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Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society

Chou, Roger, MD*; Loeser, John D., MD; Owens, Douglas K., MD, MS‡§; Rosenquist, Richard W., MD; Atlas, Steven J., MD, MPH; Baisden, Jamie, MD, FACS**; Carragee, Eugene J., MD††; Grabois, Martin, MD‡‡; Murphy, Donald R., DC, DACAN§§; Resnick, Daniel K., MD¶¶; Stanos, Steven P., DO∥∥; Shaffer, William O., MD***; Wall, Eric M., MD, MPH††† For the American Pain Society Low Back Pain Guideline Panel

doi: 10.1097/BRS.0b013e3181a1390d
Literature Review

Study Design. Clinical practice guideline.

Objective. To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.

Summary of Background Data. Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain.

Methods. A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group.

Results. Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations.

Conclusion. Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Evidence-based recommendations from an interdisciplinary panel convened by the American Pain Society on use of invasive diagnostic tests, interventional therapies, surgery, and interdisciplinary therapy for persistent and disabling low back pain are presented.

From the *Department of Medicine, Oregon Evidence-based Practice Center, Oregon Health and Science University, Portland, OR; †Department of Neurological Surgery, University of Washington, Seattle, WA; ‡Veterans Affairs Medical Center, Palo Alto, CA; §Stanford University, Stanford, CA; ¶Department of Anesthesiology, University of Iowa, Iowa City, IA; ∥Medical Services,General Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; **Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI; ††Department of Orthopedic Surgery, Stanford University, Stanford, CA; ‡‡Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, The Institute for Rehabilitation and Research, Houston, TX; §§Department of Community Health, Rhode Island Spine Center, Alpert Medical School of Brown University, Pawtucket, RI; ¶¶Department of Neurosurgery, University of Wisconsin, Madison, WI; ∥∥Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL; ***Department of Orthopaedics, University of Kentucky, Lexington, KY; and †††Qualis Health, Seattle, WA.

Acknowledgment date: October 21, 2008. Revision date: December 19, 2008. Acceptance date: December 22, 2008.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Professional Organizational funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Supported by the American Pain Society (APS).

This article is based on research conducted at the Oregon Evidence-based Practice Center. The authors are solely responsible for the content of this article and the decision to submit for publication.

Registered products and procedures: Coblation Technology, ArthroCare Corporation, 7500 Rialto Boulevard, Building Two, Suite 100, Austin, TX 78735; Dekompressor, Stryker Instruments, 4100 East Milham Avenue, Kalamazoo, MI 49001; and Prodisc II and Prodisc-L, Synthes Spine, Inc., 1302 Wright Lane East, West Chester, PA 19380.

Address correspondence and reprint requests to Roger Chou, MD, 3181 SW Sam Jackson Park Road, Mail code BICC, Portland, OR 97239; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.