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Low Back Pain Medical Monotherapies: Difference between revisions

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==Drug Therapies==
==Drug Therapies==
===NSAIDs===
'''[[Paracetamol]]''': For [[Acute Low Back Pain|acute low back pain]] it is not more effective than placebo. There is no published evidence for chronic low back pain.<ref>Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016 Jun 7;2016(6):CD012230. doi: 10.1002/14651858.CD012230. PMID: 27271789; PMCID: PMC6353046.</ref>
* CLBP: Mean pain reduction -3.3 on a 0 to 100 scale for CLBP. <ref>Cochrane 2016</ref>
* ALBP: Mean pain reduction difference -7.3 on a 0 to 100 scale for ALBP. <ref>Cochrane 2020</ref>
* Function: Small benefit of -0.85 on a 0 to 24 scale for CLBP. <ref>Cochrane 2016</ref>
* 12 weeks statistically the same to 4 weeks. <ref>Birbana 2003</ref>
* Home based exercise superior for function but similar for pain <ref>Shirado 2010</ref>


===Muscle Relaxants===
'''[[Nonsteroidal Anti-Inflammatory Drugs|NSAIDs]]''': these agents appear to have an effect superior to placebo, but the effect is modest. The mean reductions have been reported by various reviews as 12/100<ref name=":8">Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):480-492. doi: 10.7326/M16-2458. Epub 2017 Feb 14. PMID: 28192790.</ref>, 3/100,<ref name=":9">Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians, Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP, Humphrey LL, Vijan S. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.</ref> and 7/100.<ref name=":10">Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev. 2016 Feb 10;2(2):CD012087. doi: 10.1002/14651858.CD012087. PMID: 26863524; PMCID: PMC7104791.</ref> From a categorical outcome viewpoint, NSAIDs increase the chances of obtaining 30% relief of pain from 30% to 50%.<ref name=":8" /> There is also limited benefit in function, for example one report of 0.85 on a 0 to 24 scale.<ref name=":10" /> Side effects limit their use. There are no NSAIDs that appears to be more effective than others.<ref name=":10" />
*Shaheed 2016 – 15 eligible RCTs, significant short term relief for nonbenzodiazepines for acute (but not chronic) pain, but no improvement in disability. No benefit for benzodiazepines.  
*Orphenadrine, baclofen, and dantrolene research didn’t meet inclusion criteria. One positive study for tetrazepam in 1990 for reducing “muscle spasm” but the study is not on the internet and we don’t have that in NZ anyway
*Cochrane 2003 - 24 studies (various benzos, nonbenzos, and antispasticity relaxants). Effective for acute back pain 0.80 relative risk at 5-7 days, and 0.7 at 10-14 days.
*Friedman 2018 – Orphenadrine + naproxen not superior to placebo + naproxen for disability and pain.
*The longest follow up I found was 30 days Tinzanidine vs Epirisone Rossi 2013
*None of the muscle relaxants on the NZ formulary as of June 2020 had evidence that met the inclusion criteria of the Shaheed 2016 metaanalysis.


===Opioids===
'''Muscle relaxants''': Neither non-benzodiazepine muscle relaxants<ref>van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;2003(2):CD004252. doi: 10.1002/14651858.CD004252. PMID: 12804507; PMCID: PMC6464310.</ref><ref name=":11">Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017 Feb;21(2):228-237. doi: 10.1002/ejp.907. Epub 2016 Jun 22. PMID: 27329976.</ref> nor benzodiazepines<ref name=":9" /> have evidence to support their use in chronic low back pain. The longest follow was 30 days for Tinzanidine vs Epirisone.<ref>Rossi M, Ianigro G, Liberatoscioli G, Di Castelnuovo A, Grimani V, Garofano A, Camposarcone N, Nardi LF. Eperisone versus tizanidine for treatment of chronic low back pain. Minerva Med. 2012 Jun;103(3):143-9. PMID: 22653094.</ref> There is only some data to support the use of non-benzodiazepine muscle relaxants in acute low back pain, but not benzodiazepines, and none of the muscle relaxants that are available in New Zealand. Orphenadrine didn't meet inclusion criteria. Side effects also limit their use.<ref name=":11" />
* Small short term benefit in pain (SMD -0.43) <ref>Cochrane 2013 review</ref>
* No benefit for long acting opioids <ref>Cochrane 2013 review</ref>
* Opioids not superior to non-opipids at 12 months for chronic back, hip, and knee pain, with more side effects in non blinded trial. <ref>SPACE trial 2018</ref>
* No benefit compared to NSAIDs or antidepressants <ref>Cochrane 2013 review</ref>
* Small benefit (SMD -0.26) in the short term in CLBP <ref>Cochrane 2013 review</ref>
* Worse pain in the long term in a mixed pain condition study.<ref>{{#pmid:29509867|reload}}</ref>
* Aberrant drug taking behaviours in up to 24% of CLBP <ref>Martell et al 2007</ref>
* Tramadol - No benefit when only assessing registered and pre-registered trials <ref>https://openMetaAnalysis.github.io/tramadol</ref>


===Antidepressants===
'''Neuromodulatory Agents''': TCAs and SSRIs are no more effective than placebo on a variety of outcome measures. Likewise there is a lack of evidence for gabapentinoids for chronic low back pain<ref>Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ, Bhandari M. Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017 Aug 15;14(8):e1002369. doi: 10.1371/journal.pmed.1002369. PMID: 28809936; PMCID: PMC5557428.</ref><ref name=":8" />, and clear evidence that pregabalin doesn't work for radicular pain.<ref>Maher CG, Lin CWC, Mathieson S. Trial of Pregabalin for Acute and Chronic Sciatica. N Engl J Med. 2017 Jun 15;376(24):2396-7. doi: 10.1056/NEJMc1705241. PMID: 28614682.</ref> There are some reports of abuse of gabapentinoids.
*Duloxetine <ref>Konno 2016, Skljarevski 2010, Skljarevski 2009, Skljarevski 2010, Alev 2017</ref>
**4 x 12 week RCTs showed benefit vs placebo  (n=1,295)
**Average <1 point improvement on 0-10 scale
**11.9% had >30% pain reduction
**Responders tended to have early pain reduction at 2 weeks (≥15%), ≥ 2 pain sites, be female
**Not available in NZ
*Venlafaxine
**No RCTs, Only one positive non controlled trial for both depression and CLBP <ref>Rej 2014</ref>
*TCAs
**Possible benefit for pain (modest) but not function, but there are only find systematic reviews, no meta-analysis. <ref>Staiger 2003, Ilmanita 2019</ref>
*Gabapentinoids
**Not effective for CLBP, chronic radiculopathy, or as an adjunct to another analgesic.<ref>{{#pmid:28809936}}</ref><ref>{{#pmid:29970367}}</ref>. One of the large well known studies was in NEJM<ref>Maher CG, Lin CWC, Mathieson S. Trial of Pregabalin for Acute and Chronic Sciatica. N Engl J Med. 2017;376(24):2396‐2397. doi:10.1056/NEJMc1705241</ref>


Duloxetine, an SNRI, has a modest effect on pain and function,<ref name=":8" /><ref name=":9" /> but is not available in New Zealand. However the average pain reduction was <1, and only 11.9% had >30% pain reduction. Responders tended to have early pain reduction at 2 weeks (≥15%), ≥ 2 pain sites, and be female.
Venlafaxine is available in New Zealand but has no RCT data. There is only one positive non controlled trial for both depression and CLBP.<ref>Rej S, Dew MA, Karp JF. Treating concurrent chronic low back pain and depression with low-dose venlafaxine: an initial identification of "easy-to-use" clinical predictors of early response. Pain Med. 2014 Jul;15(7):1154-62. doi: 10.1111/pme.12456. Epub 2014 Jul 4. PMID: 25040462; PMCID: PMC4111978.</ref> Although both are SNRIs, the two agents have some key pharmacological differences and so it shouldn't be assumed that venlafaxine would work, too.
'''[[Opioids]]''': There is no role for the use of strong opioids in chronic low back pain, and many include weak opioids in this statement too.
In a mixed pain study that included patients with chronic low back pain, strong opioids are ineffective and there is even a trend for ''worse'' pain.<ref>Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. doi: 10.1001/jama.2018.0899. PMID: 29509867; PMCID: PMC5885909.</ref> For people already on opioids there is no worsening of pain with ceasing their use.<ref>McPherson S, Lederhos Smith C, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Lovejoy TI. Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain. 2018 Oct;159(10):2097-2104. doi: 10.1097/j.pain.0000000000001315. PMID: 29905648; PMCID: PMC6993952.</ref> (See [[Opioid Deprescribing]]). Furthermore, there is no benefit compared to NSAIDs or antidepressants.<ref>Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. doi: 10.1002/14651858.CD004959.pub4. PMID: 23983011.</ref> Aberrant drug taking behaviours occur in up to 24% of patients with chronic low back pain.<ref>Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007 Jan 16;146(2):116-27. doi: 10.7326/0003-4819-146-2-200701160-00006. PMID: 17227935.</ref> The idea of "pseudo-addiction" has no support base in evidence and is an obsolete term. Tramadol has a small effect but a lack of long term data,<ref name=":8" /> and no effect when only including registered and pre-registered trials<ref>[https://github.com/openMetaAnalysis/back-pain-chronic-treatment-with-tramadol/blob/master/README.md Back pain (chronic) treatment with tramadol. A living systematic review]</ref>
'''Other''': Agents like [[Low Dose Naltrexone|low-dose naltrexone]] and antihistamines have no high quality data to make a statement either way on their effectiveness.
===Drug Therapies Bottom Line===
===Drug Therapies Bottom Line===
* Low to moderate quality evidence that NSAIDs may have a small benefit for acute and chronic pain and function, and early response is predictive of later response
* Low to moderate quality evidence that NSAIDs may have a small benefit for acute and chronic pain and function, and early response is predictive of later response
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* Editorial in 2013 BMJ – No single drug will treat more than a minority of patients, but failure with one drug does not mean to expect failure with others, even within a class. Success or failure can be determined within 2-4 weeks. However evidence is still limited.
* Editorial in 2013 BMJ – No single drug will treat more than a minority of patients, but failure with one drug does not mean to expect failure with others, even within a class. Success or failure can be determined within 2-4 weeks. However evidence is still limited.


==Injection Therapies==
==Simple Needle Treatments==


===Epidural Steroid Injections===
=== Acupuncture ===
* Probably slightly reduce leg pain and disability in the short term, 25 trials, evidence quality moderate. <ref>Cochrane 2020</ref>
Low-quality evidence of better immediate (0-7 days) and short-term (1wk - 3mths) pain relief and functional improvement than sham or no treatment, or oral analgesics: 7- to 24-point immediate improvement in pain on 0- to 100-point scale. Moderate-quality evidence of no long-term benefit.<ref>FurlanAD, van TulderMW, CherkinD, TsukayamaH, LaoL, KoesBW, BermanBM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.</ref><ref>Xiang Y, He JY, Tian HH, Cao BY, Li R. Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials. Acupunct Med. 2020;38(1):15-24. doi:10.1136/acupmed-2017-011445</ref><ref name=":13">Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14. PMID: 28192793.</ref>
* MD may not be clinically significant at less than 10%
* Leg pain: MD -4.93 (0 to 100 scale) at 2 weeks to 3 months
* Disability: MD -4.18 (0 to 100 scale) at 2 weeks to 3 months
* Apparently some controversy as to trial selection in the Cochrane metaanalysis.
* For back pain, probably no effect <ref>Cochrane 2020</ref>
* Bogduk in 2002 said there were issues at the time of trials mixing up radicular pain and back pain but they seem to be well separated in the Cochrane 2020 meta-analysis.


===Tender Point Injections===
===Tender Point Injections===
Malanga and Wolff in 2008 describe the technique as follows: "
Malanga and Wolff in 2008 describe the technique of as follows: Holding the syringe in the dominant hand while palpating the trigger with the thumb or index finger of the opposite hand. Needle insertion was into the subcutaneous tissue adjacent to the [trigger point] at a 50 to 70 angle to the skin aiming at the taut band. Multiple insertions in different directions from the subcutaneous layer were ‘‘fast in’’ and ‘‘fast out’’ to probe for latent triggers. Each thrust coincided with the injection of 0.02 to 0.05 mL of injectate to a total of 0.5 to 1 mL in each TrP. Compression of the point for 2 minutes allowed hemostasis, which was followed by stretching of the muscle. <ref name=":15">Malanga G, Wolff E. Evidence-informed management of chronic low back pain with trigger point injections. Spine J. 2008 Jan-Feb;8(1):243-52. doi: 10.1016/j.spinee.2007.10.029. PMID: 18164472.</ref>
It described holding the syringe in the dominant hand while palpating the trigger with the thumb or index finger of the opposite hand. Needle insertion was into the subcutaneous tissue adjacent to the TrP at a 50 to 70 angle to the skin aiming at the taut band. Multiple insertions in different directions from the subcutaneous layer were ‘‘fast in’’ and ‘‘fast out’’ to probe for latent triggers. Each thrust coincided with the injection of 0.02 to 0.05 mL of injectate to a total of 0.5 to 1 mL in each TrP. Compression of the point for 2 minutes allowed hemostasis, which was followed by stretching of the muscle. They noted that the best responses to injection were found when the ‘‘local twitch response’’ was provoked by impaling the active point "
 
They noted that the best responses to injection were found when the ‘‘local twitch response’’ was provoked by impaling the active point.<ref name=":15" />


* Possibly effective in the short term.
Trigger point injections are possibly effective in the short term. In ''acute'' low back pain they are superior to intravenous NSAIDs at 60 minutes,<ref>Kocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med. 2019 Oct;37(10):1927-1931. doi: 10.1016/j.ajem.2019.01.015. Epub 2019 Jan 15. PMID: 30660342.</ref> and are at least as effective as cold spray plus acupressure.<ref>Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine (Phila Pa 1976). 1989 Sep;14(9):962-4. doi: 10.1097/00007632-198909000-00008. PMID: 2528826.</ref> There is limited evidence beyond the short term<ref name=":15" /> and so they have no evidence based support for chronic low back pain. It is interesting to note that the saline often used as a control in trials may contain (unless preservative-free) 0.9% benzyl alcohol
**Kocak 2018: TPI superior to i.v. NSAID at 60 mins for acute back pain
**Garvey 1989: TPI at least as effective as cold spray + acupressure
**Malanga 2008: Narrative review, limited evidence beyond the short term.
**It is interesting to note that the saline often used as a control in trials may contain (unless preservative-free) 0.9% benzyl alcohol


*Total Dorsal Rami Block
=== Total Dorsal Rami Block ===
**Miyakoshi 2007: bilateral L4/5 total dorsal rami block (5mL each side mepivacaine) by CT better than TPI at 7 days for CLBP in elderly.
Total dorsal rami block refers to blocking all branches of the dorsal rami - medial, intermediate, and lateral. This would theoretically cover the three major longitudinal back muscles (multifidus for medial, longissimus for intermediate, and iliocostalis for lateral), and the facet joints (medial branches). Bilateral L4/5 total dorsal rami blocks (5mL each side mepivacaine) by CT is more effective than trigger point injections at 7 days for chronic low back pain in the elderly.<ref>Miyakoshi N, Shimada Y, Kasukawa Y, Saito H, Kodama H, Itoi E. Total dorsal ramus block for the treatment of chronic low back pain: a preliminary study. Joint Bone Spine. 2007 May;74(3):270-4. doi: 10.1016/j.jbspin.2006.07.006. Epub 2007 Mar 7. PMID: 17383923.</ref> There is no long term data.
**They note "The facet joints, back muscles, fascia, ligaments, and skin of the low back region are all innervated by the medial, intermediate, and/or lateral branches of the lumbar dorsal rami. Each dorsal ramus of the lumbar spinal nerve divides into three branches: medial, intermediate, and lateral branches [10,11] (Fig. 1). These three branches principally innervate three major longitudinal back muscles: multifidus, longissimus, and iliocostalis, respectively [10,11]. Furthermore, deep to multifidus, articular branches from the medial branch innervate the facet joints above and below theoretically, all the low back pains originating from myofascial structures [1], facet joint [9,12,13], or both should be alleviated by blocking all three branches of the lumbar dorsal ramus. They confirmed spread over both adjacent branches using contrast of medial branches plus intermediate and lateral branches"


===Prolotherapy===
===Prolotherapy===
* Nonspecific low back pain – probably not effective
For undiagnosed chronic low back pain prolotherapy is probably not effective. The latest cochrane review is now quite old but concluded that prolotherapy alone is not effective for chronic low back pain. However 4/5 studies used a mixture dextrose-glycerine-phenol and no specific diagnosis.<ref>Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2007 Apr 18;2007(2):CD004059. doi: 10.1002/14651858.CD004059.pub3. PMID: 17443537; PMCID: PMC6986690.</ref>
**Cochrane 2007 (5 studies) concluded that prolotherapy alone is not effective for chronic low back pain. However 4/5 studies used a mixture dextrose-glycerine-phenol and no specific diagnosis  
**Best study Yelland 2004: n=110 CLBP, 20% dextrose/lignocaine repeated over 6 months, 2 year follow up, significant improvements in pain and disability but no different to saline Cochrane 2007, Yelland 2004.  At 12 months, the proportions achieving more than 50% reduction in pain from baseline by injection group were glucose-lignocaine: 0.46 versus saline: 0.36 they also randomised to do flexion/extension exercises and there was no benefit.
*Sacroiliac Joint Pain
**1 x positive study. prolotherapy vs steroid (intraarticular), n = 48 <ref>Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010;16(12):1285‐1290. doi:10.1089/acm.2010.0031</ref>
**Inclusion: sacroiliac joint pain >3 months, confirmed by fluoroscopic block (pain decrease of 50%). Pain just below PSIS and positive Patrick or Gaenslens test and pain reduction >50% with bupivacaine injection fluoroscopic
**Exposure: 2.5mL of 25% dextrose with bupivacaine into SI joint (fluoroscopically) every two weeks up to three times until pain relief at least 90%.
**Control: same but with triamcinolone 40mg
**Results: Significant sustained improvements for prolotherapy
*Botox
**May provide partial relief of pain, with no data beyond 2 months
**Three studies, with Foster et al being the best one. The other two have significant problems.<ref>Cochrane 2011</ref>
**Cost is $1100 for 2 vials (200 units) for the dose used in Foster et al study. Not covered by ACC or Southern Cross for this indication.
 
===Injection Therapies Bottom Line===
*Epidural Steroid Injections
**Low to moderate quality evidence that probably works for radicular leg pain but effect size may not be clinically significant.
**They generally don’t have a role for back pain.
*Tender Point Injections
**low quality evidence that effective in the short term for acute pain.
**Interesting concept of total dorsal rami blocks.
*Prolotherapy
**low quality evidence that effective in the short and long term for sacroiliac joint pain (intraarticular injections).
**Unclear if it is effective for other causes of back pain.
*Botox
**low quality evidence that effective in the short term


==Surgery==
The best RCT for prolotherapy on undiagnosed chronic low back pain had 110 patients and compared 20% dextrose/lidocaine repeated over 6 months, with 2 year follow up. They found significant improvements in pain and disability but there was no difference to saline. At 12 months, the proportions achieving more than 50% reduction in pain was 46% for prolotherapy and 36% for saline. They also randomised to do flexion/extension exercises or normal activity and found no difference there.<ref>Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine (Phila Pa 1976). 2004 Jan 1;29(1):9-16; discussion 16. doi: 10.1097/01.BRS.0000105529.07222.5B. PMID: 14699269.</ref>
===Placebo Controlled Surgery Trials===
* Astoundingly few placebo controlled trials (i.e. sham studies) in all of orthopaedic surgery. All no difference <ref>Louw 2017 and Wartolowska 2014</ref>
**Bradley 2002: tidal irrigation v placebo for knee OA
**Moseley 2002: lavage/debridement v placebo for knee OA
**Kallmes 2009: vertebroplasty v placebo
**Buchbinder 2009: vertebroplasty v placebo
**Kroslak 2013: debridement v placebo for lateral epicondylitis
* The remaining RCTs are all non-placebo controlled, i.e. comparing surgery A to surgery B, or surgery A to physiotherapy.


===Discectomy for Sciatica===
Intra-articular sacroiliac joint prolotherapy has also been studied as a precision treatment. For 48 patients with sacroiliac joint pain (pain below PSIS, positive Patrick or Gaenslens test, and single positive fluoroscopic block with a pain decrease of 50%), fluoroscopic injection of prolotherapy was compared to steroid. The exposure group had 2.5mL of 25% dextrose injected fluoroscopically every two weeks up to three times until relief of at least 90%. The control had the same but with triamcinolone 40mg. The outcomes were the same at 3 months, but the results of the prolotherapy group were durable up to 15 months.<ref>Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010;16(12):1285‐1290. doi:10.1089/acm.2010.0031</ref>
*Sciatica lasting 4-12 months
**Bailey 2020: microdiscectomy superior to nonoperative care (incl. epidural injection) with surgery if needed for pain with 1 year follow up. (pain difference 2.4 scale 0 to 10). At 6 months, the score for leg-pain intensity was 2.8±0.4 in the surgical group and 5.2±0.4 in the nonsurgical group
**At 1 year, the leg-pain intensity score was 2.6±0.4 in the surgical group and 4.7±0.4 in the nonsurgical group;
the ODI score was 22.9±2.3 and 34.7±2.4,


*Sciatica lasting 6 to 12 weeks
=== Botox ===
**Peul 2008: Surgery conferred more rapid relief of pain, but the benefit was not sustained at 6, 12, and 24 months. 20% reported unsatisfactory outcome at 2 years.
Botox may provide partial relief of pain, with no data beyond 2 months. There are three published studies, with Foster et al being the best one. The other two have significant problems.<ref>Waseem Z, Boulias C, Gordon A, Ismail F, Sheean G, Furlan AD. Botulinum toxin injections for low-back pain and sciatica. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008257. doi: 10.1002/14651858.CD008257.pub2. PMID: 21249702.</ref> The cost is $1100 for 2 vials (200 units) for the dose used in Foster et al study. It is not covered by ACC or Southern Cross for this indication
**Osterman 2006: Surgery more rapid initial recovery, but no difference at 6 weeks with 2 year follow up. Subgroup analysis discectomy superior if herniation at L4/5 (needs verification)


*Sciatica lasting “at least 6 weeks”
===Injection Therapies Bottom Line===
**Weinstein 2006: ~80% pain less than 6 months. Major crossover issues. Intent-to-treat both improved. Advantage of surgery in as-treated analysis, worse outcome in post-hoc analysis if >6 months. Significant advantage for non-workers compensation group
*Tender Point Injections and total dorsal rami blocks have low quality evidence that effective in the short term for acute pain.  
 
*Prolotherapy has low quality evidence that effective in the short and long term for sacroiliac joint pain (intraarticular injections). Unclear if it is effective for other causes of back pain.
===Spinal Stenosis Surgery - Surgery vs non operative management===
*Botox has low quality evidence that effective in the short term
*Cochrane 2016: 5 RCTs. Studies low quality. “We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis”.
*Weinstein 2008 (SPORT): n=289. Significant nonadherence and crossover. Surgery vs nonoperative. Intention to treat showed improvement in pain in surgery group but not  disability. 2 year follow up. As treated analysis showed improvement in all outcomes in surgery group.
*Malmivaara 2007: n=94. Surgery (segmental decompression and an undercutting facetectomy) vs nonoperative. Surgery superior but benefits diminished overtime with both groups improving. 2 year follow up.
*Brown 2012: n=38, mild decompression vs epidural steroid. At 6 weeks epidural better for function (claudication questionnaire), but worse for VAS. Significant crossovers at 12 weeks preventing further analysis.
 
===Spinal Stenosis - Decompression plus fusion vs decompression-alone===
*Forsth 2016: n=247, decompression surgery equal to decompression plus fusion with 5 years of follow up. (pain and disability)
*Ghogawala 2016: n=66 with grade I spondylolisthesis, fusion better than decompression (“physical quality of life”) by year 2 (but not by year one). Nut no improvement in disability score.
*Cochrane 2016: Newer techniques are not superior to decompression. Didn’t include above two studies.
*Chang 2017: meta-analysis (15 studies) including the above newer studies, no benefit for decompression plus fusion over decompression alone at 2 years. Fusion has higher risk of complications. “We believe decompression alone to be a sound choice for LSS”
 
===Fusion for Non-Specific CLBP===
*Harris 2018:
**Analysis of 33 meta-analyses mostly of 4 non-placebo controlled RCTs (!). Fritzell 2001, Brox 2003, Fairbank 2005, Brox 2006.
**The most recent moderate quality review (Chou 2009): not more effective than intensive rehabilitation.
**None of the post 2009 trials was of sufficiently high quality to change this conclusion
**Complications are common at 16%
*Mannion 2013
**Long term follow up (8-11 years) of the three classic RCTs Fritzel, Brox, Fairbank
**Surgery no better than CBT and exercise both intention-to-treat and as-treated.
**Findings mirror the two years results (Swedish study outlier but reporting bias and less effective non-operative treatment)
**Just 50-60% of patients in each group reported their back was better/much better.
**Just 40% had disability scores in the normal range
**25% crossover
**Swedish trial the outlier, they reported positive outcomes at 2 years, but no difference at 10 years. But significant reporting bias using “global assessment” as the reported measure Non operative treatment was unstructured, nonspecific physiotherapy
*Good Editorial 2016 Spine Mannion
**ITT analyses may be supported by analyses in which cases are grouped as “per protocol” (those who underwent the treatment to which they were assigned and completed all the follow-ups) or “as treated” (the treatment actually received) or “worst case” (group crossovers considered as “failing” the treatment to which they were randomized). These subgroup analyses present their own problems. Patients moving from non-operative to surgical treatment can be tracked with relative ease, but not those having surgery, failing it, and then going on to have successful non-operative treatment. Any subgrouping based on group changes in one direction only and on the assertion that a group change from non-operative to surgery indicates failure of non-operative treatment but revision surgery does not count as failure of surgery will inevitably be biased
*Mino 2017: Cohort study, 95% of those on opioids preoperatively continued on them postoperatively with 2 year follow up.
*Surgeries: posterolateral fusion in Norway, up to surgeon in UK studies
*There is no evidence that surgery undertaken without a valid diagnosis is effective for chronic low back pain
**Brox 2003: Eligibility CLBP >1 year, and degeneration L4/5 and/or L5/S1 on XR.  
**Fritzell 2001: Eligibility severe CLBP >2 years, back>leg pain, clinician should interpret pain arising from L4/5 and/or L5/S1 using history/exam/radiology, major disability >1 year, degenerative change at above levels
**Fairbank 2005: eligible if patient/surgeon uncertain which treatment best, >1 year CLBP
**It is unclear whether discography is useful for patient selection Harris 2018
 
===Lumbar Disc Replacement===
*Hellum 2011
**Lumbar disc prosthesis v rehabilitation, 2 year follow up
**Statistically significant benefit for surgery
**Disability: less than clinically significant benefit at 8 points on 0 to 100 scale.
**Pain: 12 point difference favouring surgery.
**only study comparing with rehab
*Cochrane 2013
**Systematic review comparing disc replacement v fusion
**No blinding and bias with sponsorships.
**Statistically significant but not clinically significant benefit for replacement
**Prevention of adjacent level disease and/or facet disease was not properly assessed.
*Not really done in NZ
 
===Surgery Bottom Line===
*There are no placebo controlled trials for any spinal surgery, below all low quality evidence
*Microdiscectomy for Sciatica
**Possibly effective if pain 4 – 12 months {{CEBM|1c}}
**If done early then possibly more rapid recovery but no difference by 6 weeks.
*Spinal Stenosis Surgery
**Possibly effective but benefits diminish over time
**The addition of fusion to decompression is probably not necessary, and adds significant extra complications.
*Fusion for CLBP
**No more effective than intensive rehabilitation
**Possibly more effective than non-intensive rehabilitation, but benefits not sustained.
**Disc Replacement for CLBP
**Possibly statistically but no clinically significant benefit for surgery over non-intensive rehabilitation
**No more effective than fusion


==Epidural Steroid Injections==
For [[Lumbar Radicular Pain|radicular pain]] there is good evidence for efficacy (see linked article). However for back pain, epidural steroids do not appear to have an effect.<ref name=":16">Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020 Apr 9;4(4):CD013577. doi: 10.1002/14651858.CD013577. PMID: 32271952; PMCID: PMC7145384.</ref>
==Spinal Cord Stimulation==
==Spinal Cord Stimulation==
Spinal cord stimulation involves placement of electrodes in the epidural space adjacent to the spinal area presumed to be the source of pain. An electric current is then applied to achieve sympatholytic and other neuromodulatory effects. The number and type of electrode leads and parameters of electrical stimulation can vary
Spinal cord stimulation involves placement of electrodes in the epidural space adjacent to the spinal area presumed to be the source of pain. An electric current is then applied to achieve sympatholytic and other neuromodulatory effects. The number and type of electrode leads and parameters of electrical stimulation can vary
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*[[Low Back Pain Nonmedical Monotherapies]]
*[[Low Back Pain Nonmedical Monotherapies]]
*[[:Category:Precision Techniques]]
*[[:Category:Precision Techniques]]
==References==
==References==


[[Category:Lumbar Spine]]
[[Category:Lumbar Spine]]
[[Category:Partially complete articles]]
[[Category:Partially complete articles]]

Latest revision as of 19:10, 3 January 2022

This article is still missing information.

Drug Therapies

Paracetamol: For acute low back pain it is not more effective than placebo. There is no published evidence for chronic low back pain.[1]

NSAIDs: these agents appear to have an effect superior to placebo, but the effect is modest. The mean reductions have been reported by various reviews as 12/100[2], 3/100,[3] and 7/100.[4] From a categorical outcome viewpoint, NSAIDs increase the chances of obtaining 30% relief of pain from 30% to 50%.[2] There is also limited benefit in function, for example one report of 0.85 on a 0 to 24 scale.[4] Side effects limit their use. There are no NSAIDs that appears to be more effective than others.[4]

Muscle relaxants: Neither non-benzodiazepine muscle relaxants[5][6] nor benzodiazepines[3] have evidence to support their use in chronic low back pain. The longest follow was 30 days for Tinzanidine vs Epirisone.[7] There is only some data to support the use of non-benzodiazepine muscle relaxants in acute low back pain, but not benzodiazepines, and none of the muscle relaxants that are available in New Zealand. Orphenadrine didn't meet inclusion criteria. Side effects also limit their use.[6]

Neuromodulatory Agents: TCAs and SSRIs are no more effective than placebo on a variety of outcome measures. Likewise there is a lack of evidence for gabapentinoids for chronic low back pain[8][2], and clear evidence that pregabalin doesn't work for radicular pain.[9] There are some reports of abuse of gabapentinoids.

Duloxetine, an SNRI, has a modest effect on pain and function,[2][3] but is not available in New Zealand. However the average pain reduction was <1, and only 11.9% had >30% pain reduction. Responders tended to have early pain reduction at 2 weeks (≥15%), ≥ 2 pain sites, and be female.

Venlafaxine is available in New Zealand but has no RCT data. There is only one positive non controlled trial for both depression and CLBP.[10] Although both are SNRIs, the two agents have some key pharmacological differences and so it shouldn't be assumed that venlafaxine would work, too.

Opioids: There is no role for the use of strong opioids in chronic low back pain, and many include weak opioids in this statement too.

In a mixed pain study that included patients with chronic low back pain, strong opioids are ineffective and there is even a trend for worse pain.[11] For people already on opioids there is no worsening of pain with ceasing their use.[12] (See Opioid Deprescribing). Furthermore, there is no benefit compared to NSAIDs or antidepressants.[13] Aberrant drug taking behaviours occur in up to 24% of patients with chronic low back pain.[14] The idea of "pseudo-addiction" has no support base in evidence and is an obsolete term. Tramadol has a small effect but a lack of long term data,[2] and no effect when only including registered and pre-registered trials[15]

Other: Agents like low-dose naltrexone and antihistamines have no high quality data to make a statement either way on their effectiveness.

Drug Therapies Bottom Line

  • Low to moderate quality evidence that NSAIDs may have a small benefit for acute and chronic pain and function, and early response is predictive of later response
  • Low quality evidence that a couple of non-benzodiazepine muscle relaxants may be effective for ALBP but aren’t available in NZ
  • Low quality evidence that strong opioids have a small benefit for pain and function in the short term, but cause increased pain and addiction in the longer term.
  • Moderate quality evidence that the antidepressant Duloxetine may be effective for CLBP
  • Unclear role of TCAs
  • Moderate quality evidence that gabapentinoids are likely not effective for CLBP or radicular pain, either in isolation or as an adjunct.
  • Editorial in 2013 BMJ – No single drug will treat more than a minority of patients, but failure with one drug does not mean to expect failure with others, even within a class. Success or failure can be determined within 2-4 weeks. However evidence is still limited.

Simple Needle Treatments

Acupuncture

Low-quality evidence of better immediate (0-7 days) and short-term (1wk - 3mths) pain relief and functional improvement than sham or no treatment, or oral analgesics: 7- to 24-point immediate improvement in pain on 0- to 100-point scale. Moderate-quality evidence of no long-term benefit.[16][17][18]

Tender Point Injections

Malanga and Wolff in 2008 describe the technique of as follows: Holding the syringe in the dominant hand while palpating the trigger with the thumb or index finger of the opposite hand. Needle insertion was into the subcutaneous tissue adjacent to the [trigger point] at a 50 to 70 angle to the skin aiming at the taut band. Multiple insertions in different directions from the subcutaneous layer were ‘‘fast in’’ and ‘‘fast out’’ to probe for latent triggers. Each thrust coincided with the injection of 0.02 to 0.05 mL of injectate to a total of 0.5 to 1 mL in each TrP. Compression of the point for 2 minutes allowed hemostasis, which was followed by stretching of the muscle. [19]

They noted that the best responses to injection were found when the ‘‘local twitch response’’ was provoked by impaling the active point.[19]

Trigger point injections are possibly effective in the short term. In acute low back pain they are superior to intravenous NSAIDs at 60 minutes,[20] and are at least as effective as cold spray plus acupressure.[21] There is limited evidence beyond the short term[19] and so they have no evidence based support for chronic low back pain. It is interesting to note that the saline often used as a control in trials may contain (unless preservative-free) 0.9% benzyl alcohol

Total Dorsal Rami Block

Total dorsal rami block refers to blocking all branches of the dorsal rami - medial, intermediate, and lateral. This would theoretically cover the three major longitudinal back muscles (multifidus for medial, longissimus for intermediate, and iliocostalis for lateral), and the facet joints (medial branches). Bilateral L4/5 total dorsal rami blocks (5mL each side mepivacaine) by CT is more effective than trigger point injections at 7 days for chronic low back pain in the elderly.[22] There is no long term data.

Prolotherapy

For undiagnosed chronic low back pain prolotherapy is probably not effective. The latest cochrane review is now quite old but concluded that prolotherapy alone is not effective for chronic low back pain. However 4/5 studies used a mixture dextrose-glycerine-phenol and no specific diagnosis.[23]

The best RCT for prolotherapy on undiagnosed chronic low back pain had 110 patients and compared 20% dextrose/lidocaine repeated over 6 months, with 2 year follow up. They found significant improvements in pain and disability but there was no difference to saline. At 12 months, the proportions achieving more than 50% reduction in pain was 46% for prolotherapy and 36% for saline. They also randomised to do flexion/extension exercises or normal activity and found no difference there.[24]

Intra-articular sacroiliac joint prolotherapy has also been studied as a precision treatment. For 48 patients with sacroiliac joint pain (pain below PSIS, positive Patrick or Gaenslens test, and single positive fluoroscopic block with a pain decrease of 50%), fluoroscopic injection of prolotherapy was compared to steroid. The exposure group had 2.5mL of 25% dextrose injected fluoroscopically every two weeks up to three times until relief of at least 90%. The control had the same but with triamcinolone 40mg. The outcomes were the same at 3 months, but the results of the prolotherapy group were durable up to 15 months.[25]

Botox

Botox may provide partial relief of pain, with no data beyond 2 months. There are three published studies, with Foster et al being the best one. The other two have significant problems.[26] The cost is $1100 for 2 vials (200 units) for the dose used in Foster et al study. It is not covered by ACC or Southern Cross for this indication

Injection Therapies Bottom Line

  • Tender Point Injections and total dorsal rami blocks have low quality evidence that effective in the short term for acute pain.
  • Prolotherapy has low quality evidence that effective in the short and long term for sacroiliac joint pain (intraarticular injections). Unclear if it is effective for other causes of back pain.
  • Botox has low quality evidence that effective in the short term

Epidural Steroid Injections

For radicular pain there is good evidence for efficacy (see linked article). However for back pain, epidural steroids do not appear to have an effect.[27]

Spinal Cord Stimulation

Spinal cord stimulation involves placement of electrodes in the epidural space adjacent to the spinal area presumed to be the source of pain. An electric current is then applied to achieve sympatholytic and other neuromodulatory effects. The number and type of electrode leads and parameters of electrical stimulation can vary They may be implanted percutaneously or by laminectomy. Power is supplied by implanted battery or transcutaneously through an external radiofrequency transmitter. Implantation is a two stage process. A trial is performed, followed by permanent implantation for successful trials. High frequency/burst stimulation associated with greater benefit than conventional SCS. The pain-suppressing effect of SCS is likely related to a combination of a spinal and supraspinal mechanism (2, 31). The spinal mechanism involves antidromic activation of ascending dorsal column fibers, but SCS might also interact via orthodromic ascending fibers with descending serotoninergic pain modulatory systems. Kirketeig 2019: good overview of the research [28]

Tonic Stimulation

  • North 2005: n=50, persistent pain after surgery with leg pain greater or equal to back pain. SCS superior to reoperation for achieving >50% pain relief (38% v 12%)
  • Kumar 2007: n=100, persistent radicular pain following surgery for herniated disc. SCS superior to “conventional medical management” for pain (48% v 9%)
  • 26-32% in these RCTs experienced a complication. Electrode migration, infection, generator pocket-related complications, and lead problem.
  • Only been studied in Failed Back Surgery Syndrome. Turner 2010: prospective cohort study, workers compensation, no previous surgery. outcomes at 12 and 24 months no better than pain clinic management.
  • No RCTs done for primary back pain. North 2005 patients had improvement in both leg and back pain.
  • No placebo controlled trials for tonic stimulation, because it is impossible, because it causes paraesthesias.

Burst Stimulation

  • Doesn't cause paraesthesias so can perform placebo controlled tirals
  • De Ridder 2013: placebo controlled RCT, n=15, intractable back and limb pain. 12/15 were failed back surgery syndrome. Burst mode effective for back/limb and reducing attention to pain, tonic mode effective only for limb pain. 4 week follow up
  • Schu 2014: placebo controlled RCT, n=20, FBSS with pre-existing SCS, burst stimulation superior to tonic. 3 week follow up
  • Tjepkema-Cloostermans 2016: placebo controlled RCT, n=40, FBSS with pre-existing SCSS, high/low amplitude burst stimulation superior to tonic
  • Deer 2017: RCT (non-placebo controlled), n=100, FBSS plus other conditions, burst superior to tonic, but 24% preferred tonic. 1 year follow up. Designed under FDA guidance.

Attenuation

  • RCTs longest follow up is 3 years
  • Nissen 2018: prospective trial of 20 years of consecutive patients, average follow up was 6 years of 224 consecutive FBSS patients.
  • 75% who received a SCS after a trial period continued to use it throughout the follow up period which was 18 years in some patients

SCS Bottom Line

  • This is a palliative treatment (improvement in pain but generally not function)
  • It should only be considered for those with
    • Predominant radicular pain PLUS
    • “Failed back surgery syndrome” PLUS
    • Clear anatomical source of pain PLUS
    • No abnormal illness behaviour PLUS
    • A positive trial period with an external device
  • There is a significant complication rate
  • Burst stimulation is superior to tonic stimulation for most patients
  • Extremely expensive with limited availability in NZ
  • The evidence may change as technology improves

Intraspinal Opioids

  • No RCTs for any non cancer pain condition after 30 years of use. $30,000 - $40,000 USD, with refills costing $500/visit in 2014
  • Turner 2007 (systematic review): 41% had urinary retention, 37% required catheterisation, nausea/vomiting 33%, pruritis 26%, catheter related complications 18%, pump malposition 17%, wound infection 12%, meningitis 3%
  • Loeser 2014 (Editorial):
    • Very little information on the proper selection of patients
    • Most studies show that those on high-dose opioids without relief are poor candidates
    • Dose escalation and side effects occur with any route of delivery
    • Multidisciplinary pain management is more effective and cheaper
    • May be considered for palliative care. Smith 2002: n=202, RCT, refractory cancer pain (not only back pain). Success in 84.5% vs 70.8% for comprehensive medical management.

Intrathecal Opioids Bottom Line

No valid use in the realm of Musculoskeletal Medicine.

See Also

References

  1. ↑ Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016 Jun 7;2016(6):CD012230. doi: 10.1002/14651858.CD012230. PMID: 27271789; PMCID: PMC6353046.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):480-492. doi: 10.7326/M16-2458. Epub 2017 Feb 14. PMID: 28192790.
  3. ↑ 3.0 3.1 3.2 Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians, Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP, Humphrey LL, Vijan S. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.
  4. ↑ 4.0 4.1 4.2 Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev. 2016 Feb 10;2(2):CD012087. doi: 10.1002/14651858.CD012087. PMID: 26863524; PMCID: PMC7104791.
  5. ↑ van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;2003(2):CD004252. doi: 10.1002/14651858.CD004252. PMID: 12804507; PMCID: PMC6464310.
  6. ↑ 6.0 6.1 Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017 Feb;21(2):228-237. doi: 10.1002/ejp.907. Epub 2016 Jun 22. PMID: 27329976.
  7. ↑ Rossi M, Ianigro G, Liberatoscioli G, Di Castelnuovo A, Grimani V, Garofano A, Camposarcone N, Nardi LF. Eperisone versus tizanidine for treatment of chronic low back pain. Minerva Med. 2012 Jun;103(3):143-9. PMID: 22653094.
  8. ↑ Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ, Bhandari M. Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017 Aug 15;14(8):e1002369. doi: 10.1371/journal.pmed.1002369. PMID: 28809936; PMCID: PMC5557428.
  9. ↑ Maher CG, Lin CWC, Mathieson S. Trial of Pregabalin for Acute and Chronic Sciatica. N Engl J Med. 2017 Jun 15;376(24):2396-7. doi: 10.1056/NEJMc1705241. PMID: 28614682.
  10. ↑ Rej S, Dew MA, Karp JF. Treating concurrent chronic low back pain and depression with low-dose venlafaxine: an initial identification of "easy-to-use" clinical predictors of early response. Pain Med. 2014 Jul;15(7):1154-62. doi: 10.1111/pme.12456. Epub 2014 Jul 4. PMID: 25040462; PMCID: PMC4111978.
  11. ↑ Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. doi: 10.1001/jama.2018.0899. PMID: 29509867; PMCID: PMC5885909.
  12. ↑ McPherson S, Lederhos Smith C, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Lovejoy TI. Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain. 2018 Oct;159(10):2097-2104. doi: 10.1097/j.pain.0000000000001315. PMID: 29905648; PMCID: PMC6993952.
  13. ↑ Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. doi: 10.1002/14651858.CD004959.pub4. PMID: 23983011.
  14. ↑ Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007 Jan 16;146(2):116-27. doi: 10.7326/0003-4819-146-2-200701160-00006. PMID: 17227935.
  15. ↑ Back pain (chronic) treatment with tramadol. A living systematic review
  16. ↑ FurlanAD, van TulderMW, CherkinD, TsukayamaH, LaoL, KoesBW, BermanBM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.
  17. ↑ Xiang Y, He JY, Tian HH, Cao BY, Li R. Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials. Acupunct Med. 2020;38(1):15-24. doi:10.1136/acupmed-2017-011445
  18. ↑ Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14. PMID: 28192793.
  19. ↑ 19.0 19.1 19.2 Malanga G, Wolff E. Evidence-informed management of chronic low back pain with trigger point injections. Spine J. 2008 Jan-Feb;8(1):243-52. doi: 10.1016/j.spinee.2007.10.029. PMID: 18164472.
  20. ↑ Kocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med. 2019 Oct;37(10):1927-1931. doi: 10.1016/j.ajem.2019.01.015. Epub 2019 Jan 15. PMID: 30660342.
  21. ↑ Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine (Phila Pa 1976). 1989 Sep;14(9):962-4. doi: 10.1097/00007632-198909000-00008. PMID: 2528826.
  22. ↑ Miyakoshi N, Shimada Y, Kasukawa Y, Saito H, Kodama H, Itoi E. Total dorsal ramus block for the treatment of chronic low back pain: a preliminary study. Joint Bone Spine. 2007 May;74(3):270-4. doi: 10.1016/j.jbspin.2006.07.006. Epub 2007 Mar 7. PMID: 17383923.
  23. ↑ Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2007 Apr 18;2007(2):CD004059. doi: 10.1002/14651858.CD004059.pub3. PMID: 17443537; PMCID: PMC6986690.
  24. ↑ Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine (Phila Pa 1976). 2004 Jan 1;29(1):9-16; discussion 16. doi: 10.1097/01.BRS.0000105529.07222.5B. PMID: 14699269.
  25. ↑ Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010;16(12):1285‐1290. doi:10.1089/acm.2010.0031
  26. ↑ Waseem Z, Boulias C, Gordon A, Ismail F, Sheean G, Furlan AD. Botulinum toxin injections for low-back pain and sciatica. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008257. doi: 10.1002/14651858.CD008257.pub2. PMID: 21249702.
  27. ↑ Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020 Apr 9;4(4):CD013577. doi: 10.1002/14651858.CD013577. PMID: 32271952; PMCID: PMC7145384.
  28. ↑ Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst Spinal Cord Stimulation: A Clinical Review. Pain Med. 2019;20(Suppl 1):S31‐S40. doi:10.1093/pm/pnz003
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