Back Pain: Shaffer WO

Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM, Anonymous00055. · Department of Medicine, Oregon Evidence-based Practice Center, Oregon Health and Science University, Portland, OR, USA. · Spine (Phila Pa 1976). · Pubmed #19363457 No free full text.

Abstract: 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.

Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. · Department of Medicine, Oregon Evidence-based Practice Center, OR Health and Science University, Portland, OR, USA. · Spine (Phila Pa 1976). · Pubmed #19363455 No free full text.

Abstract: STUDY DESIGN: Systematic review. OBJECTIVE: To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. SUMMARY OF BACKGROUND DATA: Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions. 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 the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS: For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms. CONCLUSION: Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

Cassidy RC, Shaffer WO. · University of Kentucky Medical Center, K-401, Kentucky Clinic, 740 South Limestone Street, Lexington, KY 40536, USA. · Spine J. · Pubmed #17602884 No free full text.

Abstract: BACKGROUND: Congenital insensitivity to pain is a rare disorder that can lead to neuropathic arthropathy of any joint including the spine. Most of the case reports in the literature are in the pediatric population. PURPOSE: This case report emphasizes the importance of anterior and posterior fusion in patients with congenital insensitivity to pain. The patient was initially treated as if the deformity was postinfectious. STUDY DESIGN SETTING: The patient was treated in a university-based tertiary care center. METHODS: The patient underwent an anterior decompression and fusion with instrumentation that failed with ambulation. An anterior and posterior revision with instrumentation was then performed to stabilize the Charcot spine. RESULTS: The patient had an excellent final outcome. At 2 years postoperatively, he is solidly fused and back to his normal occupation. CONCLUSION: Anterior and posterior fusion is essential in neuropathic spinal arthropathy. Congenital insensitivity to pain can manifest problems into adulthood.

Cassidy RC, Shaffer WO, Johnson DL. · University of Kentucky Medical Center, Lexington, KY 40536, USA. · Orthopedics. · Pubmed #16295191 No free full text.

Abstract: Though athletes may be able to return to their sport after treatment of spondylolysis and spondylolisthesis, prevention of back injury in at-risk patient athletes should be the treating physician's primary goal.