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Advanced diagnostic imaging, spinal surgery, and alternative therapies such as acupuncture, are widely used in the diagnosis and treatment of patients with low back pain. Three new studies, supported by the Agency for Healthcare Research and Quality, examine the use of acupuncture, surgery, and imaging tests for low back pain.
The first study shows that, like physicians, acupuncturists also vary in their treatment approach to low back pain. The second study finds that patients with moderate or severe sciatica due to a herniated disc who undergo surgery have better outcomes than those who don't after 5 years. A third study distinguishes certain magnetic resonance imaging (MRI) spinal changes that are common among people without back pain from those that more readily identify people who have experienced back pain.
Kalauokalani, D., Sherman, K.J., and Cherkin, D.C. (2001, May). "Acupuncture for chronic low back pain: Diagnosis and treatment patterns among acupuncturists evaluating the same patient." (AHRQ grants HS09351, HS09989, and HS09565). Southern Medical Journal 94(5), pp. 486-491.
Acupuncturists practicing Traditional Chinese Medicine (TCM) varied substantially in their treatment recommendations for the same patient in this study, despite agreement on their diagnoses. The patient was an otherwise healthy 40-year-old woman whose low back pain developed after a head-on motor vehicle accident 20 years earlier. She had negative imaging results, found 6 months of chiropractic therapy to be of no benefit, and took 1,500 mg of acetaminophen each day for the discomfort. This same patient visited each of seven acupuncturists during a 2-week interval, but one failed to record treatment data. According to TCM, Qi stagnation (normal movement of energy or Qi is impaired in a particular organ, meridian, or other part of the body causing distension, soreness, or pain) and occasionally blood stagnation along the urinary bladder meridian are frequently the source of low back pain.
Not surprisingly, the most commonly assigned diagnoses were Qi stagnation (six acupuncturists), and blood stagnation (five). Despite general consensus on diagnosis, treatments differed substantially. Recommendations varied between use of 5 to 14 specific acupuncture points and from 7 to 26 needles. All but one acupuncturist chose points located throughout the back, and all but one chose points in the leg. However, of 28 acupuncture points selected, only 4 were used by two or more acupuncturists.
Four acupuncturists chose points on the urinary bladder meridian, and five combined points on this meridian with points from other meridians. The time that needles remained in place after insertion ranged from 15 to 30 minutes. All practitioners manipulated the needle to elicit de qi, the deep dull ache, numbness, or tingling associated with needle insertion, for at least some of their insertions. Most recommended various forms of adjuvant heat. The researchers point out that use of different acupoints along the same meridian may be considered a similar therapeutic option, diminishing some of the apparent variability in treatment.
Atlas, S.J., Keller, R.B., Chang, Y., and others. (2001). "Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation." (AHRQ grants HS06344, HS08194, and HS09804). Spine 26(10), pp. 1179-1187.
Patients with moderate or severe sciatica due to a herniated disc who undergo surgery improve more than those who don't after 5 years, according to this study. The researchers interviewed patients with moderate or severe sciatica from practices in Maine. They mailed the patients followup questionnaires at 3, 6, and 12 months and annually thereafter to 60 months. Patients were asked about symptoms of leg and back pain, functional status, satisfaction, and employment and compensation status.
Of the 507 patents initially enrolled, 5-year outcomes were available for 402: 220 had been treated surgically and 182 had been treated nonsurgically. Surgically treated patients had worse baseline symptoms and functional status than those initially treated nonsurgically. By 5 years, 19 percent of surgical patients had undergone at least one additional lumbar spine operation, and 16 percent of nonsurgical patients had opted for at least one lumbar spine operation. Overall, patients treated initially with surgery reported better outcomes. After 5 years, 70 percent of the surgical patients had improved back or leg pain versus 56 percent of those initially treated nonsurgically.
Similarly, a larger proportion of surgical patients reported satisfaction with their current status (63 vs. 46 percent). The relative advantage of surgery was greatest early in followup and narrowed over 5 years but still remained superior to nonsurgical treatment. There was no difference in the proportion of patients receiving disability compensation 5 years later. The least symptomatic patients at baseline did well regardless of initial treatment, although function improved more in the surgical group.
Jarvik, J.J., Hollingworth, W., Heagerty, P., and others. (2001). "The longitudinal assessment of imaging and disability of the back (LAIDBack) study." (AHRQ grants HS08194 and HS09499). Spine 26(10), pp. 1158-1166.
Many magnetic resonance imaging (MRI) findings are typical in patients without low back pain and therefore are of limited use in diagnosing patients with low back pain. On the other hand, less common MRI findings of moderate or severe central stenosis, root compression, and disc extrusions are likely to be diagnostically and clinically relevant, according to this study. The researchers randomly selected patients without low back pain in the past 4 months from clinics at a VA hospital to examine
which findings were related to age or previous back symptoms.
The researchers found several MRI findings to be common among patients without low back pain. Of the 148 patients, 46 percent had never experienced low back pain. Yet about 83 percent of them had moderate to severe desiccation of one or more discs, 64 percent had one or more bulging discs, and 56 percent had loss of disc height. About 32 percent had at least one disc protrusion, and 6 percent had one or more disc extrusions. On the other hand, moderate or severe central stenosis, root compression, and disc extrusions were more likely to be diagnostically and clinically relevant.
For example, those who had experienced five or more episodes of previous low back pain were much more likely to have a disc extrusion than those who had never experienced low back pain. The prevalence of moderate or severe central stenosis or nerve root compromise was also higher in those with multiple previous episodes of low back pain. Unlike the other MRI findings, which were linked to aging, disc extrusions and nerve root compromise were not significantly associated with age but were associated with previous low back pain.
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