Letters CMAJ 696 CMAJ, June 10, 2014, 186(9) © 2014 Canadian Medical Association or its licensors Recommendations for management of low-back pain misleading We have concerns regarding the article by Kennedy and Baerlocher, 1 in which they advise that most instances of low- back pain will resolve without treat- ment. A recent systematic review 2 showed that 65% of patients with acute low-back pain continue to report pain one year after onset, which suggests that optimal management of acute low-back pain requires chronic condition manage- ment strategies. The authors 1 recom- mend that most patients with acute low- back pain can be managed with analgesia and physiotherapy; however, recent evidence shows that stratiied care is superior to a general approach. 3 The authors 1 state that magnetic res- onance imaging (MRI) should be obtained for patients who experience low-back pain for more than six weeks. This contradicts the guidelines put forth by the American College of Physi- cians. 4 Kennedy and Baerlocher 1 tout the potential beneits of load-bearing MRI as a more sensitive method of detecting degenerative changes in the spine. Degenerative changes in the spine are common in asymptomatic adults, and the more pressing issue in Canada appears to be the overuse of advanced imaging for low-back pain. A recent study in Alberta showed that only 44% of 1000 referrals for lumbar spine MRI were appropriate. 5 The authors 1 promote vertebroplasty as an effective treatment for painful, acute vertebral compression fractures, and cite an open-label trial. 6 When ver- tebroplasty has been evaluated in ran- domized trials with a sham surgery control group, resulting in blinding of patients, no speciic effect for vertebro- plasty has been shown. 7 The literature does not support the use of selective root block for low-back pain. 8 The authors 1 advocate the use of radiofrequency denervation or ablation for low-back pain with nerve-root involvement, and cite a trial 9 that showed no difference between radiofre- quency denervation and intra-articular lumbar facet joint steroid injections for patients with chronic low-back pain. When compared with a sham surgical procedure, a number of trials have shown no speci ic effect associated with radiofrequency facet joint dener- vation for chronic low-back pain. 10 Jason W. Busse DC PhD, Y. Raja Rampersaud MD, Lawrence M. White MD, Thomas E. Feasby MD Assistant professor, Departments of Anesthesia and Clinical Epidemiology & Biostatistics (Busse), McMaster University, Hamilton, Ont.; Associate professor, Divisions of Orthopaedic and Neurosurgery (Rampersaud), University of Toronto, Toronto, Ont.; Professor, Department of Medical Imaging and Orthopedics (White), University of Toronto, Toronto, Ont.; Professor of neurology, Faculty of Medicine (Feasby), University of Calgary, Calgary, Alta. References 1. Kennedy SA, Baerlocher MO. New and experi- mental approaches to back pain. CMAJ 2014; Feb. 10 [Epub ahead of print]. 2. Itz CJ, Geurts JW, van Kleef M, et al. Clinical course of non-speciic low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain 2013;17:5-15. 3. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratiied primary care management for low back pain with current best practice (STarT Back): a ran- domized controlled trial. Lancet 2011;378:1560-71. 4. Chou R, Qaseem A, Owens DK, et al.; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154: 181-9. 5. Emery DJ, Shojania KG, Forster AJ, et al. Overuse of magnetic resonance imaging. JAMA Intern Med 2013;173:823-5. 6. Klazen CA, Lohle PN, de Vries J, et al. Vertebro- plasty versus conservative treatment in acute osteo- porotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet 2010;376: 1085-92. 7. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteo- porotic vertebral fractures. N Engl J Med 2009;361: 557-68. 8. Staal JB, Nelemans PJ, de Bie RA. Spinal injection therapy for low back pain. JAMA 2013;309:2439-40. 9. Lakemeier S, Lind M, Schultz W, et al. A compari- son of intraarticular lumbar facet joint steroid injec- tions and lumbar facet joint radiofrequency denerva- tion in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg 2013; 117: 228- 35. 10. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clini- cal practice guideline. Spine (Phila Pa 1976) 2009; 34: 1078-93. CMAJ 2014. DOI:10.1503/cmaj.114-0040 The authors respond We appreciate the dialogue initiated by Busse and colleagues 1 surrounding the very complex and controversial ield of low-back pain. The deinitions of pain resolution are critical. In the meta-analysis 2 referenced by Busse and colleagues 1 many of the included studies deine resolut ion of pain as the complete absence of pain. Other studies deine resolut ion of pain as a sig- niicant improvement that results in low levels of pain. 3,4 Chronic back pain is a serious concern and often does warrant long-term management strategies, as noted by Busse and colleagues. 1 Although back pain often resolves (improves signif- icantly) without treatment, it frequently persists with substantially lesser severity. In our article, 5 we refer only to anal- gesia, not to narcotics speci ically. Analgesia, which includes nonsteroidal anti-inlammatory drugs, COX-2 inhibitors and acetaminophen, is most certainly a well-accepted and valid means to control chronic low-back pain. Busse and colleagues 1 warn against the use of narcotics. In the appropriate clinical circumstances, nar- cotic use is indeed also indicated. 6 Implying otherwise would be a great disservice to the large number of patients with intractable pain. The American College of Radiology periodically releases appropriateness criteria for nearly every type of radiol- ogy exam, which describe the relevant indications for referral. These criteria include speciic indications that warrant lumbar magnetic resonance imaging (MRI), one of which is pain that lasts more than six weeks. As Busse and col- leagues 1 note, this speciic criterion is discordant with the American College of Physicians’ criteria for ordering lum- bar MRI. 7 Guidelines can be discordant with one another. We agree that lumbar MRIs are frequently ordered inappro- priately. Although inappropriate use of lumbar MRIs may not alter outcomes, MRI must be used for the appropriate indication of complicated back pain. We make no reference to the utiliza- tion of lumbar MRI to indiscriminately screen patients with low-back pain as