Low Back Pain: An Approach to Diagnosis and Management

Potential Role for Stem Cell Regenerative Therapy as a Treatment for Degenerative Disc Disease and Low Back Pain: A Systematic Review

Back pain is the single leading cause of disability worldwide. Despite the prevalence and morbidity of lower back pain, we still lack a gold-standard treatment that restores the physiological function of degenerated intervertebral discs. Recently, stem cells have emerged as a promising strategy for regenerative therapy for degenerative disc disease. In this study, we review the etiology, pathogenesis, and developing treatment strategies for disc degeneration in low back pain with a focus on regenerative stem cell therapies. A systematic search of PubMed/MEDLINE/Embase/Clinical Trials.gov databases was conducted for all human subject abstracts or studies. There was a total of 10 abstracts and 11 clinical studies (1 RCT) that met the inclusion criteria. The molecular mechanism, approach, and progress of the different stem cell strategies in all studies are discussed, including allogenic bone marrow, allogenic discogenic cells, autologous bone marrow, adipose mesenchymal stem cells (MSCs), human umbilical cord MSC, adult juvenile chondrocytes, autologous disc derived chondrocytes, and withdrawn studies. Clinical success with animal model studies is promising; however, the clinical outcomes of stem cell regenerative therapy remain poorly understood. In this systematic review, we found no evidence to support its use in humans. Further studies on efficacy, safety, and optimal patient selection will establish whether this becomes a viable, non-invasive therapeutic option for back pain.

Translation and Adaptation of the French Version of the Risk Stratification Index, a Tool for Stratified Care in Chronic Low Back Pain: A Pilot Study

Background and Objectives: Low back pain is a worldwide health problem. An early diagnosis is required to develop personalized treatment strategies. The Risk Stratification Index (RSI) was developed to serve the purpose. The aim of this pilot study is to cross-culturally translate the RSI to a French version (RSI-F) and evaluate the test-retest reliability of RSI-F using a French active population. Materials and Methods: The RSI was translated from German to French (RSI-F) based on the guidelines of cross-cultural adaptation of self-report measures. A total of 42 French recreational athletes (age 18−63 years) with non-specific low back pain were recruited and filled in the RSI-F twice. The test-retest reliability was examined using intraclass correlation coefficient (ICC1,2) and Pearson correlation coefficient. Results: Finally, 33 questionnaires were analyzed (14 males and 19 females, age 31 ± 10 years, 9.5 ± 3.2 h/week of training). The test-retest of RSI-F CPI and DISS were excellent (CPI: ICC1,2 = 0.989, p < 0.001; r = 0.989, p < 0.001; DISS: ICC1,2 = 0.991, p < 0.001; r = 0.991, p < 0.001), as well as Korff pain intensity (ICC1,2 = 0.995, p < 0.001; r = 0.995, p < 0.001) and disability (ICC1,2 = 0.998, p < 0.001; r = 0.998, p < 0.001). Conclusion: The RSI-F is linguistically accurate and reliable for use by a French-speaking active population with non-specific low back pain. The RSI-F is considered a tool to examine the evolution of psychosocial factors and therefore the risk of chronicity and the prognostic of pain. Further evaluations, such as internal, external validity, and responsiveness should be evaluated in a larger population.

Candidate Biomarkers to Distinguish Spinal Tuberculosis From Mechanical Back Pain in a Tuberculosis Endemic Setting

Background

Spinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain.

Methods

Patients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain.

Results

Twenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation.

Conclusion

This study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

Evaluation of Challenges in Diagnosis of Spontaneous Subacute Pyogenic Spondylodiscitis in Immunocompetent Patients: Experiences from a Tertiary Care Center

Study Design

Prospective clinical study.

Purpose

We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis.

Overview of Literature

Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis.

Methods

Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis.

Results

Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated.

Conclusions

Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum Creactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.

Most Relevant Neuropathic Pain Treatment and Chronic Low Back Pain Management Guidelines: A Change Pain Latin America Advisory Panel Consensus

Objective

Chronic pain conditions profoundly affect the daily living of a significant number of people and are a major economic and social burden, particularly in developing countries. The Change Pain Latin America (CPLA) advisory panel aimed to identify the most appropriate guidelines for the treatment of neuropathic pain (NP) and chronic low back pain (CLBP) for use across Latin America.

Methods

Published systematic reviews or practice guidelines were identified by a systematic search of PubMed, the Guidelines Clearinghouse, and Google. Articles were screened by an independent reviewer, and potential candidate guidelines were selected for more in-depth review. A shortlist of suitable guidelines was selected and critically evaluated by the CPLA advisory panel.

Results

Searches identified 674 and 604 guideline articles for NP and CLBP, respectively. Of these, 14 guidelines were shortlisted for consensus consideration, with the following final selections made: "Recommendations for the pharmacological management of neuropathic pain from the Neuropathic Pain Special Interest Group in 2015-pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis.""Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society" (2007).

Conclusions

The selected guidelines were endorsed by all members of the CPLA advisory board as the best fit for use across Latin America. In addition, regional considerations were discussed and recorded. We have included this expert local insight and advice to enhance the implementation of each guideline across all Latin American countries.

A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain

OBJECTIVE

To identify the prognostic factors for conventional physical therapy in patients with chronic low back pain (CLBP).

METHODS

Prospective observational study.

PARTICIPANTS

One hundred thirteen patients with CLBP selected at the Spinal Disease Outpatient Clinic.

MAIN OUTCOME MEASURES

Pain intensity was scored using the Numeric Rating Scale (NRS), and function was measured using the Roland-Morris Disability Questionnaire (RMDQ).

RESULTS

The Fear-Avoidance Beliefs Questionnaire work subscale results (FABQ-work; odds ratio [OR]=0.27, 95% confidence interval [CI] 0.13-0.56, p<0.001) and extraspinal pain (OR=0.35, 95% CI 0.17-0.74, p=0.006) were independently associated with a decreased response to conventional physical therapy for CLBP.

CONCLUSION

We identified high FABQ-work and extraspinal pain scores as key determinants of a worse response to physical therapy among CLBP patients, supporting the need for a special rehabilitation program for this subgroup.

Clinical efficacy and safety of eperisone for low back pain: A systematic literature review

Eperisone, an analgesic and centrally acting muscle relaxant has been in use for the treatment of low back pain (LBP). The present systematic review evaluates the efficacy and safety of eperisone in patients with LBP. Cochrane Back and Neck (CBN) Group and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were adopted to perform this systematic review. For risk of bias assessment CBN Group and Moga tools were used. Seven (5 randomized controlled trials [RCTs] and 2 uncontrolled studies) studies involving 801 participants were included. Eperisone intervention may be effective in acute LBP patients with less adverse effects (relative risk, 0.25; 95% confidence interval, 0.15-0.41; p<0.0001). Eperisone also improved paraspinal blood flow and was found to have efficacy similar to tizanidine in chronic LBP patients. The included studies in this review are of smaller sample size and short duration to support eperisone use in LBP. However, we recommend well-designed RCTs of high quality with larger sample size and longer follow-up to confirm the clinical benefits of eperisone in the treatment of acute or chronic LBP.

DISC (Degenerate-disc Infection Study With Contaminant Control): Pilot Study of Australian Cohort of Patients Without the Contaminant Control

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To evaluate if degenerative disc-related back or neck pain and/or radicular symptoms are caused by infection with low virulent bacterial organisms.

SUMMARY OF BACKGROUND DATA

The potential relationship between disc infection and disc degeneration-related symptoms remains controversial, with contradictory evidence available in the literature. Several studies have demonstrated the presence of infected extruded nucleus tissue from first-time disc herniation, implicating the role of disc microbial infection in disc degeneration. The current study is a pilot study evaluating if high infection rates are prevalent in the Australian degenerate disc cohort.

METHODS

Institutional ethics approval was obtained (HREC 13/218). The pilot project was a single spine center prospective cohort of patients undergoing spine surgery for degenerate disc disease. In each case, disc material was obtained and prolonged aerobic and anaerobic cultures performed as per methods used by Stirling et al.

RESULTS

To date, a total of 168 patients have been enrolled, with male: female = 1:1. Surgical caseload includes 17.9% anterior cervical fusion, 35.0% anterior lumbar fusion, 40.7% lumbar discectomy, and 5.7% posterior lumbar fusions; 34.1% patients presented with neck pain, 31.6% with arm pain, 59.3% with leg pain, and 64.2% with back pain, and 20.2% of the patients received transforaminal or epidural or facet joint injections prior to surgery. In this pilot study, 19.6% were culture positive, with P. acnes predominant in 50%. Disc-only cultures were positive in 27.8% of lumbar cases and 18.5% of cervical cases, with predominant organisms being P. acnes.

CONCLUSION

Similar to the infection rates from previous studies, this Australian cohort had 19.6% infection rates when disc-only cultures are performed. P. acnes is the predominant organism followed by Streptococcus sp. It is imperative to perform contaminant controls as such high infection with skin bugs is a significant finding.

LEVEL OF EVIDENCE

4.

A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain

OBJECTIVE

To identify the prognostic factors for conventional physical therapy in patients with chronic low back pain (CLBP).

METHODS

Prospective observational study.

PARTICIPANTS

One hundred thirteen patients with CLBP selected at the Spinal Disease Outpatient Clinic.

MAIN OUTCOME MEASURES

Pain intensity was scored using the Numeric Rating Scale (NRS), and function was measured using the Roland-Morris Disability Questionnaire (RMDQ).

RESULTS

The Fear-Avoidance Beliefs Questionnaire work subscale results (FABQ-work; odds ratio [OR]=0.27, 95% confidence interval [CI] 0.13 to 0.56, p<0.001) and extraspinal pain (OR=0.35, 95% CI 0.17 to 0.74, p=0.006) were independently associated with a decreased response to conventional physical therapy for CLBP.

CONCLUSION

We identified high FABQ-work and extraspinal pain scores as key determinants of a worse response to physical therapy among CLBP patients, supporting the need for a special rehabilitation program for this subgroup.

PRIMARY LIPOSARCOMA OF THE LUMBAR SPINE: CASE REPORT

We report a rare case of primary bone liposarcoma of the lumbar spine, for which only one case has been reported. A female patient, 60 years of age, with lumbar pain and left sciatalgy for six months. In the imaging exams, a destructive tumor was found in the L4 vertebral body, and magnetic resonance imaging (MRI) revealed a tumoral lesion with T1 hiposignal and T2 hypersignal. Histological diagnosis was difficult, and immunohistochemistry confirmed the diagnosis. Surgical treatment was performed with wide ressection, spinal cord decompression, and anterior and posterior fusion of L3 to L5 complemented by radiotherapy and chemotherapy. After three years, a computed tomography (CT) scan evidenced an expansive injury in the lung. Despite its rarity, liposarcoma should be considered in the differential diagnosis of sciatica and primary tumors of the spine.

Persistent back pain in the absence of clear red flags

A 62-year-old woman with low back pain was eventually diagnosed with vertebral osteomyelitis after multiple visits to emergency, primary and specialty care. The absence of traditional 'red flags' from her history and examination serves as an important reminder that their absence does not necessarily reflect benign pathology.

Low back pain: pharmacologic management

Adequate treatment of low back pain is essential, but has been challenging for many primary care physicians. Most patients with low back pain can be treated in the primary care environment, provided the physician has enough knowledge of the medications used to treat low back pain. The main treatment goal for acute low back pain is to control the pain and maintain function. For patients with chronic back pain, the goal is continual pain management and prevention of future exacerbations. This article reviews current pharmacological options for the treatment of low back pain, and possible future innovations.

The history of lower back pain: a look "back" through the centuries

The diagnosis and treatment of low back pain must be standardized, based on evidence and solid research. The cost to individuals and society is great and only those diagnostic tests or treatments that can improve the quality and cost of care should be advocated.

A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

PURPOSE

The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade.

METHODS

This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome.

RESULTS

Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes.

CONCLUSIONS

Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.