86. Therapies For Low Back Pain

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86. Therapies For Low Back Pain

 

 

CATEGORY:Alternative Medicines 300 Courses

COURSE NUMBER: 86

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Executive Summary………………………………………………………………………………………………….ES-1
Introduction………………………………………………………………………………………………………………….. 1
Background…………………………………………………………………………………………………………….. 1
Scope of Review and Key Questions………………………………………………………………………….. 2
Methods………………………………………………………………………………………………………………………… 4
Input From Stakeholders…………………………………………………………………………………………… 4
Literature Search Strategy…………………………………………………………………………………………. 4
Study Selection ……………………………………………………………………………………………………….. 5
Data Extraction ……………………………………………………………………………………………………….. 6
Assessing Quality…………………………………………………………………………………………………….. 6
Assessing Research Applicability………………………………………………………………………………. 7
Evidence Synthesis and Rating the Body of Evidence ………………………………………………….. 7
Peer Review and Public Commentary ………………………………………………………………………… 9
Results ………………………………………………………………………………………………………………………… 10
Key Question 1. In patients with low back pain, what is the effectiveness of epidural
corticosteroid injections, facet joint corticosteroid injections, medial branch blocks, and
sacroiliac joint corticosteroid injections versus epidural nonsteroid injection, nonepidural
injection, no injection, surgery or nonsurgical therapies on outcomes related to pain, function
and quality of life? …………………………………………………………………………………………………….. 14

Key Question 1a. How does effectiveness vary according to the medication used
(corticosteroid, local anesthetic, or both), the dose or frequency of injections, the number of

Key Question 1b. How does effectiveness vary according to use of imaging guidance or route
of administration (interlaminar, transforaminal, caudal for epidural injections or intra-articular,

One trial compared transforaminal versus interlaminar epidural corticosteroid injection in
Key Points…………………………………………………………………………………………………………….. 14
Detailed Synthesis………………………………………………………………………………………………….. 18
Epidural Injections………………………………………………………………………………………………. 18
Facet Joint Injections …………………………………………………………………………………………… 24
Sacroiliac Joint Injections…………………………………………………………………………………….. 26
levels treated, or degree of provider experience? …………………………………………………………… 27
Key Points…………………………………………………………………………………………………………….. 27
Detailed Synthesis………………………………………………………………………………………………….. 27
Epidural Injections For Radiculopathy…………………………………………………………………… 27
Epidural Injections For Spinal Stenosis………………………………………………………………….. 29
Facet Joint Injections …………………………………………………………………………………………… 30
extra-articular [peri-capsular], or medial branch for facet injections)? ……………………………… 30
Key Points…………………………………………………………………………………………………………….. 30
Detailed Synthesis………………………………………………………………………………………………….. 32
Epidural Injections for Radiculopathy……………………………………………………………………. 32
Epidural Injections For Spinal Stenosis………………………………………………………………….. 35
Epidural Injections For Nonradicular Low Back Pain………………………………………………. 35
patients with nonradicular low back pain, but only reported results in subgroups stratified
by presence of imaging findings of herniated disc or spinal stenosis (see KQ 2).128 …….. 35
Facet Joint Injections …………………………………………………………………………………………… 36

Key Question 2. In patients with low back pain, what characteristics predict responsiveness to
injection therapies on outcomes related to pain, function, and quality of life? …………………… 37

Key Question 3. In randomized trials of low back pain injection therapies, how does
effectiveness vary according to the comparator used (e.g., epidural nonsteroid injection,

Key Question 3a. How do response rates vary according to the specific comparator evaluated

Key Question 4. What are the harms of epidural corticosteroid, facet joint corticosteroid
injections, medial branch blocks, and sacroiliac joint corticosteroid injection compared to
epidural nonsteroid injection, nonepidural injection, no injection, surgery, or nonsurgical
Key Points…………………………………………………………………………………………………………….. 37
Detailed Synthesis………………………………………………………………………………………………….. 37
Epidural Injections………………………………………………………………………………………………. 37
Facet Joint Injections …………………………………………………………………………………………… 39
nonepidural injection, no injection, surgery, or nonsurgical therapies)?……………………………. 39
Key Points…………………………………………………………………………………………………………….. 39
Detailed Synthesis………………………………………………………………………………………………….. 40
(e.g., saline epidural, epidural with local anesthetic, nonepidural injection, no injection,
surgery, nonsurgical therapies)? ………………………………………………………………………………….. 41
Key Points…………………………………………………………………………………………………………….. 41
Detailed Synthesis………………………………………………………………………………………………….. 41

therapies? …………………………………………………………………………………………………………………. 43
Key Points…………………………………………………………………………………………………………….. 43
Detailed Synthesis………………………………………………………………………………………………….. 44
Epidural Injections For Radiculopathy…………………………………………………………………… 44
Epidural Injections For Spinal Stenosis………………………………………………………………….. 45
Epidural Injections For Nonradicular Back Pain……………………………………………………… 45
Epidural Injections For Chronic Postsurgical Back Pain…………………………………………… 45
Facet Joint Injections …………………………………………………………………………………………… 45
Sacroiliac Joint Injections…………………………………………………………………………………….. 46
Observational Studies on Harms……………………………………………………………………………. 46
Discussion……………………………………………………………………………………………………………………. 47
Key Findings and Strength of Evidence Summary……………………………………………………… 47
Findings in Relationship to What is Already Known ………………………………………………….. 48
Applicability …………………………………………………………………………………………………………. 49
Implications for Clinical and Policy Decisionmaking…………………………………………………. 50
Limitations of the Comparative Effectiveness Review Process ……………………………………. 51
Limitations of the Evidence Base …………………………………………………………………………….. 51
Research Gaps……………………………………………………………………………………………………….. 52
Conclusions…………………………………………………………………………………………………………………. 53
Abbreviations ……………………………………………………………………………………………………………. 197
References…………………………………………………………………………………………………………………. 198

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