The evidence gap in low back pain management strategies

In their Seminar,1Knezevic NN Candido KD Vlaeyen JWS Van Zundert J Cohen SP Low back pain.Lancet. 2021; 398: 78-92Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar Nebojsa Nick Knezevic and colleagues concluded that surgery is more effective than conservative management in the treatment of lumbar spinal stenosis, and that decompression combined with fusion had no substantial benefit compared with decompression alone. We believe that this conclusion was not evidence-based, and could have the potential to prejudice the spine surgeon against the choice of treatment for lumbar spinal stenosis. A meta-analysis that included 64 cohort studies (3774 participants) found that although patients with lumbar spinal stenosis had a 50% reduction in pain and disability at 3 months after surgery, mild–moderate pain and disability persisted for up to 5 years.2Fritsch CG Ferreira ML Maher CG et al.The clinical course of pain and disability following surgery for spinal stenosis: a systematic review and meta-analysis of cohort studies.Eur Spine J. 2017; 26: 324-335Crossref PubMed Scopus (29) Google Scholar Furthermore, a Cochrane systematic review3Zaina F Tomkins-Lane C Carragee E Negrini S Surgical versus non-surgical treatment for lumbar spinal stenosis.Cochrane Database Syst Rev. 2016; 2016CD010264Google Scholar (five randomised controlled trials; 643 patients) in 2016 showed no statistically significant benefit of surgery compared with non-surgical treatment in the treatment of lumbar spinal stenosis. 10–24% of patients undergoing surgery had side-effects, whereas none were found in non-surgical treatment. Thus, we cannot conclude on the basis of current evidence whether surgical or non-surgical treatment is better for individuals with lumbar spinal stenosis. Decompression alone had shown satisfactory clinical efficacy and low rate of complications in the treatment of lumbar spinal stenosis; however, this treatment is mainly used in patients with stable lumbar spinal stenosis or with only mild spondylolisthesis.4Urakawa H Jones T Samuel A et al.The necessity and risk factors of subsequent fusion after decompression alone for lumbar spinal stenosis with lumbar spondylolisthesis: 5 years follow-up in two different large populations.Spine J. 2020; 20: 1566-1572Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar For patients with lumbar spinal stenosis and evidenced dynamic instability or moderate–severe spondylolisthesis, fusion is recommended to achieve a stable lumbar sequence.5Leschke JM Chen CC Supplementing decompression with instrumented fusion for symptomatic lumbar spinal stenosis— a critical appraisal of available randomized controlled trials.Neurosurg Rev. 2021; 44: 643-648Crossref PubMed Scopus (4) Google Scholar Therefore, whether fusion is required should be personalised according to type of lumbar spinal stenosis. We declare no competing interests. Low back painLow back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. Full-Text PDF The evidence gap in low back pain management strategies – Authors' replyWe thank Xing Du and Yunsheng Ou for bringing up the contentious issue of spine surgery for further discussion. However, we do not agree that the conclusions in our Seminar1 oppose evidence-based medicine; rather, we believe that they bolster the argument that there is insufficient evidence to draw firm conclusions. Full-Text PDF The evidence gap in low back pain management strategiesIn their Seminar1 on low back pain, Nebojsa Nick Knezevic and colleagues state that “MRI…can contribute to higher rates of spine surgery and result in higher satisfaction rates”. Full-Text PDF