CLINICAL CROSSROADS CLINICIAN’S CORNER

CONFERENCES WITH PATIENTS AND DOCTORS

A 50-Year-Old Man
With Chronic Low Back Pain
James P. Rathmell, MD, Discussant
Mr S, a 50-year-old man, has long-standing low back pain.
DR LIBMAN: Mr S is a 50-year-old man with chronic low back His pain began more than 20 years earlier with a lumbar
pain. In the mid-1970s he developed persistent right leg pain
disk herniation and has persisted despite diskectomy. He
and was diagnosed by myelogram as having a herniated disk.
L5-S1diskectomywasperformedin1977withmodestimprove- has undergone numerous treatments, but he remains dis-
ment in his leg pain. He developed low back pain, which was abled with ongoing pain. His treatment course is used
treated with physical therapy and nonopioid and opioid drugs. to frame the epidemiology and pathophysiology under-
Over the next decade, his intermittent back and right leg pain lying acute and chronic lumbosacral and radicular pain.
caused him to modify his daily activities. It worsened in 1994 The roles of neuropathic pain medications, chronic opi-
after he fell out of a bathtub. He was evaluated in a local pain oid therapy, physical therapy, spinal manipulation, and
unit and received local injections with limited benefit. In 1996,
multidisciplinary pain treatment programs are re-
Mr S underwent repeat diskectomy, which improved his right
leg pain but not his back pain. Following surgery, he had a crush viewed. The indications for and outcomes associated with
injuryofhisrightfoot,whichslowedhisrecovery.Between1996 interventional pain treatments, including epidural ste-
and 2002, he had facet blocks, epidural injections, and physi- roid injection, facet blocks and radiofrequency treat-
cal therapy, all of which were ineffective. Since 2003, he has ment for facet-related pain, intradiskal electrothermal
been followed up at a pain unit. He takes methadone with therapy, spinal cord stimulation, and intrathecal drug de-
oxycodone-acetaminophen for breakthrough pain with mod- livery, are discussed. Clinicians are given an evidence-
est relief, but he wants better treatment options. based approach to using available treatment options for
His back pain is a constant dull ache, sometimes throb-
low back pain.
bing and radiating to both legs. It worsens with sitting and
JAMA. 2008;299(17):2066-2077 www.jama.com
standing. There are no other musculoskeletal or neuro-
logic symptoms.
Mr S also has hypertension, gastroesophageal reflux dis- tinent physical findings include mild paravertebral tender-
ease, seasonal allergies, depression, anemia, and hyperlip- ness in the lumbar region, 4/5 motor strength in his right
idemia. In the 1990s, he underwent tonsillectomy and ad- lower extremity, and 1⫹/4⫹ right ankle jerk. He has pain
enoidectomy for obstructive sleep apnea. on straight leg raising on the right side at 60°.
He takes clonazepam, 1 mg 3 times per day; cyclobenza- Magnetic resonance imaging of the lumbosacral spine with
prine, 10 mg by mouth 3 times per day; methadone, 40 mg and without contrast (performed in 2005) is shown in FIGURE 1.
every morning, 30 mg at noon, and 40 mg at bedtime; Degenerative disk changes are noted at multiple lumbar lev-
naproxen, 500 mg twice per day; and oxycodone- els, which are similar to those seen on a magnetic reso-
acetaminophen, 5 mg/325 mg (one tablet) 4 times per day nance imaging study obtained several years earlier.
as needed. He also takes atorvastatin, fenofibrate, lisinopril/ MR S: HIS VIEW
hydrochlorothiazide, omeprazole, ranitidine, sertraline, and
verapamil. About 30 years ago, I developed pain in my leg, which I
Mr S, a former restaurant worker, is now receiving dis- thought was a groin pull. I was athletic at the time. I limped
ability benefits and lives with his longtime female partner. This conference took place at the Anesthesia Grand Rounds of the Beth Israel Dea-
He does not smoke cigarettes or use alcohol but occasion- coness Medical Center, Boston, Massachusetts, on January 24, 2007.
Author Affiliation: Dr Rathmell is Director of the Center for Pain Medicine, De-
ally uses marijuana for pain control. There is no other his- partment of Anesthesia and Critical Care, Massachusetts General Hospital, and
tory of drug use. Associate Professor, Department of Anaesthesia, Harvard Medical School, Bos-
ton, Massachusetts.
He is 5 ft, 7 in tall, weighs 209 lb [94 kg], and has a blood Corresponding Author: James P. Rathmell, MD, Center for Pain Medicine, Mas-
pressure of 108/80 mm Hg and a heart rate of 72/min. Per- sachusetts General Hospital, 15 Parkman St, WACC 333, Boston, MA 02114
(jrathmell@partners.org).
Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and ed-
CME available online at www.jamaarchivescme.com ited by Tom Delbanco, MD, Howard Libman, MD, Eileen E. Reynolds, MD, Amy
and questions on p 2096. N. Ship, MD, and Anjala V. Tess, MD. Risa B. Burns, MD, is series editor.
Clinical Crossroads Section Editor: Margaret A. Winker, MD, Deputy Editor.

2066 JAMA, May 7, 2008—Vol 299, No. 17 (Reprinted) ©2008 American Medical Association. All rights reserved.

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 CLINICAL CROSSROADS

for a year and a half before somebody suggested I see a back go down to the other side of my left leg. In 1994, I fell
doctor. That’s how I found out that I had a herniated disk. out of my bathtub, which set off the pain in both legs and
I was in the hospital the next day for a myelogram, and the my back.
following day I had surgery. Time-release medications and long-acting medications,
I still had leg pain and went for another consult. And the like Oxycontin or a patch, are helpful. But at times the pain
doctor’s famous words were, “If it didn’t work the first time, is so acute that I need a short, quick-acting narcotic—to block
we can try it again.” And I said, “No, thank you,” and went it for an hour or two.
on to adopt a better lifestyle. Physical therapy has come far. They know more about
I took it upon myself to do a physical therapy regimen how the muscles and bones are interacting. If I had the
to develop some way to control the pain. I tried to build money, I would have a massage twice a day. Acupuncture,
up my legs, back, and stomach muscles. I lived with the because it looks at your whole body and not just the back,
pain. Ten years later, the pain got worse, and it started to gives you an overall boost of energy.

Figure 1. Most Recent Magnetic Resonance Imaging (MRI) Study of Mr S’s Lumbosacral Spine (April 2005)

Axial T2-weighted magnetic resonance images

B L3-4 level

A Sagittal T2-weighted magnetic resonance image

L1

L2

L3 C L4-5 level

L4

L5

D L5-S1 level

A, Sagittal T2-weighted image near midline demonstrating advanced

degenerative disk disease at the L3-4, L4-5, and L5-S1 levels. Note
presence of a Schmorl node (black arrowhead). White lines indicate levels
of axial images. B, Axial T2-weighted image at the L3-4 level
demonstrating degenerative disk changes and a diffuse disk bulge (yellow
arrowheads) resulting in mild stenosis of the central spinal canal. C, Axial
T2-weighted image at the L4-5 level demonstrating degenerative disk
changes and right-sided postoperative changes with indentation of the
thecal sac (white arrowhead). D, Axial T2-weighted image at the L5-S1
level demonstrating degenerative disk changes and prior right
hemilaminotomy (blue arrowhead). Overall, there were no significant
changes in this MRI study compared with an earlier study performed in
September 2003.

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Dealing with doctors at any level, you have to tread AT THE CROSSROADS:
very lightly. If you say, “I need pain medication,” it seems QUESTIONS FOR DR RATHMELL
like a bell goes off. They think, “This person just wants What is known about the epidemiology and pathogenesis
pain medication, nothing else.” of chronic low back pain? What about facet and epidural
injections, physical therapy, acupuncture, and other alter-
native care approaches? Would cognitive, behavioral, and
Figure 2. Distribution of Lumbosacral and Radicular Pain psychological therapies help? In patients for whom sur-
gery is not indicated, how should treatment be ap-
proached? What is the role of neuropathic pain medica-
A Lumbosacral spinal pain
POSTERIOR VIEW
tions and short- and long-acting opioid medications? What
L1 about newer treatments such as spinal cord stimulation and
intrathecal drug delivery? What does the future hold in this
Lumbar spinal pain
field?
Sacral spinal pain
DR RATHMELL: Mr S is a middle-aged man disabled by
chronic low back pain. He has had extensive evaluation and
L5
treatment, including spinal surgery and injections to re-
duce his pain. However, he is left with significant pain. It is
difficult to recommend what more can be done to help him.
However, understanding of low back pain has advanced and
has made treatments available that reduce or eliminate pain
associated with specific spine disorders.

Definitions
B Lumbar (L4) radicular pain and lumbar and sacral dermatomes Low back pain, a nonspecific term, refers to pain centered
(right leg) over the lumbosacral junction. To be precise in the
ANTERIOR VIEW POSTERIOR VIEW
approach to diagnosis and treatment, pain primarily over
L1
L2 the axis of the spinal column is differentiated from that
Radicular pain
L3 which refers primarily to the leg (FIGURE 2). Lumbar spi-
S3 nal pain is pain inferior to the tip of the twelfth thoracic
S4 L4 spinous process and superior to the tip of the first sacral
L1 S5 spinous process.1 Sacral spinal pain is inferior to the first
L2 sacral spinous process and superior to the sacrococcygeal
L1 S2
S1 L5 joint.1 Lumbosacral spinal pain is pain in either or both
L3
L2
regions and constitutes “low back pain.” Other patients
present with sciatica, or pain predominantly localized in
L4 L3 the leg. The proper term is radicular pain because stimu-
lation of the nerve roots or the dorsal root ganglion of a
spinal nerve evokes the pain.
Pain is a normal physiologic process and serves as a
L AT E R A L MEDIAL L AT E R A L signal of actual or impending tissue injury. Pain from tis-
L5 sue injury is usually well localized and associated with
S2 S1 sensitivity in the region. Pain signals are carried toward
the central nervous system via the sensory nerves. This
type of pain is termed nociceptive pain1 or physiological
L4
pain.2 In contrast, persistent pain following injury to the
nervous system, neuropathic pain,1,2 has unique character-
S1
L5
istics: spontaneous pain (pain without any stimulus),
hyperalgesia (more pain than expected from a painful
stimulus), and allodynia (pain following a nonpainful
stimulus).3
A, “Low back pain” is more precisely termed lumbosacral spinal pain, which en-
compasses both lumbar spinal pain (L) and sacral spinal pain (S). Lumbosacral
Mr S describes a deep ache in his low back with inter-
spinal pain is pain in either or both regions and constitutes “low back pain.” mittent radiation of pain to his legs; thus, he has both lum-
B, Radicular pain is caused by stimulation of a spinal nerve and describes pain that bosacral pain and radicular pain, likely with mixed etiol-
is referred to the lower extremity along the corresponding dermatome.
ogy (ie, both nociceptive and neuropathic).
2068 JAMA, May 7, 2008—Vol 299, No. 17 (Reprinted) ©2008 American Medical Association. All rights reserved.

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 CLINICAL CROSSROADS

Epidemiology Initial Evaluation and Treatment

Low back pain, ranked fifth among the most common prob- In first evaluating a patient with low back pain, several fea-
lems that lead patients to seek medical attention, ac- tures in the history—“red flag” conditions—require prompt
counted for nearly 15 million physician visits in a 1990 US investigation, including new-onset or worsening back pain
survey.3 Most episodes of acute low back pain, with or with- after trauma, infection, or previous cancer. Patients with pro-
out radicular pain, resolve without treatment. Overall, 60% gressive neurologic deficits (typically worsening numb-
to 70% of those affected recover by 6 weeks and 80% to 90% ness or weakness) or bowel or bladder dysfunction also war-
by 12 weeks.4 However, recovery after 12 weeks is slow and rant immediate radiologic imaging to rule out a compressive
uncertain; fewer than half of patients disabled for longer than lesion.10
6 months return to work. The return-to-work rate for those If no red flag condition is apparent, diagnosis and treat-
absent for 2 years is near zero.5 Back pain is the most com- ment rely on location and duration of symptoms and de-
mon reason for limitation of activity in younger adults and termining if the pain is acute or chronic and primarily ra-
is the most frequent cause of absences from work.6 Low back dicular or lumbosacral in nature. There is no clear point in
pain is frequently recurrent; most patients experience more time when acute back pain becomes chronic, but one well-
than 1 episode.4 Risk factors for developing chronic low back accepted definition is acute low back pain is present for less
pain include older age, female sex, low socioeconomic sta- than 3 months, while chronic low back pain is present for a
tus and lower education level, higher body mass index, to- longer time.1
bacco use, lower perceived general health status, physical Acute Radicular Pain. Herniated nucleus pulposus typi-
activity (eg, bending, lifting, twisting), repetitive tasks, job cally causes acute radicular pain, with or without radicu-
dissatisfaction, depression, spinal anatomic variations, and lopathy (radiculopathy would be indicated by numbness,
imaging abnormalities.6 weakness, or loss of deep tendon reflexes referable to a spe-
cific spinal nerve). In elderly patients and those with ex-
Pathophysiology tensive lumbar spondylosis, acute radicular symptoms caused
The basic unit of the spine is the functional spinal unit and com- by narrowing of 1 or more intervertebral foramina can oc-
prises 2 adjacent vertebral bodies with 2 posterior facet joints, cur.11 Initial treatment is symptomatic, and following HNP,
an intervertebral disk, and the surrounding ligamentous struc- symptoms resolve without specific treatment in about 90%
tures (FIGURE 3). The intervertebral disk absorbs energy and of patients.12 Trials comparing advice to stay active vs stay
distributes weight evenly from one spinal segment to the in bed show no difference in pain or functional out-
next while allowing movement of the protective bony ele- comes.13 For those with persistent pain after HNP, lumbar
ments.7 Lifting, bending, twisting, or whole body vibration diskectomy may be indicated. A controlled trial of surgical
can damage elements of the spine. With injury and aging, vs nonoperative treatment showed significant improve-
progressive degenerative changes appear in each element of ment in both groups over 2 years but remained inconclu-
the functional spinal unit, along with the onset of charac- sive about the superiority of either approach.14
teristic symptoms (FIGURE 4). The earliest change in the lum- Chronic Radicular Pain. Persistent leg pain in the dis-
bar facet joints is synovitis, which progresses to degrada- tribution of a spinal nerve may occur in patients with disk
tion of the articular surfaces, capsular laxity and subluxation, herniation with or without subsequent surgery. In those with
and, finally, enlargement of the articular processes (facet hy- persistent pain, a search for a reversible cause of spinal nerve
pertrophy). Progressive degeneration also occurs within the compression is warranted. In some individuals, after sur-
intervertebral disks, starting with loss of hydration of the gery, scarring around the nerve root at the operative site can
nucleus pulposus, followed by appearance of tears within be seen on magnetic resonance imaging,15 and electrodiag-
the annulus fibrosis (internal disk disruption). nostic studies show a pattern suggesting chronic radicu-
Lumbosacral pain can arise from the facet joints or the lopathy.16 This patient group has characteristics similar to
annulus fibrosis.8 With internal disruption of the annu- those with other nerve injuries, and initial management
lus, some of the gelatinous central nucleus pulposus can should consist of pharmacologic treatment for neuro-
extend beyond the disk margin as a disk herniation (her- pathic pain.17
niated nucleus pulposus [HNP]). When HNP extends to Acute Lumbosacral Pain. Most patients presenting with
the region adjacent to the spinal nerve, it incites an acute onset of lumbosacral pain without radicular symptoms
intense inflammatory reaction.9 Patients with HNP typi- have no obvious abnormal findings18 and radiologic imaging
cally present with acute radicular pain. Hypertrophy of is unlikely to be helpful.19 Traumatic sprain of the muscles and
the facet joints and calcification of the ligamentous struc- ligaments of the lumbar spine or the zygapophyseal joints and
tures can reduce the size of the intervertebral foramina early internal disk disruption are significant causes of acute
and/or central spinal canal (spinal stenosis), with onset of lumbosacral pain. Similar to acute radicular pain, this type of
radicular pain and/or neurogenic claudication (intermit- pain is best managed symptomatically. Advice for patients to
tent, unilateral or bilateral pain in the buttock, thigh, or stay active results in improved functional status and pain re-
leg that is brought on by walking or prolonged standing). duction at 3 to 4 weeks relative to advice to stay in bed.13
©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, May 7, 2008—Vol 299, No. 17 2069

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 CLINICAL CROSSROADS

Chronic Lumbosacral Pain. There are many causes of uncontrolled local anesthetic blocks for diagnostic pur-
chronic lumbosacral pain, and identification of the ana- poses is plagued by placebo response.22 For patients achiev-
tomic cause cannot be made with certainty in up to 90% of ing significant short-term pain relief with diagnostic blocks,
cases.10 The structures most commonly implicated include randomized controlled trials (RCTs) suggest that radiofre-
the sacroiliac joint, lumbar facets, and lumbar interverte- quency treatment can provide pain reduction for 3 to 6
bral disks.20 In chronic low back pain, the incidence of in- months in those with facet-related pain. Pain from degen-
ternal disk disruption has been estimated to be 39% (range, erating intervertebral disks is also a source of chronic axial
29%-49%); facet joint pain, 15% (range, 10%-20%); and sac- back pain.20 Diagnostic diskography may identify sympto-
roiliac joint pain, 15% (range, 7%-23%).20 The gold stan- matic disks prior to management with therapies such as in-
dard for diagnosing sacroiliac and facet joint pain is injec- tradiskal electrothermal therapy (IDET) or surgical fusion.
tion of local anesthetic at the site.21 However, the use of Overall, the evidence regarding treatment of chronic lum-

Figure 3. Normal Anatomy of the Functional Spinal Unit (L4-5) and Associated Neural Structures

S U P E R O L AT E R A L V I E W SUPERIOR VIEW

Cauda equina Posterior Spinal canal

Ligamentum flavum
longitudinal ligament Cauda equina
Dura mater

Ligamentum flavum Spinal nerve

Superior articular
process of L4 Intervertebral
Sinuvertebral
foramen
nerve (sensory
Facet (zygapophyseal) innervation of
joint capsule Anterior intervertebral
L4 longitudinal disk)
Posterior ligament Posterior
primary ramus longitudinal Gray ramus
ligament communicans

Inferior articular Annulus

Intervertebral Nucleus fibrosus
process of L5 L5 Anterior
disk pulposus
longitudinal Intervertebral
ligament disk (cut)
Gray ramus
Spinal nerves communicans

Superior articular
S A G I T TA L S E C T I O N ,
process of L4
M E D I A L S U R FA C E

Ligamentum
L4 Nu
Nucleus
flavum
P O S T E R I O R V I E W O F FA C E T J O I N T pu
pulposus
L4 (CAPSULE REMOVED)

An
Annulus
fib
fibrosus
Inferior articular L5
L5 et joint
Facet
process of L4
sule
capsule
A
Anterior
llongitudinal
lligament
Inferior articular Posterior
process of L5 longitudinal
ligament

Medial branch of posterior Superior articular

primary ramus (sensory process of L5
innervation of facet joint)

The basic unit of the spine, the functional spinal unit, is composed of 2 adjacent vertebral bodies with 2 posterior facet joints, an intervertebral disk, and surrounding
ligamentous structures. See online interactive supplement at http://jama.ama-assn.org/cgi/content/full/299/17/2066/DC1.

2070 JAMA, May 7, 2008—Vol 299, No. 17 (Reprinted) ©2008 American Medical Association. All rights reserved.

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 CLINICAL CROSSROADS

Figure 4. Progressive Degenerative Changes of the Functional Spinal Unit (L4-5) Associated With Repetitive Mechanical Stress and Aging

A Early degenerative changes (type of associated pain)

Internal disk disruption Herniated nucleus pulposus
Spinal canal (lumbosacral pain) (radicular pain)
Spinal canal

Irritation of
spinal nerve by
Disk
nucleus pulposus
innervation

Nucleus
pulposus

Annulus fibrosis
SUPERIOR VIEW SUPERIOR VIEW

B Advanced degenerative changes (type of associated pain)

SUPERIOR VIEW S A G I T TA L S E C T I O N , M E D I A L S U R F A C E

Central canal stenosis Facet hypertrophy

Facet hypertrophy
(neurogenic claudication) (lumbosacral pain) Thickening and calcification Osteophyte
of the posterior
longitudinal ligament
and ligamentum flavum L4

Disk degeneration
Foraminal stenosis
(radicular pain)
Lateral recess Disk bulge L5
stenosis
(radicular pain)
Loss of nucleus
Schmorl node
pulposus

S U P E R O L AT E R A L
Dura VIEW
Thickening and P O S T E R I O R V I E W O F FA C E T J O I N T
calcification of (CAPSULE REMOVED)
ligamentum flavum

Fa
Facet hypertrophy

Lateral recess stenosis Foraminal

stenosis

Enlarged capsule
surrounding facet
Facet h
F hypertrophy
h hypertrophy

Patterns of pain associated with specific degenerative changes are shown in red. A, Early degenerative changes of the functional spinal unit include loss of hydration of
the nucleus pulposus accompanied by mild loss of height of the intervertebral disk. Internal disk disruption (left) begins with radial and/or concentric fissures that
extend from the periphery of the nucleus pulposus into the annulus fibrosus. Extension of these fissures or of material from the nucleus pulposus to the peripheral
portion of the annulus fibrosis can produce lumbosacral pain mediated by the sinuvertebral nerve. Extension of material from the nucleous pulposus posterolaterally
outside the annulus fibrosis (herniated nucleus pulposus, right) can produce an intense inflammatory reaction surrounding the spinal nerve leading to radicular pain.
B, Advanced degenerative changes include complete loss of hydration of the nucleus pulposus, marked loss of height of the intervertebral disk, osteophyte formation,
and thickening of ligaments. Central canal stenosis results from the combined effects of facet hypertrophy and thickening of the ligamentum flavum and posterior
longitudinal ligaments. These degenerative changes can produce neurogenic claudication. Progressive degeneration of the disk or facets can produce chronic lumbo-
sacral pain. Facet hypertrophy can produce stenosis of the lateral recess of the spinal canal and the intervertebral foramen, which may result in radicular pain.

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bosacral pain is conflicting, precluding strong conclusions pathic pain: diabetic neuropathy, and postherpetic
from being drawn. neuralgia.42,43 Tricyclic antidepressants (eg, nortriptyline, de-
Patients with prior lumbar surgery and either recurrent sipramine) and newer selective norepinephrine reuptake in-
or persistent low back pain, often termed failed back sur- hibitors (eg, venlafaxine, duloxetine) are effective in the treat-
gery syndrome, need mention.23 Knowing the type of sur- ment of neuropathic pain.42,43 Antiepileptic drugs (eg,
gery performed, the indications for and results of the sur- gabapentin, pregabalin) also treat neuropathic pain.42,43 De-
gery, and the time course and characteristics of any changes cisions regarding pharmacologic treatment of neuropathic
in the pattern and severity of postoperative pain is essen- pain may be based on an analysis of the number needed
tial. Recurrent pain or progressive symptoms signal the need to treat derived from treatment of diabetic neuropathy and
for further diagnostic evaluation. Mr S’s back pain began as postherpetic neuralgia. Across various neuropathic pain con-
acute radicular pain from a disk herniation, but his pain per- ditions, the numbers needed to treat (95% confidence in-
sisted, worsening after diskectomy. Now the pattern and se- terval [CI]) for tricyclic antidepressants ranged from 2.1 (1.8-
verity of his pain are stable, suggesting that further diag- 2.6) to 3.1 (2.2-5.5); for selective norepinephrine reuptake
nostic evaluation is of questionable benefit. inhibitors, 5.1 (3.9-7.4); for gabapentin, 3.8 (3.1-5.1); and
for pregabalin, 3.7 (3.2-4.4).43 If Mr S has not already re-
Medical Therapies ceived a trial of neuropathic pain medications, a trial to re-
Numerous pharmacologic agents and minimally invasive duce his chronic radicular pain would be worthwhile.
treatments are beneficial in treating specific types of pain. Long-term Opioid Therapy. Long-term opioid therapy
There is no consensus on the order in which these thera- in the management of non–cancer-related pain remains con-
pies should be initiated for persistent low back pain; the gen- troversial.44-46 Advocates point to long-term efficacy and im-
eral approach to each therapy is shown in the TABLE. provement in function in patients with chronic painful con-
Neuropathic Pain Medications. Treatments of neuro- ditions, including low back pain. Opponents cite difficulties
pathic pain such as chronic lumbar radicular pain are ex- in prescribing these drugs long-term.26 While aberrant drug-
trapolated from RCTs examining common forms of neuro- related behavior (eg, losing prescriptions, escalating drug

Table. Rational Sequence for Application of Medical Therapies in Treating Low Back Pain and Level of Evidence Supporting Each Treatment a
Treatment Costs and
Type of Pain Initial Therapy Therapy for Persistent Pain Insurance Coverage b
Acute radicular Seven- to 10-day course of an oral analgesic Two to 6 weeks after onset of acute radicular Oxycodone-acetaminophen ⫹
pain (NSAID or acetaminophen with or without pain, consider lumbar epidural steroid muscle relaxant ⫻ 7-10
opioid analgesic) with a muscle relaxant for injection to speed resolution of radicular days: $; variable coverage
those with superimposed muscle spasm symptoms (level 2).25 Lumbar epidural steroid
(level 1).24 injection: $$; covered by
most insurers
Chronic radicular Chronic radicular pain may respond to Consider evaluation for a trial of spinal cord Medication (see text): $;
pain treatment with chronic opioids, but stimulation (level 2).28-33 variable coverage
neuropathic pain is less responsive to Spinal cord stimulation: $$$$;
opioids than nociceptive pain (level 2).26,27 covered by most insurers
Acute Seven- to 10-day course of an oral analgesic Two to 6 weeks after onset of chronic radicular Physical therapy (2-3⫻/wk for
lumbosacral (NSAID or acetaminophen with or without pain, consider referral for physical therapy 3-4 wk): $$; single course
pain opioid analgesic) with a muscle relaxant for for stretching, strengthening, and aerobic covered by most insurers
those with superimposed muscle spasm exercise in conjunction with patient
(level 1).24 education (level 1).24,34
Chronic Consider diagnostic medial branch blocks of Consider a formal multidisciplinary pain program Radiofrequency treatment: $$;
lumbosacral the nerves to the facet joints. If ⬎50% pain that incorporates medical management, covered by most insurers
pain relief with the diagnostic blocks, consider behavioral therapy, and physical therapy Multidisciplinary pain program:
radiofrequency treatment (level 2).35,36 (level 1).37 $$$; variable coverage but
Consider cognitive-behavioral therapy (level 1).38 many exclude chronic pain
If no response to diagnostic facet blocks and programs
MRI evidence of early degenerative disk Cognitive-behavioral therapy:
disease affecting a single intervertebral disk, $$; variable coverage
consider diagnostic provocative diskography IDET: $$$; variable coverage
(level 3).39 If diskography is concordant (pain
is reproduced at anatomically abnormal
level[s] and no pain at an adjacent
anatomically normal level), consider
treatment with IDET at symptomatic level(s)
(level 2).40
Abbreviations: IDET, intradiskal electrothermal therapy; MRI, magnetic resonance imaging; NSAID, nonsteroidal anti-inflammatory drug.
a Levels of evidence are defined by the Oxford Centre for Evidence-Based Medicine41: level 1, high-quality randomized controlled trials (RCTs) or systematic reviews of RCTs; level
2, low-quality RCTs, cohort studies, or systematic reviews of cohort studies; level 3, case-control studies or systematic reviews of case-control studies; level 4, case series; level
5, expert opinion.
b Relative costs represent the average US cost for a single course of treatment for 1 patient with low back pain: $, ⬍$500; $$, $500-$2000; $$$, $2000-$10 000; and $$$$,
⬎$10 000.

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 CLINICAL CROSSROADS

use) is relatively common in patients receiving opioids for of behavioral therapy, operant conditioning and cognitive
chronic pain,47 overt addiction is unusual.48 However, treat- therapy, are used for back pain. Operant conditioning aims
ing acute pain in opioid-tolerant patients is difficult,49,50 and to eliminate maladaptive pain behaviors. Cognitive therapy
it is becoming evident that chronic opioid use can worsen addresses how patients cope with their pain: what they do
pain by inducing hyperalgesia.51 Few high-quality RCTs are as a result of their pain and how their thoughts and feelings
available to guide the use of opioids in treating chronic low influence their behavior. Cognitive-behavioral therapy is
back pain. A Cochrane review identified only 3 trials deemed superior to a wait-list control for reducing short-term pain
methodologically sufficient; all compared tramadol with pla- intensity (SMD, 0.59; 95% CI, 0.10-1.09) but not for improv-
cebo over a 30- to 90-day period.27 Pooled results showed ing functional status (SMD, 0.31; 95% CI, −0.20 to 0.82).38
that tramadol was more effective than placebo for pain re- Behavioral outcomes (eg, pain behavior, cognitive errors,
lief, with a standardized mean difference (SMD) of 0.71 (95% perceived or observed levels of tension, anxiety, depres-
CI, 0.39-1.02), and for improving function, with an SMD sion) were also superior to no treatment.38
of 0.17 (95% CI, 0.04-0.30).
When treating a patient with long-term opioids, many Multidisciplinary Pain Treatment Programs
drugs are available. The traditional paradigm for opioid treat- A typical multidisciplinary treatment program includes a
ment is based on cancer pain management.52 In this ap- medical manager, usually a physician, overseeing all aspects
proach, patients with significant chronic pain are given a of care and working with other health care professionals
long-acting opioid for continuous analgesia and a short- who deliver physical and behavioral therapies. However,
acting opioid for intermittent pain that “breaks through” the declining reimbursement has forced many inpatient pro-
control provided by the long-acting drug alone. grams to transition to the outpatient setting.58 In a system-
Nearly every available opioid has been used successfully atic review of 10 high-quality RCTs, intensive (⬎100 hours
in treating chronic low back pain, including short-acting of therapy) multidisciplinary biopsychosocial
agents (eg, hydrocodone, oxycodone) alone or in combi- rehabilitation significantly reduced pain and improved
nation with ibuprofen or acetaminophen, and long-acting function over the long term (as long as 60 months after
agents (eg, methadone, transdermal fentanyl, controlled- program completion) vs inpatient or outpatient nonmul-
release oxycodone). A new type of “ultra-fast-onset” opi- tidisciplinary approaches or usual care.37 Multidisciplinary
oid (eg, oral transmucosal fentanyl citrate, fentanyl buccal pain treatment programs are an important option for
tablet) has emerged for rapid treatment of breakthrough patients with chronic pain whose function is significantly
pain.53 As with the patient selection process, choosing impaired.
the opioid drug and appropriate dose remains empirical. The
decision to use short- or long-acting agents alone or in Interventional Pain Therapy
combination should be tailored to the individual patient’s Interventional pain therapy refers to a group of targeted treat-
pattern of pain. Mr S receives methadone, a potent, long- ments used for specific spine disorders, ranging from epi-
acting oral opioid, and oxycodone-acetaminophen, a short- dural injection of steroids to percutaneous intradiskal tech-
acting combination analgesic, for breakthrough pain. niques. Some have been rigorously tested in RCTs, while
others are in widespread use without critical evaluation.
Physical Therapy When these treatment techniques are used for the disor-
Physical therapy, generally consisting of stretching, strength- ders they are most likely to benefit (Table), they can be highly
ening, and aerobic exercise, is widely used and improves effective; however, when used haphazardly, they are un-
both pain and physical function in those with low back pain likely to be helpful and, indeed, may cause harm.
persisting beyond 6 weeks.34 In the first weeks following acute Epidural Injection of Steroids. Numerous RCTs have ex-
lumbar strain with or without radicular pain, exercise therapy amined the efficacy of epidural corticosteroid injection for
is no more effective than other conservative treatments or acute radicular pain. Such injections into the epidural space
no treatment at all.54 are thought to combat the inflammatory response after acute
Even brief patient education through one-on-one, group, disk herniation.59 In acute radicular pain with HNP, evi-
or video instruction can lead to significantly less disability dence59-61 shows that epidural steroids reduce the severity
and worry about reinjury.55 Modalities such as heat, ultra- and duration of leg pain if given between 3 and 6 weeks af-
sound, and transcutaneous electrical stimulation are often ter onset. Adverse effects, such as injection site pain and tran-
used by physical therapists; these may provide short-term sient worsening of radicular pain, occur in less than 1% of
symptomatic relief, but there is no evidence that they alter those treated.59 Beyond 3 months after treatment, there ap-
the long-term course of acute or chronic low back pain.54,56 pear to be no long-term reductions in pain or improve-
ments in function.59,62 This therapy has never proven help-
Behavioral Therapy ful for lumbosacral pain without radicular symptoms. Soon
Persistent pain is a problem that often has physical, psy- after the onset of Mr S’s radicular pain, use of epidural in-
chological, and social/occupational components.57 Two types jection of steroids would have been reasonable. Epidural ste-
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roid injections should be considered for future exacerba- no effect.69 A meta-analysis of 17 studies showed a 50% re-
tions of his radicular pain. duction in pain and improvement in sitting and standing
Facet Blocks and Radiofrequency Treatment. Pain from tolerance in 40% to 50% of patients receiving IDET at a single
the lumbar facet joints affects up to 15% of patients with level with concordant diskography and well-preserved disk
chronic low back pain.63 These patients typically have re- height.40 For Mr S, the numerous disks involved and his ad-
ferred pain, with maximal pain located directly over the facet vanced disk degeneration suggest that IDET is unlikely to
joints and pain on palpation over the facets; radiographic benefit him.
findings are variable, but some degree of facet arthropathy Spinal Cord Stimulation. Based on the theory that non-
is typically present.64 Case series and studies lacking ad- noxious sensory input interferes with the perception of pain,
equate comparator groups or blinding suggest that the intra- direct activation of the dorsal columns of the spinal cord is
articular injection of anesthetics and corticosteroids leads used to treat chronic back pain. A pacemaker-like im-
to intermediate-term pain relief (1-3 months) in patients with planted pulse generator is connected to a small electrode
an active inflammatory process.63 Radiofrequency denerva- array positioned within the dorsal epidural space. This sys-
tion delivers energy through an insulated, small-diameter tem is implanted in a simple, brief surgical procedure.28 Ob-
needle positioned adjacent to the sensory nerve to the facet servational trials29-31 and a recent RCT28 support that spinal
joint, creating a small area of tissue coagulation that dener- cord stimulation is effective in patients with chronic radicu-
vates the facet joint. Two systematic reviews concluded that lar pain following prior lumbar surgery. Trials are of low qual-
there is moderate evidence that radiofrequency denerva- ity but suggest that half of patients report at least 50% on-
tion provides better pain relief than sham intervention.35,36 going pain relief 5 years after device implantation.31 Use of
The quality of the 6 available RCTs was deemed adequate, spinal cord stimulation for chronic lumbosacral pain has been
but they were conducted in a technically heterogeneous man- less satisfactory, but results have improved, with new dual-
ner (eg, varying inclusion criteria, differing treatment pro- lead systems and electrode arrays providing a broad area of
tocols); thus, their findings could not be easily combined. stimulation.28,29 Spinal cord stimulation is less expensive and
Approximately half of patients treated reported at least 50% more effective than reoperation in the management of per-
pain reduction. Pain typically returned 6 and 12 months af- sistent postoperative radicular pain; at a mean 3.1-year follow-
ter treatment, and denervation could be repeated.65 Ad- up, 13 of 21 patients (62%) crossed over from reoperation
verse events were uncommon; in 1% of treated patients, pain vs 5 of 19 patients (26%) who crossed over from spinal cord
at the treatment site lasted 2 weeks or less.66 Mr S has re- stimulation to reoperation (P⬍ .025).33 In the most recent
ceived facet injections but had no pain relief; this lack of RCT, 32% of patients had at least 1 complication, with lead
response and the reproduction of his pain during subse- displacement requiring reoperation in 10% and infection or
quent diskography suggests that his ongoing lumbosacral wound breakdown in 8%.28 Observational studies29-31 and
pain arises from his intervertebral disks. 2 recent high-quality RCTs28,33 suggest that spinal cord stimu-
Intradiskal Electrothermal Therapy. Intervertebral disks lation has the most favorable outcomes in unilateral radicu-
are estimated to be involved in 39% of chronic low back pain lar pain. Based on these data,28 Mr S is a candidate for spi-
cases.20 Provocative diskography is a controversial diagnos- nal cord stimulation for his persistent lumbosacral pain.
tic test in which needles are placed into the intervertebral Intrathecal Drug Delivery. Direct application of mor-
disks; radiographic contrast is then introduced to try to re- phine to the spinal cord produces spinally mediated anal-
produce the patient’s typical pain and determine the offend- gesia, and small, programmable pumps are now available
ing disk. This test has been used to select patients for sur- that can be implanted in the abdominal wall to deliver pre-
gical fusion, but its ability to predict outcome is cise, continuous drug infusions to patients with chronic non–
questionable.39 Mr S had diskography some years ago, pre- cancer-related pain.70 Intrathecal drug delivery is usually re-
sumably in preparation for lumbar fusion surgery. How- served for patients with severe pain that does not respond
ever, numerous disks produced his pain, and no specific lev- to conservative management. In cancer-related pain, pain
els could be identified to target the fusion. relief was similar and opioid-related adverse effects were fewer
Diskography has also been used to select patients for IDET, than with orally administered opioids.71 While morphine is
which is used to treat chronic diskogenic lumbosacral pain. currently the only opioid that is approved for intrathecal use
A steerable thermal resistance wire is placed along the pos- by the US Food and Drug Administration, other drugs are
terior anulus fibrosus and thermal energy is applied to de- also used, singly and in combination. An RCT of intrathe-
stroy penetrating nociceptive fibers and to change the cross- cally delivered ziconotide for severe chronic pain demon-
linking of glycosaminoglycans, thereby stiffening the strated a mean pain reduction of 50% vs a 20% reduction
intervertebral disk.67 Clinical study results are mixed; one in those receiving placebo (P ⬍ .001). However, adverse ef-
high-quality RCT showed that 40% of patients achieved fects were common, with 97% of treated patients experi-
greater than 50% pain relief while 50% of patients had no encing 1 or more adverse effect vs 73% of those receiving
appreciable benefit (number needed to treat to achieve 75% placebo, with the most common being central nervous sys-
relief of pain=5),68 while a second high-quality RCT showed tem adverse effects.72 Intrathecal drug delivery in noncan-
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cer pain has not been subject to controlled trials and re- proteoglycans within isolated intervertebral disk cells,84,85 their
mains controversial, but observational studies suggest it short elimination half-lives preclude direct delivery. Adenoviral-
relieves pain in some patients whose chronic low back pain mediated delivery of growth factors increases proteoglycan syn-
fails to respond to more conservative management.70,73 thesis.86,87 Intradiskal injection of the genes (in rabbits) that
encode growth factors could be used to regenerate or slow de-
Other Therapeutic Approaches generation of disks. Clinical trials have not yet begun.
Acupuncture. A meta-analysis of 33 RCTs comparing acu-
puncture with sham interventions in treating back pain found RECOMMENDATIONS FOR MR S
that for short-term pain relief, acupuncture was signifi- Mr S’s chronic low back pain is associated with degenera-
cantly more effective than sham treatment (SMD, 0.54; 95% tive disk disease; diskography points to several lumbar in-
CI, 0.35-0.73 in 7 trials). Acupuncture was also more ef- tervertebral disks. He underwent treatments for facet-
fective than no treatment (SMD, 0.69; 95% CI, 0.40-0.98 related pain with little or no success. He continues to take
in 8 trials). For acute low back pain, data were “sparse and chronic opioid therapy and reports reasonable pain relief
inconclusive.”74 The effectiveness of acupuncture in com- with moderate doses of methadone (a long-acting opioid)
parison with other treatments has not been studied, nor has in combination with oxycodone-acetaminophen, a short-
the frequency and duration of acupuncture required to pro- acting combination analgesic.
duce durable pain reduction.75 Additional treatment depends entirely on Mr S’s lifestyle
Spinal Manipulation. Generally, spinal manipulation in- and goals; there is no clear path to certain pain reduction
volves the hands being applied to the patient to deliver a or improvement in his functional status. If his overall level
forceful load to specific body tissues to reduce pain and/or of function is poor or declining, enrollment in a multidis-
improve range of movement.76 Mechanisms include in- ciplinary program offers the best hope of long-term im-
crease of joint movement, changes in joint kinematics, in- provement; weight reduction may also improve his level of
crease of pain threshold and muscle strength, and release function and his back pain. Given the duration of his chronic
of endogenous analgesic peptides.77 Available data are con- pain, he is unlikely to have dramatically improved analge-
flicting and the methodologic quality is low, with lack of sia or functional status. Treatment with spinal cord stimu-
blinding and/or meaningful comparator groups. However, lation or intrathecal drug delivery are reasonable ap-
spinal manipulation generally results in more rapid recov- proaches, with stronger evidence supporting the use of spinal
ery if applied within 3 weeks of onset of acute low back pain.78 cord stimulation, but selecting patients for these therapies
The outcomes for treatment of chronic low back pain are is difficult. It is essential that Mr S understand that he should
less clear, and the conclusions of systematic reviews are in- not ignore exacerbations of pain; changing patterns often
consistent. One systematic review concluded that spinal ma- signal the need for further diagnostic evaluation. These can
nipulation for chronic low back pain provides benefits simi- often be successfully managed, even in the context of long-
lar to a prescription nonsteroidal anti-inflammatory drug; standing pain.
it is more effective in the short-term than placebo and gen-
eral practitioner care and in the long term vs physical QUESTIONS AND DISCUSSION
therapy.78 However, in a review of 16 systematic reviews, spi- QUESTION: Would a personal trainer be of benefit for Mr S?
nal manipulation was ineffective in treating any condition, DR RATHMELL: Why not use a personal trainer? Well, who’s
including low back pain.76 Nonetheless, the authors under- going to pay for a personal trainer? Mr S mentions the ben-
scored the low quality of the available evidence and the need efits he got from massage. He says, “I used to get massages,
for additional clinical trials.76 but I couldn’t afford it.” So, even when treatments prove use-
ful, who will pay for it in our health care reimbursement
Experimental Treatment Options system? Evidence from trials and meta-analyses shows the
Tumor necrosis factor ␣ is an important mediator of sci- efficacy of multidisciplinary pain treatment programs.37 But
atica in animal models of disk herniation,79 but while early these programs are becoming less available because of the
uncontrolled trials of the anti–tumor necrosis factor ␣ agents expense and the difficulty in gathering all of the needed prac-
infliximab80 and etanercept81 showed faster pain reduc- titioners in one place to coordinate their patients’ care.
tion, a subsequent RCT showed no benefit of infliximab over QUESTION: How are we training medical students or resi-
placebo.82 Trials examining periradicular application are cur- dents to be more empathetic to patients with chronic pain?
rently under way.83 One of Mr S’s biggest complaints about physicians is that
The progressive loss of proteoglycan within the nucleus the first thing we think is that this man wants drugs.
pulposus, a characteristic finding in degenerative disk dis- DR RATHMELL: When adopting a reasonable approach to
ease, has suggested a possible role for growth factors. Al- chronic opioid therapy for chronic noncancer pain, there
though some growth factors (human transforming growth fac- are no easy answers. It is hard to decide who should and
tor ␤1, tissue inhibitor of matrix metalloproteinase 1) may up- should not receive opioids; there is no objective measure
regulate the anabolism or inhibit the catabolism of of pain. I think that young physicians see such widely vary-
©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, May 7, 2008—Vol 299, No. 17 2075

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 CLINICAL CROSSROADS

ing approaches during their education that they do not know Additional Information: An online interactive supplement is available at
http://jama.ama-assn.org/cgi/conent/full/299/17/2066/DC1.
what is right. Additional Contributions: We thank the patient for sharing his story and for pro-
As pain specialists, what we do now is rely more on pri- viding permission to publish it.
mary care physicians to help us make decisions about the
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Financial Disclosures: None reported. tional medical management for neuropathic pain: a multicentre randomised con-
Funding/Support: This Clinical Crossroads was made possible in part by a grant trolled trial in patients with failed back surgery syndrome. Pain. 2007;132(1-2):
from the Florence and Richard Koplow Charitable Foundation. 179-188.
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