Lower Back Pain and Lumbar Disc Herniation Recommendations
Lower Back Pain and Lumbar Disc Herniation
Recommendations of WFNS Spine Committee 2023
1. Acute Back Pain: Epidemiology, Etiology and Prevention
* Although there is limited recent data, one-year-prevalence in acute low back pain is reported to be up to 11% to 38%, and lifetime prevalence is up to 40%.
* A significant difference of prevalence and incidence of acute back pain is found, and it is more frequent in high-income countries.
* Although there is no information of the exact cost of acute low back pain treatment, there are significant direct and indirect cost factor in all studies.
* In contrast to chronic and recurrent back pain, risk factors for acute back pain are not well defined.
* Exercise and having a higher educational status reduce the likelihood of acute low back pain to become chronic.
2. Acute Back Pain: Clinical and Radiological Diagnostics
* Axial backpain with worsening on flexion, coughing or Valsalva manoeuvre and pain relief on recumbency is suggestive of discogenic backpain.
* Backpain with unilateral or bilateral distribution that worsened on lumbar extension is suggestive of facet joint pain.
* Facet joint pain may radiate to buttock or thigh but not below the knee and is not exaggerated by Valsalva manoeuvre or coughing.
* Having 3 positive provocative tests for sacroiliac joint, is suggestive of sacroiliac joint pain, which can be confirmed with the diagnostic injection.
* Presence of a taut band trigger point on back with hyperesthesia that reproduces pain on firm palpation is suggestive of myofascial pain.
* Patients with persistent radiculopathic symptoms, or severe progressive neurologic deficits and serious underlying conditions with acute back pain should have diagnostic imaging.
* A Patient with first presentation of acute low back pain without red flags does not require radiological investigation.
* MRI is recommended imaging for acute low back pain patients.
* CT scans are not as useful in depicting extradural soft-tissue pathologies, such as disc disease compared to MRI, but is superior in showing bone.
* There is strong evidence that routine imaging for acute low back pain does not provide clinical benefit. Diagnostic imaging studies might reveal incidental findings without pathological value and should be performed only in selected patients.
3. The Role of Drugs, Physical Medicine and Rehabilitation in Backpain and Sciatica
* Paracetamol is recommended for acute low backpain first line usage in patients of advanced age, gastrointestinal, cardiovascular and renal comorbidities, either alone or as a support in opioid use.
* NSAIDS is first line drug in acute backache / radiculopathy. COX2 are preferred due to lower side effects.
* Opioids have limited benefit over conservative measures for acute lower back pain. It is Indicated when first line drugs (NSAID’s, Paracetamol) are contraindicated or not tolerated. A short course of opioids may be considered in patients with intractable pain.
* Pregabalin is not recommended for managing acute low backpain without radiculopathy.
* Although the evidence is inconclusive, non-benzodiazepine myorelexants may be recommended for spasm with acute low backpain.
* There is mixed evidence that Benzodiazepines as muscle relaxant work for acute low backpain. It may be used selectively to reduce severe spasm and pain.
* Bed rest for more than 48 hours in acute back pain is not recommended. Staying active leads to better symptomatic and functional outcomes with acute low backpain.
* Lumbar support belt may reduce the pain level and augment the functional status. There is no negative effect by the use of lumbosacral support in means of muscle weakness and deconditioning.
* Thermotherapy and cryotherapy are efficacious on relieving acute lumbar backpain TENS (transcutaneous electric nerve stimulation) may be beneficial for the reduction of acute low backpain and has no serious side effects.
* There is no evidence that exercise programs work in acute low backpain.
* Spinal manipulative therapy may provide short-term (up to 6 weeks) improvement in patients with acute low back pain, comparable with other standard treatments. There is unclear evidence that massage therapy is more effective than inactive controls for pain at short-term.
* There is moderate evidence of benefit of acute low backpain intensity with acupuncture.
4. Acute back pain: Role of Injection Techniques and Surgery
* Epidural injection showed significant benefit to discogenic back pain, and even saline injection showed a significant impact on pain relief.
* A more lateral approach in epidural injection seems to be superior to a midline approach.
* Short term effect (< 1 week) of epidural injection is probably similar between particular(depot) and non-particular steroids. A longer lasting effect (> 1 week) can probably be achieved with particular steroids.
* There is a variety of potential complications of epidural injections. They are usually not lasting. Rare but severe complications have been described and should be considered.
* In lumbar facet block or ablation CT or fluoroscopy (lower costs, faster time and less radiation exposure than CT) can be used for lumbar medial branch blocks. Ultrasound may be useful in patients in whom radiation exposure is associated with potential harm (eg, pregnant), or when radiological imaging is unavailable.
* Lumbar medial branch radiofrequency ablation on pain recurrence can be performed in patients experiencing a minimum of 3 months improvement following a previous radiofrequency ablation. The procedure may be repeated no more than two times per year.
* The acute back pain is usually self-limiting, resolving in 6 weeks in the majority of the cases and does not require surgical interventions.
5. Acute back pain: How to prevent from becoming a chronic back pain
* A significant portion (30-60%) of acute back pain patients are at risk of developing chronic pain syndrome.
* Psychological evaluation may be helpful for patients who might develop chronic pain syndrome.
* Early mobilization of the patient with acute back pain and non-pharmacologic treatment may prevent transition to chronic pain syndrome.
6. Lumbar disc herniation: Epidemiology, clinical and radiological diagnostics as well as prevention.
* The lifetime risk for lumbar disc herniation is about 30%. Symptomatic disc herniation risk is 1-3%, of these 60-90% resolve spontaneously.
* Risk factors for lumbar disc herniation include genetic and environmental factors, strenuous activities and smoking.
* Radicular pain having specific radiation in one or both legs is usually associated with herniated disc.
* Pain history is the most important part of clinical evaluation. It should include questions on intensity, onset and localization. Pain should be assessed with visual or numeric analogue scale and Oswestry disability index.
* Essential diagnostic tests in patients with suspected herniated disc are evaluation of muscle strength, sensory disturbance, sphincter dysfunction as well as supine straight leg raise, Lasegue sign, and crossed Lasegue sign.
* Muscle strength testing should be examined and documented using MRC (Medical Research Council) scale:
Grade 0 - No Muscles Movement
Grade 1 - Muscle Movement without joint Motion
Grade 2 - Moves with gravity eliminated
Grade 3 - Moves against gravity but not resistance
Grade 4 - Moves against gravity and light resistance
Grade 5 - Normal Strength
* Lumbar facet joint blocks are gold standard for diagnosis of facet joint syndrome.
* There is no convincing evidence for lumbar discography in the diagnostic of discogenic pain.
* In case of symptoms consistent for lumbar disc herniation a radiological assessment is suggested between 6 to 12 weeks without neurological deficit and persistent symptoms. In presence of motor deficit radiological investigation is recommended to be performed earlier.
* Magnetic Resonance Imaging (MRI) is the most appropriate non-invasive test to confirm the presence of lumbar disc herniation.
* Plain X-ray images can only be considered in adjunct for differential diagnosis of lumbar disc herniation from other lumbar pathological diseases.
7. Lumbar disc herniation: Role of conservative therapy
* One to two days of bed rest maybe recommended for patients with severe back and radicular pain.
* NSAID have significant effect on improving acute low back pain and sciatica caused by lumbar disc herniation.
* Spontaneous lumbar disc herniation resorption can be found in around 2/3 of the cases. Conservative treatment is recommended for the patients that have no deficit.
8. Lumbar Disc Herniation: Role of surgery
* Surgery for lumbar disc herniation is individualized. It is recommended for:
- Failure of conservative treatment
- Severe motor deficit
- Progressive neurological impairment
- Cauda Equina Syndrome
* Earlier surgery in lumbar disc herniation is suggested in case of major motor deficit and is associated with faster recovery and might improve motor outcomes.
* Although minimally invasive procedures have short term advantages, there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure for lumbar disc herniation.
* Sequestrectomy and standard microdiscectomy have similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short/medium term.
* Lumbar fusion is not recommended as a routine treatment following primary discectomy in patients with isolated herniated lumbar discs causing radiculopathy. Lumbar fusion may be considered in patients with herniated discs who have evidence of significant chronic axial back pain, have severe degenerative changes, or have instability associated with radiculopathy caused by herniated lumbar discs.
9. Lumbar disc herniation: Prevention and Treatment of Recurrence
* Recurrent lumbar disc herniation is a new disc herniation at the same index level and side. Recurrence incidence is between 3-8%. Reoperation rate is up to 5%.
* Smoking, younger age, male gender, obesity, diabetes, persistence of weight-lifting after first surgery, Modic changes, migration grade, presence of lumbosacral transitional vertebrae may be factors to predict recurrent disc herniation.
* The level of lumbar microdiscectomy surgery has no correlation with rate of recurrence. There is a trend toward intervertebral disc lavage reducing the rate of recurrence.
* There is no linear relationship between experience of surgeon and rate of reoperation.
* There is no evidence to conclude that recurrence can be prevented by activity restriction, weight loss, smoking cessation and muscle-strengthening exercises.
* Clinical outcomes after surgery of recurrent disc herniations are inferior then initial surgery.
* There is no good evidence to decide the best treatment option for recurrent disc herniation. Although back pain responds more to discectomy and fusion, the routine addition of fusion surgery for recurrent lumbar disc herniation is not recommended. Fusion should only be considered as an option when spinal instability, spinal deformity, and back pain more than leg pain is present.
10. Cauda equina syndrome, conus medullaris syndrome and syndromes mimicking sciatic pain
* The optimal treatment modality for Cauda equina syndrome and Conus medularis syndrome with MRI confirmed compression is decompression surgery.
* Studies regarding Cauda equina- and Conus medularis syndrome showed improvement after surgery compared to baseline. Surgery should be performed as soon as possible. We can expect better outcomes if the surgery is performed within 24h.
* The outcome in Cauda equina- and Conus medularis syndrome highly depends on various factors, especially its preoperative neurological severity.
* Evidence for the benefit of steroids in Cauda equina- and Conus medularis syndrome is lacking.
* Piriformis syndrome is a clinical diagnosis after exclusion of other pain syndromes. It includes patients with chronic buttock and posterior hip pain without correlation in the neuroimaging.
* For the diagnosis of piriformis syndrome, at least one of the piriformis stretching tests needs to be positive.
* Conservative therapy with pain medication and physical therapy is the first line treatment for piriformis syndrome. Second line treatment is local lidocaine and botulinum injections. Surgery (decompression with/without piriformis muscle resection) is reserved for selected refractory cases, which showed good but short-term effect of injections.