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Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline

Chou, Roger, MD*†; Atlas, Steven J., MD, MPH; Stanos, Steven P., DO§; Rosenquist, Richard W., MD

doi: 10.1097/BRS.0b013e3181a103b1
Literature Review

Study Design. Systematic review.

Objective. To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

Summary of Background Data. Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

Methods. Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

Results. For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.

Conclusion. Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Epidural steroid injection and chemonucleolysis are more effective than placebo injection for radiculopathy with herniated disc. Spinal cord stimulation is effective for failed back surgery syndrome with radiculopathy. For other interventional therapies, there was insufficient evidence from randomized trials to reliably evaluate benefit, or good or fair evidence showing no benefit.

From the Departments of *Medicine, and †Medical Informatics and Clinical Epidemiology, Oregon Evidence-Based Practice Center, Oregon Health and Science University, Portland, OR; ‡Division of General Medicine, Medical Services, MA General Hospital, Harvard Medical School, Boston, MA; §Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL; and ¶Department of Anesthesiology, University of Iowa, Iowa City, IA.

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 Organization 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. No statement in this article should be construed as an official position of the APS.

Registered Products and Procedures: Coblation, ArthroCare Corporation, 7500 Rialto Boulevard, Building Two, Suite 100, Austin, TX 78735; and Ovid, 333 Seventh Avenue, 20th Floor, New York, NY 1000.

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.