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Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain

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Abstract

The objective of the North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Low Back Pain is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of adult patients with nonspecific low back pain. This guideline is based upon a systematic review of the evidence and reflects contemporary treatment concepts for low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment and functional recovery from nonspecific low back pain.
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... The aim of CLBP management is to reduce pain and improve quality of life while minimizing potential side effects. The basic noninvasive therapy of CLBP, recommended by existing clinical guidelines, includes bed rest, psychosocial therapy, pharmacotherapy, physical exercises, spinal manipulation, therapeutic ultrasound, and multidisciplinary rehabilitation programs [8][9][10][11]. Despite active treatment, only 31%-47% of CLBP patients fully recover within one year, indicating the necessity of more effective treatment methods for CLBP [12,13]. ...
... However, owing to its noninvasive nature and negligible complications, the use of ESWT has been gaining in popularity worldwide for treating various musculoskeletal disorders, such as tendinitis, plantar fasciitis, humeral epicondylitis, and other soft tissue conditions, with a satisfying success rate of 65%-91% [15][16][17]. However, the current clinical guidelines do not recommend ESWT for CLBP management [8][9][10][11]. In a systematic review, Seco et al. concluded that there was not enough evidence to support the effectiveness of ESWT for treating low back pain (LBP) [18]. ...
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Objective: To assess the effectiveness and safety of extracorporeal shockwave therapy (ESWT) for the treatment of chronic low back pain (CLBP). Methods: This was a systematic review and meta-analysis of randomized controlled trials (RCTs) designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement standard. We identified relevant studies by searching multiple electronic databases, trial registries, and websites up to April 30, 2021, and examining reference lists. We selected RCTs that compared ESWT, in unimodal or multimodal therapeutic approaches, with sham ESWT or other active therapies. Two investigators independently extracted data and assessed the risk of bias and quality of the evidence. The main outcomes were pain intensity and disability status, examined as standardized mean differences (SMD) with 95% confidence intervals (CI). The risk of bias was assessed by using Cochrane Back and Neck (CBN) Group risk of bias tool and Jadad score, and GRADE was applied to determine the confidence in effect estimates. Heterogeneity was explored using sensitivity analysis and meta-regression. Results: Ten RCTs, including a total of 455 young to middle-aged individuals (29.2-55.8 years), were identified. Compared with control, the ESWT group showed lower pain intensity at month 1 (SMD = -0.81, 95% CI -1.21 to -0.42), as well as lower disability score at month 1 (SMD = -1.45, 95% CI -2.68 to -0.22) and at month 3 (SMD = -0.69, 95% CI -1.08 to -0.31). No serious shockwave-related adverse events were reported. Conclusion: The use of ESWT in CLBP patients results in significant and quantifiable reductions in pain and disability in the short term. However, further well-conducted RCTs are necessary for building high-quality evidence and promoting the application of ESWT in clinical practice.
... In some studies, it was reported that distraction manipulation and neural mobilization might be beneficial in the treatment of LSS (Level IV Evidence). 12 In another study, it was found that the use of a lumbosacral corset can increase walking distance before claudication and reduce pain in patients with lumbar spinal stenosis. There is no evidence that use of a brace has any lasting results once discontinued (Level III Evidence). ...
... In another study that evaluated 82 patients with LSS with medical/intervention (methylcobalt, education, activity modification, exercise, physical therapy, NSAIDS, analgesic), it was found that approximately 40% of patients treated medically/ interventionally showed improvements in pain and physical functions (Level IV Evidence). 12 In this study, results showed that there were improvements in VAS and ODI in patients treated conservatively, even though not in all cases, which agrees with previous research works, given the effect of TENS as an analgesia and the effect of NSAIDS as an anti-inflammation agent as we know in Kirkaldy Willis, which is used for treating the onset of degeneration in spinal cord that starts with dysfunction due to synovial reaction, meniscal and annulus tear, and cartilage destruction that causes the inflammation. In this study, it was found that cut points of sensitivity and specificity were of the highest value ≥ 3.50 with the best sensitivity and specificity, respectively, at 81% and 93%. ...
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Background: Approximately 75% men have low-back pain, and most of them come to get treated for acute low-back pain and cure without operation. Conservative treatment procedures, including surgery, have never been evaluated carefully. Objectives: To assess the efficacy of conservative treatment in Lumbar Spinal Stenosis (LSS) and how to choose the patient for conservative treatment. Material and Methods: As many as 30 patients (9 men and 21 women) who were undergoing treatment between January and December 2014 in Orthopaedic and Traumatology Department, Faculty of Medicine, Airlangga Unversity-dr. Soetomo General Hospital, Orthopaedic and Traumatology Hospital (RSOT) Surabaya were recruited for the study. The mean of age of the participants was 51.9 years LSS (diagnostic with plain radiography and MRI) without indicated operation and they were treated conservatively with TENS, WSD, and ultrasonography and NSAIDs for 6–12 weeks. We evaluate VAS and ODI and assigned scores to predict the efficacy of conservative treatment. Results: VAS decreased significantly in patients with mild and moderate VAS prior to conservative treatment 68.1% (p < 0.001). ODI improved significantly in a patient with a mild and moderate disability prior to conservative treatment 87.5% (p < 0,000). On the basis of scores assigned to predict the efficacy of conservative treatment, we fixed sensitivity and specificity at cut point £ 3.50. Conclusions: Conservative treatment can be effective in some LSS patients if the indications are correctly presented.
... Lumbar spinal stenosis (LSS) is a degenerative spinal condition caused by narrowing of the spinal canal, which often results in compression of neural elements and symptoms of neurogenic claudication (NC) [1]. Patients with NC frequently present with multiple degenerative spinal conditions, including intervertebral disc bulging and herniation, facet arthropathy, and hypertrophic ligamentum flavum (HLF) [2]. ...
Article
Objective The purpose of this study is to provide Level-1 objective, real-world outcome data for patients with lumbar spinal stenosis suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum(HLF). Design The MOTION Study is a prospective, multi-center, randomized controlled trial comparing the mild® Procedure as a first-line therapy in combination with non-surgical conventional medical management (CMM) to CMM alone as the active control. Methods Patients in the test group received the mild Procedure at baseline. Both the mild+CMM and the control group were allowed unrestricted access to conventional real-world therapies. Patient reported outcomes included Oswestry Disability Index, Zurich Claudication Questionnaire, and Numeric Pain Rating Scale. A validated Walking Tolerance Test, incidence of subsequent lumbar spine interventions, and occurrence of adverse events were used to measure objective outcomes. Results Sixty-nine patients in each group were analyzed at 1-year follow-up. No device or procedure-related adverse events were reported in either group. Results from all primary and secondary outcome measures showed statistical significance in favor of mild+CMM. Conclusions One-year results of this Level-1 study demonstrated superiority of mild+CMM over the use of CMM-Alone for LSS patients suffering from neurogenic claudication secondary to HLF. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically-significantly better outcomes for mild+CMM versus CMM-Alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the mild Procedure was reaffirmed. mild is a safe, durable, minimally-invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic LSS.
... To achieve effectiveness over two to three years, five or more ESI treatments per year are often required [10,11]. The North American Spine Society (NASS) recommendations for treatment of degenerative spinal stenosis conclude that multiple ESIs for symptomatic relief of LSS with neurogenic claudication may be considered an optional treatment based on minimal evidence (recommendation grade C) [12], with insufficient evidence to make a recommendation of transforaminal ESI in the treatment of lumbar radicular pain in the setting of central stenosis [13]. The immunosuppressive properties of the steroids commonly used in ESI treatments are well-known and have been shown to increase susceptibility to opportunistic infections, leading to recommendations for patients with existing risk factors for infection to consider avoiding or limiting steroid therapy [14,15]. ...
Article
Background: A modified algorithm for the treatment of lumbar spinal stenosis with hypertrophic ligamentum flavum using minimally-invasive lumbar decompression (mild®)was assessed, with a focus on earlier intervention. Patients & methods: Records of 145 patients treated with mild after receiving 0-1 epidural steroid injections (ESIs) or 2+ ESIs were retrospectively reviewed. Pain assessments as measured by visual analog scale (VAS) scores were recorded at baseline and 1-week and 3-month follow-ups. Results: Improvements in VAS scores at follow-ups compared with baseline were significant in both groups. No statistically significant differences were found between the two groups. Conclusion: Multiple ESIs prior to mild showed no benefit. A modified algorithm to perform mild immediately upon diagnosis or after the failure of the first ESI is recommended.
... Of the available conservative treatments, only the cervical epidural steroid injections shown to be efficacious in relieving cervical radicular pain. 4,5 In Nigeria, cervical epidural steroid injections are not part of the readily available conservative treatment options being offered to patients with cervical radicular pain due to the dearth of expertise. This is majorly responsible for the paucity of literature in Nigeria on the evaluation of clinical effectiveness and complications of cervical epidural steroid injections. ...
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Cervical radicular pain is a common cause of chronic neck pain especially among adult population; and it impairs functions and reduces qualities of life of patients. Of the available conservative non-operative treatment options such as analgesic medications, exercises, heat therapy, stabilizing the cervical spine with neck collar among others, epidural steroid injections are the only conservative treatment with proven efficacy. This treatment option is not readily available in Nigeria due to the dearth of expertise and equipment. We present two successful cases of cervical epidural steroid injections with good relief of pain and without complications. The procedures were done under fluoroscopy after correlating clinical symptoms and signs with MRI findings and exclusion of reduced posterior epidural space from large inter-vertebral disc herniation.
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Misdiagnosis of symptomatic lumbar lateral stenosis (LS) may result in an unfavourable prognosis after surgical treatment. This study investigated the diagnostic accuracy of a standardised qualitative sensory test (SQST) in the detection of symptomatic LS in patients who had degenerative spinal disorders involving the L5 spinal nerve. We prospectively identified 75 patients, of which 60 met the inclusion criteria. Lateral recess stenosis at the L5 level or foraminal stenosis at the L5/S1 level on MRI was identified and graded by a neurosurgeon blinded to any clinical information. The reference criteria for the diagnosis of symptomatic LS were grade III LS on MRI and relevant clinical symptoms. Cutaneous sensory functions of the L5 dermatome on the symptomatic side were evaluated using the SQST. Each item of the SQST showed a satisfactory performance in the diagnosis of LS (sensitivity = 0.455–0.727, specificity = 0.868–1.0). A stepwise selection model identified low-strength von-Frey, high-strength von-Frey, and vibration as the most accurate predictors of symptomatic LS with an area under the receiver operating characteristic curve of 0.9563 (95% confidence interval = 0.9003–1.0). In combination with MRI, the SQST is a promising diagnostic tool for detecting symptomatic LS involving L5 nerve roots.
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