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by Alf Nachemson ©2000
Professor of Orthopaedics, University of Goteborg, Sweden.
Published by the Swedish Council on Technology Assessment


Back pain is rarely a symptom of serious disease.

The total financial cost of back pain is about three times higher than the total cost of all forms of cancer - yet only 0.2% of randomised trials in medicine concern back pain.

10-15% of patients suffering from back pain account for 80-90% of the total health care consumption costs for treating spinal disorders and of this group 1-2% who undergo surgery are the most expensive group. The rapid development of many new and expensive surgical procedures is of particular concerrn (p305).

Magnetic Resonance Imaging - although this has increased the diagnostic capabilities of visualising abnormalities of spinal structures including 'red flag' conditions (suspected specific treatable diseases), no evidence is available to show that MRIs have improved the treatment of common back syndromes.

The MRI image of a prolapsed disc in the absence of strong correlation with clinical findings should not be used as an indication for surgery because among 46 asymptomatic persons who had no pain, 73% of their MRIs were positive!

The following diagnostic and treatment devices have been found to lack scientific rigor or clinical utility:
Facet blocks EMGs; Discography; nerve root infiltration; bone scintigraphy; thermography; temporary external fixation

Epidural Steroid Injections - there was minimal difference after one month between patients who had an injection and those who did not.

Trigger Point Injections - no evidence is available on their effectiveness and they can expose patients to "serious potential complications" (p 255).

Traction and bed rest is not effective with strong evidence that traction has no effect on lower back pain (p 295).

Manipulation should not be used in patients with progressive neurologic deficit.

Transcutaneuous Electrical Nerve Stimulation (TENS) - no differences regarding pain and functional status were recorded between a placebo application (simulated treatment) and TENS (p298).

There is moderate evidence that manual therapy is more effective than care offered by the general practitioner.

Whiplash injuries to the neck - of 17 patients who underwent surgery - none had an excellent outcome (p356).

The Cervical Spine Research Society conducted a clinical review of surgical patients after one year and found that in 26% of cases there was "persistent excruciating or horrible pain" as a result of the surgery (p357).

There is no acceptable evidence on the efficacy of any form of fusion for back pain or 'instability' or for decompression for stenosis or lumbar disc disease (p318). There is limited direct evidence on the efficacy of surgical discectomy for lumbar disc prolapse (p313). There is no evidence that any form of surgery for disc disease is effective compared with conservative treatment (p 318/322). It is not possible to support any method of spinal fusion(p. 358).

According to the report of the UK Clinical Standards Advisory Group Committee on Back Pain - patients should be referred for manual therapy for pain relief (p. 300).

CONCLUSION: Primary care is the appropriate treatment level for most patients with back pain (p. 395).