients like it

- Spinal manipulation (2017 systematic review - modest improvements in pain/fn)

- CBT has limited use

- Mindfulness and rehabilitation insufficient evidence


Paracetamol is increasingly unclear. (2016 Cochrane suggested no better than placebo)

NSAIDs can be used short term (Modest symptom relief)

Opioids should be used only in extremely rare circumstances (max 3 days as per 2016 CDC recommendation)

Other medications have limited or no evidence of benefit


Epidural steroid injection - not recommended

Surgery no acute


Psychosocial yellow flags should always be assessed


Prognosis

70-90% get better within seven weeks

Recurrences are common 50% in 6 months, 70% in 12 months


References:

Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014-15. General practice series no.38. Sydney: Sydney University Press


ANZCA - 5th Scientific Evidence Guidelines

 

3.3.19 - Discuss the indications for and evidence base for the efficacy of psychological therapies in chronic spinal pain including but not limited to:

The Psychotherapeutic approach should involve:

  1. Patient-clinician relationship and rapport building

  2. Reassurance

Cognitive behavioural therapy

It is a goal-oriented problem-solving psychotherapeutic approach where negative thinking patterns and coping behaviours are addressed.


GRIOTS - RIOTS CAUSED BY GIRL PRIYA

- Goal setting

- Reconceptualise pain

- Identify obstacles

- Target unhelpful thoughts and emotions

- Skills

- Sleep hygiene


Systematic review suggested CBT improves disability and pain catastrophising in patients with chronic LBP after treatment and at follow-up

CBT focuses on restructuring negative thoughts into a realistic appraisal.

This may also involve optimistic thinking rather than a pessimistic style


Acceptance and Commitment therapy

Focuses on the concepts of acceptance and mindfulness.

Mindfulness has been associated with a small effect of improved pain symptoms compared with controls over 30 RCTs but significant heterogeneity in studies

Similar efficacy to CBT


Self management encouragement



Reference:

Ikemoto, T., Miki, K., Matsubara, T., & Wakao, N. (2018). Psychological Treatment Strategy for Chronic Low Back Pain. Spine surgery and related research, 3(3), 199–206. https://doi.org/10.22603/ssrr.2018-0050

 

3.3.20 - Discuss principles of activity prescription in the management of spinal pain


Exercise is prescribed for patients with back pain as it reduces pain and helps maintain or restore flexibility, strength and endurance.


Several systematic reviews show exercise modestly improves pain and function in patients with subacute and chronic LBP.


Benefits of exercise:

- Neurological - Reverses injury-induced neurologic changes in the sensory ganglia, spinal cord and brain in animal models

- Tissues - Injury-induced cell proliferation and neurotrophic factors may amplify the processing of pain - these may be reversed with exercise

- Inflammation - Exercise has been shown to attenuate pro-inflammatory cytokine release and reduce local oxidative stress of tissues

- Mood - It can improve mood leading to increased motivation


Patient fears:

- Educate patients that anatomic findings are not necessarily associated with their pain

- Challenging fearful movements / fear-avoidance.


Important to highlight that initially there may be a slight exacerbation in back pain - but this will improve. Exercise has not been associated with increased LBP exacerbations


No single exercise has been shown to be more beneficial:

- Walking - May be effective - 2015 Meta-analysis of 26 studies walking improved pain and function at 12 mths

- Aerobic exercise - 2015 Meta-analysis of 8 cohort studies suggested decreased pain intensity

- Stretching exercises - Only small trials for simple stretches such as at a desk and ergonomic changes leading to benefits

- Yoga - 2017 Meta-analysis 12 RCTs - Yoga produced small to moderate improvements in function and a slight reduction in pain

- Core exercises - 2016 systematic review suggested it is not superior to any other forms of exercise . 2018 systematic review was less clear


NB: Acute low back pain - exercise has not been shown to be more beneficial for acute LBP compared to other treatments


Exercise may help prevent LBP in primary prevention

- 2018 Meta-analysis - Reduced risk of LBP by 33%


Exercise may help prevent relapses of LBP also:

- Meta-analysis suggested some reduction in recurrent back pain

 

3.3.21 - Outline the indication for and evidence for the efficacy of physical therapies in chronic spinal pain


Spinal manipulation

May have short term benefits.

2011 Meta analysis of 26 RCTs and 6000 patients - compared spinal manipulation with GP care and routine other cares. Spinal manipulation had small short-term effects on pain reduction and improved functional status compared to routine therapy.

2018 Metanalysis suggested spinal manipulation added to other treatments produced a small benefit on pain and function at 12 months compared to other therapies


Acupuncture

Mixed results in studies. Well blinded trials showed little or no benefit from acupuncture vs sham acupuncture

In fact, they say it is most beneficial in those patients who have high expectations of benefit


Massage

A systematic review of 25 trials for subacute and chronic back pain had only short-term improvement in pain and function


Lumbar supports

RCT showed an elastic belt reduced need for pain medication and improved functional status at 30 and 90 days. Not recommended though as reinforces psychological sequelae of 'back problem'


Bed mattress

A soft mattress may be better - in very small trials.


TENS

Meta-analysis of 9 trials - no improvement in back pain scores

 

3.3.22 - Critically discuss the indications and evidence base for the efficacy of pharmacological treatments for chronic spinal pain


(WITHOUT SCIATICA)


NSAIDs (only in acute pain)

Systematic reviews of randomised trials showed that NSAIDs compared with placebo are slightly more effective for pain relief and improvement in function in mixed back pain (acute and chronic populations).


Paracetamol

Evidence is mostly indirect. A systematic review in patients with multi-site osteoarthritis (not just the back) showed it was more effective than placebo but was consistently inferior to NSAIDs for pain relief


Duloxetine

2021 Meta-analysis with 4 RCTs and 1400 patients, duloxetine was more effective than placebo in reducing pain and disability at 3 months. The benefit however was small. Duloxetine works regardless of co-morbid depression.


Tramadol

Can be used. I don't like it.


TCAs

2021 Meta-analysis included 7 trials and almost 600 patients with chronic low back pain, TCAs were associated with benefits at 3 months similar to those with other medication - but was not statistically significant over other types of medications.


Opioids

Systematic reviews and meta-analyses of opioid use in patients with chronic low back pain had few high-quality and no long-term trials. In the small trials available, opioids produced only small, short term improvements in pain and function compared to placebo. No benefit compared to NSAIDs or antidepressants.


In one systematic review, it found aberrant drug-taking behaviours in opioid use for low back pain occurred in up to 24% of patients (though there were flaws in the study).


Other SNRIs/SSRIs

There is no good data on their use in lower back pain


Benzodiazepines

A systematic review of 3 trials reduced pain intensity but the risk of addiction was high


Gabapentinoids (note - this is without sciatica)

Meta-analysis in 2017 of 8 RCTs - Gabapentin did not improve pain compared to placebo and pregabalin was slightly less effective than other analgesics


If radiculopathy - then small or unclear effects on pain noted


Systemic corticosteroids

Did not improve function or reduce pain


Glucosamine

6 mth RCT for 250 patients no difference in QOL between glucosamine and placebo


Alternative therapies - Cayenne, white willow bark, comfrey root extract - just - no.

 

3.3.23 - Critically evaluate the indications and evidence base for the following procedures used in chronic spinal pain

- Injections

- Radiofrequency neurotomy

- Spinal cord stimulation

- Intrathecal drug infusion


ESI for Radicular lumbar pain from disc

  • Small benefits for shorter-term pain and function vs placebo

ESI For spinal stenosis

  • Low-quality evidence of minimal benefit

Spinal cord stimulation after surgery

  • Significant benefits over conventional medical management. No RCTs have looked at SCS outside of the post-surgical back pain.

  • Economical benefits longer-term - cost-effectiveness

Intrathecal pumps:

  • Lower GI effects. Baclofen for spasticity, failed spine surgery, CRPS and cancer

  • Specifically for cancer pain, they have been shown to have improved pain control compared to comprehensive management alone

  • Decreased drug toxicities and depressed levels of consciousness

 

3.3.24 - Critically discuss the indications and evidence base for the efficacy and limitations of surgical interventions for chronic spinal pain, including:

- Decompression/laminectomy

- Discectomy

- Disc replacement

- Fusion


Spinal fusion – Systematic reviews have not shown the benefit of surgical and non-surgical management for chronic back pain. Comparators remain difficult, the elderly are often excluded from trials and few randomised trials.


Lumbar disc replacement – Systematic review 2012 – Bias and sponsorship of trials. No significant difference between groups in pain scores.


Discectomy – open or micro – RCTs show similar outcomes at 2 years. Studies were not blinded. SPORT outcomes showed no better pain outcomes after three months, 4 and 8 years. Secondary outcomes were better (e.g. sciatic bothersomeness and patient satisfaction)


Micro vs Open discectomy – Small trials have shown no significant difference


Physiotherapy after surgery – unclear benefit


Spinal canal stenosis and spondylolisthesis

- Laminectomy – some evidence of benefit over non-surgical at 4 years but gone by 8 years. Observational cohorts have favoured surgery but vary and benefits decline with time.


- Spacer implants – Good improvements at 6 months, 2 and 4 years. Higher rates of subsequent surgery and complications. Less helpful in spondylolisthesis.


- Decompression surgery in spondylolisthesis – Unclear results


Reference: UpToDate 2021

 


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