Guest Post by Daniel K. Resnick, MD
President, Congress of Neurological Surgeons
Professor, Vice Chairman and Program Director
Department of Neurosurgery University of Wisconsin
Last week, while most people were getting ready to celebrate the July 4th holiday, there were two critical developments in the arena of back pain and spine disorders. First, the July 2014 Journal of Neurosurgery: Spine published updated guidelines on lumbar spine fusion procedures. Second, an important study on the use of steroid injections for spinal stenosis was published in the New England Journal of Medicine.
First, let’s address the importance of the guidelines published. To produce meaningful guidelines, experts in organized neurosurgery and orthopedic surgery banded together to evaluate the recent literature on lumbar spine fusion procedures and to publish up-to-date evidence-based recommendations on their use. These guidelines were sponsored and published by the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves. Given the many recent advances in the arena of spinal fusion, it was crucial to update the initial version of these guidelines published in the same journal in 2005. The guidelines demonstrate that spinal fusion procedures constitute an established and successful therapy for patients with pain and/or neurological deficits due to degenerative diseases of the lumbar spine. Some of the notable findings were:
- The current evidence does not identify a single best treatment alternative for patients with intractable low-back pain. For patients whose pain is resistant to conservative therapy, however, lumbar fusion may be recommended.
- For patients suffering from a lumbar herniated disc, the surgical option of choice remains a lumbar discectomy. Some evidence suggests that lumbar fusion may be considered an option when a herniation is associated with spinal instability, chronic low-back pain and/or severe degenerative changes.
- The medical literature does not support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy.
- The use of back braces is not recommended for preventing low-back pain in a general working population. However, in laborers with a history of back pain, bracing does reduce lost workdays.
The epidural steroid injection article, published in the New England Journal of Medicine, delivers strong evidence for appropriate care of back pain and spinal disorders. Often, patients have sought steroid injections as an alternative to surgery, an intervention believed to improve quality of life with limited risks. The recent paper was a randomized, blinded, controlled study that demonstrated that the addition of steroids did not significantly improve three or six week outcomes compared to the injection of anesthetic alone. These recommendations for injections to provide relief of symptoms of lumbar stenosis have always been problematic, as lumbar stenosis is a long term issue and the value of a few days or weeks of relief may be questioned when one considers the costs and potential complications of these procedures. Insurance company requirements for injections prior to surgery will also need to be revisited, as the only interventions shown to have long-term efficacy for neurogenic claudication are surgical.
Several other interesting points are raised by the new study, including:
- There are systemic effects of steroid injection that need to be considered in a risk benefit ratio when the added benefit of steroids appears to be minimal if any.
- The important role that the placebo effect plays in the management of pain.
Further research is definitely required and should be stratified by detailed anatomical and clinical descriptions of the pain syndrome being treated.
At the end of the day, it’s important for patients to have access to therapies for treating back pain and spine disorders. Neurosurgeons are committed to identifying the right treatment, for the right patient, at the right time to optimize outcomes, and reduce healthcare costs.
For additional information, see the Spine Patient Outcomes Research Trial (SPORT) study and the North American Spine Society’s guidelines for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis.