17,326 Record Low Back Pain Study Has Sobering Conclusions

A new systemic multi-center and multi-continent review of both randomized controlled studies and trial registries found that we—as surgeons and industry—are still on the journey to successfully treating chronic non-specific low back pain without radiculopathy.

The study, “Benefits and Harms of Treatments for Chronic Non-Specific Low Back Pain Without Radiculopathy: Systematic Review and Meta-analysis,” was published online on November 15, 2022 in The Spine Journal.

The systematic review and meta-analysis compare the benefits (and harms) of treatments for the management of chronic low back pain without radiculopathy using the Benefit-Harm Scale: level 1 to 7. The team collected data from randomized controlled trials, including trial registries and from electronic databases up until May 23, 2022.

The outcome measures included comparison of pain at immediate-term (2 weeks or less) and short-term (greater than 2 weeks to less than or equal to 12 weeks) and serious adverse events using the Benefit-Harm Scale (level 1 to 7).

The interventions studied include non-pharmacological (acupuncture, spinal manipulation only), pharmacological, and invasive treatments compared to placebo.

Overall, 17,326 records were found. Only three studies provided data on the benefits of interventions and 30 provided data on harms. Studies included interventions of:

1. acupuncture,
2. manipulation,
3. pharmacological therapies, including NSAIDS and opioid analgesics,
4. surgery and
5. epidural corticosteroid injections.

The researchers found:

1. acupuncture (standardized mean difference (SMD) -0.51, 95%CI -0.88 to -0.14, n = 1 trial, moderate quality of evidence, benefit rating of 3) and
2. manipulation (SMD -0.39 (96%CI -0.56 to -0.21, n = 2 trials, moderate quality of evidence, benefit rating of 5) effective reduced pain intensity compared to sham
3. other treatments were scored as uncertain due to not being effective, statistical heterogeneity preventing pooling of effect sizes, or the absence of relevant trials.

The researchers reported that the harms level warnings were at the lowest for:

1. acupuncture,
2. spinal manipulation,
3. NSAIDs,
4. combination ingredient opioids, and
5. steroid injections

Harms warnings were higher for single ingredient opioid analgesics and surgery.

“There is uncertainty about the benefits and harms of all the interventions reviewed due to the lack of trials conducted in patients with chronic non-specific low back pain without radiculopathy. From the limited trials conducted, non-pharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions.”

“However, more research is needed. There were high harms ratings for opioid and surgery.”

Study authors include Ronald J. Feise of Institute of Evidence-Based Chiropractic in Scottsdale, Arizona; Stephanie Mathieson of The University of Sydney, Sydney, Australia; Rodger S. Kessler of the University of Colorado Denver – Anschultz Medical Campus in Aurora, Colorado; Corey Witenko of New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, New York; Fabio Zaina of Italian Scientific Spine Institute in Asti, Italy and Benjamin T. Brown of Macquarie University, Macquarie Park, Australia.