Spine

For over half a century back pain has been the most common reason for spinal fusion. Yet there is no unequivocal evidence that fusion is superior to comprehensive conservative treatment for treating back pain without focal structural pathology and concordant mechanical or neurological symptoms. It is often impossible to locate the precise source of the pain; in many cases the symptoms are multifactorial and can encompass elements such as centralized pain that exist outside the spine. The extreme heterogeneity of the low back pain population leads to unpredictable surgical results and consistently poor outcomes in those with pain from multilevel spine degeneration.

Unless the image has a direct bearing on the treatment decision it is not required. Spinal “abnormalities” in asymptomatic individuals are common and increase with age. For those with back dominant symptoms (i.e., axial back pain) there is an extremely high false positive rate; most of the findings have no correlation with the clinical picture. For the majority of low back complaints obtaining spinal imaging does not improve patient care but can lead to inappropriate interventions and does have a detrimental impact on patient outcomes. Red flags include cauda equina syndrome; severe or progressive neurologic deficits; suspected cancer; suspected infection: suspected fracture and suspected epidural abscess or hematoma.

Steroids are potent anti-inflammatory agents, but axial low back pain is not primarily an inflammatory condition and any inflammation that does exist generally cannot be accessed via the spinal canal. The outcomes of ESI for axial low back pain are poor compared to its use in radiculopathy due to disc herniation. Although serious adverse events are rare, catastrophic events can occur and any symptom relief from the injection typically lasts only for a matter of weeks. The inconsequential benefits of ESI for axial low back pain do not outweigh its risks, no matter how small they may be.

Significant controversy still exists regarding the use of bracing in AIS patients at risk for curve progression and eventual surgery. A recent high-level study has convincingly shown that bracing impacts the natural history of AIS and, in those properly braced, significantly reduces the need for a subsequent operation. In light of the resulting decrease in the indications for surgical intervention, the bias against bracing should be re-evaluated.

Although a deep surgical site infection associated with spinal implants can be a devastating adverse event, the prolonged use of peri-operative antibiotics has not been shown to reduce the incidence.  Their extended use in routine low risk cases has no proven evidence of benefit but increases the chance of creating resistant bacterial strains. A rational, evidence-based approach is required.

Over 90% of acute low back pain is a mechanical problem that is often self-limiting and can be controlled with physical treatment and non-narcotic medication. The most common entry point to prescription opioid addiction is through opioids prescribed for back pain. Adequate pain control using opioids is frequently not achieved and patients face the added risks of physical dependence and withdrawal hyperalgesia, which can lead to continued use.

Using post-operative opioid analgesics creates problems with constipation, nausea and dizziness while interfering with early mobilization and, in some patients, promoting long term use. It should be used only in a strictly limited manner and with well-defined parameters. Alternate pain management regimens offer improved pain control, enhanced rehabilitation and fewer complications.

There is no clear evidence for the benefits of long-term opioid medication on pain, function or quality of life. There is a clear correlation with a range of adverse effects including falls, fractures, testosterone suppression, hyperalgesia and depression.  It increases the risk of dependence, addiction and overdose.  Long-term use either before or following spine surgery is associated with increased medical costs and a reduced rate of return to work.