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Diagnosis and Treatment of Low Back Pain

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Diagnosis and Treatment of Low Back Pain Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain 7075 Veterans Blvd Burr Ridge, IL 60527 630-230-3600 www.spine.org © 2020 North American Spine Society 978-1-929988-65-5 Diagnosis & Treatment of Low Back Pain | Preface Authors & Contributors Evidence-Based Guideline Development Physical Medicine & Rehabilitation Section Committee Co-Chairs Section Chair: D. Scott Kreiner, MD Charles A. Reitman, MD Paul Matz, MD Authors: Diagnosis Section R. Carter Cassidy, MD Dennis E. Enix, DC, MBA Section Chair: Daniel S. Robbins, MD Daniel K. Resnick, MD, MS Alison A. Stout, DO Authors: Ryan A. Tauzell, PT, MA, MDT Norman B. Chutkan, MD, FACS Contributor: Adam C. Lipson, MD William L. Tontz, Jr., MD Anthony J. Lisi, DC Tom E. Reinsel, MD Interventional Treatment Section Robert L. Rich Jr, MD, FAAFP; Stakeholder Section Chair: Representative, American Academy of Family John E. Easa, MD, FIPP Physicians (AAFP) Authors: Contributor: Jamie Baisden, MD, FACS Robert C. Nucci, MD Shay Bess, MD Imaging Section David S. Cheng, MD David A. Provenzano, MD; Stakeholder Representative, Section Co-Chairs: American Society of Regional Anesthesia and Pain Charles H. Cho, MD, MBA Medicine (ASRA) Gary Ghiselli, MD Yakov Vorobeychik, MD, PhD; Stakeholder Authors: Representative, Spine Intervention Society (SIS) Sean D. Christie, MD Contributors: Bernard A. Cohen, PhD Michael P. Dohm, MD S. Raymond Golish, MD, PhD, MBA Thomas J. Gilbert, MD Murat Pekmezci, MD Joseph Gjolaj, MD Walter S. Bartynski, MD; Stakeholder Representative, Matthew Smuck, MD, Stakeholder Representative, American Society of Spine Radiology (ASSR) American Academy of Physical Medicine and Rehabilitation (AAPM&R) Medical & Psychological Treatment Section Section Chair: Christopher M. Bono, MD Authors: Paul Dougherty, DC Gazanfar Rahmathulla, MD, MBBS Christopher K. Taleghani, MD Terry Trammell, MD Randall P. Brewer, MD; Stakeholder Representative, American Academy of Pain Medicine (AAPM) Ravi Prasad, PhD; Stakeholder Representative, American Academy of Pain Medicine (AAPM) Contributor: John P. Birkedal, MD Recommendations were developed based on a specific definition, inclusion/exclusion criteria, and the resulting literature which excluded conditions 2 such as presence of a neurological deficit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec- ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a fixed treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. Diagnosis & Treatment of Low Back Pain | Preface Surgical Treatment Section Participating Societies Section Chair: (does not necessarily imply endorsement) William C. Watters III, MD, MS American Academy of Family Physicians (AAFP) Authors: American Academy of Orthopaedic Surgeons Thiru M. Annaswamy, MD (AAOS) Steven W. Hwang, MD American Academy of Pain Medicine (AAPM) Cumhur Kilincer, MD, PhD American Association of Neurological Surgeons RJ Meagher, MD (AANS)/Congress of Neurological Surgeons (CNS) Anil K. Sharma, MD American Society of Anesthesiologists (ASA) Kris E. Radcliff, MD; Stakeholder Representative, American Society of Regional Anesthesia and Pain American Academy of Orthopaedic Surgeons (AAOS) Medicine (ASRA) American Society of Spine Radiology (ASSR) Contributor: Spine Intervention Society (SIS) Jordan Gliedt, DC Cost-Utility Section Contributing Societies Section Chair: (does not necessarily imply endorsement) Zoher Ghogawala, MD, FACS American Academy of Physical Medicine and Rehabilitation (AAPM&R) Authors: American Physical Therapy Association (APTA) Simon Dagenais, PhD, MSc, DC Jeffrey A. King, DC, MS Paul Park, MD Daniel R. Perry, MPT, MDT Jonathan N. Sembrano, MD John E. O’Toole, MD, MS; Stakeholder Representative, American Association of Neurological Surgeons (AANS) Padma Gulur, MD; Stakeholder Representative, Ameri- can Society of Anesthesiologists (ASA) Contributors: Darren R. Lebl, MD (Cost-Utility Section) Alex Seldomridge, MD, MBA (Cost-Utility Section) Recommendations were developed based on a specific definition, inclusion/exclusion criteria, and the resulting literature which excluded conditions such as presence of a neurological deficit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec- 3 ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a fixed treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. Diagnosis & Treatment of Low Back Pain | Preface Financial Statement/ Disclosures Comments This clinical guideline was developed and funded Comments regarding this guideline may be submitted in its entirety by the North American Spine Society to the North American Spine Society at guidelines@ (NASS) with the exception that stakeholder societies spine.org and will be considered in development of provided representatives and paid for the travel future revisions of the work. and accommodation of their representatives to recommendation meetings. All participating Endorsements authors have disclosed potential conflicts of interest Letters of endorsement from external societies can consistent with NASS’ disclosure policy (http:// be found in the Technical Report associated with this www.spine.org/DisclosurePolicy). Disclosures of all document. authors and contributors are listed in the Technical Report associated with this document. Recommendations were developed based on a specific definition, inclusion/exclusion criteria, and the resulting literature which excluded conditions 4 such as presence of a neurological deficit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec- ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a fixed treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. Diagnosis & Treatment of Low Back Pain | Preface Table of Contents I. Introduction . 6 II. Guideline Development Methodology and Process ..................................8 III. Glossary and Acronyms .............................................................12 IV. Guideline Definition and Inclusion/Exclusion Criteria ...............................16 V. Summary of Recommendations ..................................................... 17 VI. Recommendations for Diagnosis and Treatment of Low Back Pain ..................40 A. Diagnosis .......................................................................40 B. Imaging .........................................................................60 C. Medical and Psychological Treatment ...........................................69 D. Physical Medicine & Rehabilitation .............................................101 E. Interventional Treatment .......................................................158 F. Surgical Treatment .............................................................190 G. Cost-Utility ....................................................................198 VII. Appendices ........................................................................213 A full bibliography and technical report, including the literature search parameters and evidentiary tables developed by the authors, can be accessed at https://www.spine.org/Research-Clinical-Care/Quality- Improvement/Clinical-Guidelines. Recommendations were developed based on a specific definition, inclusion/exclusion criteria, and the resulting literature which excluded conditions such as presence of a neurological deficit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec- 5 ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a fixed treatment protocol; it is anticipated that there will be patients who require more or less treatment than
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