Acoem practice Guidelines Plus Low Back Guidelines Frequently Requested Services

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ACOEM Practice Guidelines Plus

Low Back Guidelines

Frequently Requested Services

  1. Artificial disc replacement

  2. Core stabilization

  3. Discogram

  4. Electromyograph with nerve conduction studies (EMG/NCS)

  5. Epidural steroid injection

  6. Facet joint injections (diagnostic and therapeutic)

  7. Fusion

  8. High voltage galvanic stimulation

  9. H-Wave stimulation

  10. Interferential electrical stimulation

  11. Magnetic Resonance Imaging (MRI)

  12. Pain Management

  13. Pain pump

  14. Rhizotomy (Radio frequency lesioning, radio frequency neurotomy,

radio frequency thermocoagulation, radio frequency ablation)

  1. SI joint injections

  2. Tender and Trigger point injections


Disc Replacement - Recommendations
Not Recommended for Chronic Low Back Pain (Insufficient Evidence (I))

Artificial disc replacement is not recommended as a treatment for chronic non-specific LBP or any other spinal pain syndrome.

Additional research including demonstrated long-term safety and efficacy would be needed prior to a recommendation in support.

Artificial disc replacement was devised as an alternative to fusion for the patient with chronic non-specific LBP. Its theoretical advantage is that it preserves motion in the involved vertebral segment thus decreasing the chances of degenerative changes developing at the adjacent motion segments. The term “adjacent segment disease” is used to describe patients with degenerative changes (that are presumed to be painful) at the spinal level above or below a spinal motion segment that has been treated, for example by spinal fusion. Currently, two manufacturers have FDA approval to sell disc replacement prostheses, CHARITÉ® and ProDisc (US FDA).
There is no direct evidence that disc replacement is superior to non-surgical approaches. Results from these trials are not generalizable to those with multi-level degenerative disc disease. This treatment should still be considered experimental, as it is not known whether the encouraging results in Zigler’s RCT (Zigler 03) can be reproduced in other centers. The follow-up in the published RCTs is too short to consider this standard treatment, and disc replacement must still be considered as an experimental treatment.

Strength of Evidence
There are two moderate-quality RCTs incorporated in this analysis.

Core Strengthening – Core Stabilization Exercise – Recommendations
Strengthening and Stabilization Exercises is Recommended for Acute, Sub-Acute and Chronic Low Back Pain (Limited Evidence (C))

For acute, subacute, chronic, or post-operative LBP patients, strengthening exercises are recommended. Specific strengthening exercises, such as stabilization exercises, are helpful for the prevention and treatment (including post-operative treatment) of LBP (Hides 01, Filiz 05, Soukup 99, 01).


As evidence of efficacy of aerobic exercises appears greater (see above), these exercises should be added after aerobic exercises have already been instituted and additional treatment is needed or in situations where both are felt to be required. Exercises should be taught and then performed by the patient in a home exercise program. For those patients who do not improve, follow-up appointments to verify technique and compliance (by exercise log books) are recommended. Some patients, particularly those lacking motivation to be in a home exercise program or those with fear avoidant behaviors may benefit from a supervised exercise program, although strong questions about long-term compliance are apparent among such patients particularly with chronic LBP. More intensive programs with more intensive exercises and direct supervision with active coaching appear warranted for chronic LBP.


Home program frequency is 1 to 2 times a day for acute LBP, and 2 to 3 times a day for subacute or chronic LBP. Supervised treatment frequency and duration is dependent of symptom severity and acuity and the presence of comorbid conditions and yellow flags.

Indications for Discontinuation

Indications to discontinue strengthening exercises include development of a strain in the course of treatment or failure to improve.

  1. DISCOGRAPHY (Lumbar)

Discography - Recommendations
Not Recommended for Acute, Sub-Acute and Chronic Low Back Pain (Moderate Evidence (B))

Discography, whether performed as a solitary test or when paired with imaging (e.g., MRI), is not recommended for acute, subacute, chronic LBP.

Not Recommended for Acute, Sub-Acute and Chronic Radicular Pain Syndromes (including Sciatica) (Moderate Evidence (B))

Discography, whether performed as a solitary test or when paired with imaging (e.g., MRI), is not recommended for acute, subacute, chronic radicular pain syndromes.


Discography is a diagnostic test that attempts to determine if chronic spinal pain is coming from (caused by) disc pathology. In this test, a needle is inserted into the middle (nucleus) of a disc and x-ray dye is injected. Images are then made, usual both by plain x-ray and by computed tomography (CT). Images are able to classify a disc as normal or as having varying degrees of degeneration (Adams 86). Discography is usually used in patients with chronic spinal pain without significant leg pain, as MRI and/or CT xylography provide adequate anatomic information for surgical decisions on decompress surgery in patients with significant radiculopathy. This procedure is fairly painful and sedation is required.

Discography proponents believe that discs with more severe degrees of degeneration are more likely to be painful. Proponents analyze and place more importance on the pain response of the sedated patient. If a patient does not experience pain on injection, that disc is considered as unlikely to be the source of chronic spinal pain. If a patient experiences pain that is mild or that is clearly different in location or character to his or her chronic pain, that disc is considered as unlikely to be the source of chronic spinal pain. However, if the patient experiences significant pain that is identical in location and character to the patient’s chronic pain (“concordant pain”), proponents believe that

discography has identified the pain-generating structure responsible for chronic spinal pain. It also follows that changes on MRI (e.g., Modic changes) should be more severe in those with positive discography; however, that has not been shown (Sandhu 00).

More recent studies have added measurement of the injection pressure (pressure in the disc at the time of pain production) as a test criterion. Those discs with pain provoked at less than 15 psi are categorized as chemically sensitive, 15 to 50 psi are mechanically sensitive, and those over 50 psi are classified as not clinically significant (Cohen 05). Chemical sensitivity supposedly suggests the disc is degenerate, but not necessarily the pain-generating structure. High injection pressures may produce pain even in radiographically normal discs. Thus, discography proponents seek concordant pain response at injection pressures of 15 to 25 psi as a criterion for declaring the disc to be the pain-generating structure.

The technique of discography is not standardized. There is no universally accepted definition of what constitutes a concordant painful response. There are no published intra-rater or inter-rater reliability studies on discography. The discussion of discography is crucial to the subsequent discussion of IDET, spinal fusion for “degenerative disc disease,” and artificial disc replacement, as many North American surgeons (but not European surgeons) use discography results in surgical planning. If discography can accurately identify a disc as the pain-generating structure, then surgical procedures on that disc make sense and should lead to patient improvement. If discography can produce pain, but cannot accurately identify that disc as the pain generating structure, then surgery on that disc is presumably unlikely to be helpful.


Discography has been evaluated in quality studies. Currently, the estimated positive predictive value appears to be at or below 50%, which means the test is not helpful (Carraggee 06). These studies have failed to find that it reliably indicates what particular disc is the source of the patient’s pain. Validity of those findings through improved operative successes is not present (Juratli 06). There are a number of studies comparing lumbar discography to other imaging studies such as MRI and CT

myelography. These studies can describe how likely a given finding on imaging is to be associated with pain on injection, but can not determine whether the pain response is a

true-positive or a false-positive response. Thus, these studies are not capable of guiding surgical therapy. Studies on imaging have shown that most imaging findings do not correlate with an individual’s pain status (Carragee 06). There are a number of studies that have looked at the rate of positive or painful responses in individuals without back pain. If the asymptomatic population has a high rate of painful responses to disc injection, a similar pain response, and the inevitable age-related degeneration on imaging studies can easily be interpreted as a positive discogram (false-positive) in patients being evaluated for significant back pain. Since these are experimental subjects who do not have back pain, the pain cannot be concordant with pain they do not have; however, the intensity of the pain response is such that it could easily be misinterpreted as a painful response (false-positive).

Discography, like all invasive procedures, has complications. The 0.1 to 0.2% rate of discitis (disc space infection) is low. Temporary complications include headache, nausea, and worsened back pain. Uncommon, but serious reported complications include meningitis, epidural abscess, arachnoiditis, intrathecal hematoma, intradural injection of contrast, retroperitoneal hematoma, cauda equina syndrome, and acute disc herniation (Pneumaticos 06). Discography results in a patient exposure to radiation of 1.5 to 4.0 rads (AHCPRPracG). Discography is also expensive.


Electromyography – Recommendations
Recommended for Sub-Acute and Chronic Radicular Pain Syndromes (including Sciatica) (Limited Evidence (C))

Electrodiagnostic studies which must include needle EMG is recommended where a CT or MRI is equivocal and there are ongoing pain complaints that raise questions about whether there may be a neurological compromise that may be identifiable (i.e., leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, etc.).


Failure to resolve or plateau of suspected radicular pain without resolution after waiting 4 to 6 weeks (to provide for sufficient time to develop EMG abnormalities as well as time for conservative treatment to resolve the problems), equivocal imaging findings such as CT or MRI, and suspicion by history and physical examination that a neurologic condition other than radiculopathy may be present instead of or in addition to radiculopathy.

Not Recommended for Acute, Sub-Acute and Chronic Low Back Pain (Limited Evidence (C))

Electrodiagnostic studies are not recommended for patients with acute, subacute, or chronic back pain who do not have significant leg pain or numbness.


Electromyography (EMG) is a physiological test that involves an assessment of the function of the motor unit, including the anterior horn cell, its axon, and the neuromuscular junctions and muscle fibers it supplies. (It is to be differentiated from surface EMG which is discussed later). EMG technically refers to the needle electromyogram and the term “EMG” is usually misused as a euphemism for an electrodiagnostic exam that includes both needle EMG and peripheral nerve conduction testing. Needle EMG and not nerve conduction testing is what usually makes the

diagnosis of radiculopathy or spinal stenosis in patients with back pain and/or radiculopathy problems. Needle EMG can help determine if radiculopathy is acute or chronic (Preston 05). Nerve conduction studies are usually normal in radiculopathy (except for motor nerve amplitude loss in muscles innervated by the involved nerve root in more severe radiculopathy and H-wave studies for unilateral S1 radiculopathy). Nerve conduction studies rule out other causes for lower limb symptoms (generalized peripheral neuropathy, peroneal compression neuropathy at the proximal fibular, etc.) that can mimic sciatica. EMG requires full knowledge of the anatomy and precise innervation of each muscle to properly perform and interpret the test results. Needle EMG also requires the skills of an experienced physician who can reliably spot abnormal motor potentials and recruitment patterns.

Most lumbar disc herniations resolve over time and do not require surgery. MRI studies have documented that many disc herniations present in the first few days of sciatica get smaller or even disappear completely with time, explaining why most patients recover from sciatica. Some patients have persisting neurologic deficit despite the fact that the original disc herniation resorbed and there is no longer ongoing nerve root compression on imaging studies. An abnormal EMG that persists after anatomic resorption of the herniation and that correlates with the patient’s symptoms is proof the symptoms are due to radiculopathy. Thus, the EMG study proves that management for chronic neuropathic pain is appropriate, and the abnormal EMG permits an AMA Guides to the Evaluation of Permanent Impairment rating for radiculopathy despite the normal imaging study.


As imaging studies (especially CT and MRI) have progressed, the need for EMG has declined. However, EMG remains helpful in certain situations. These include ongoing pain complaints suspected to be of neurological origin, but without clear neurological compromise on imaging study. EMG can then be used to attempt to rule in/out a physiologically important neurological compromise. An abnormal study confirming radiculopathy permits a diagnosis of neuropathic pain (helping with pain management decisions), and may change an AMA Guides impairment rating. It is worth noting that this test should not be performed in the first month unless there is a desire to document prior (pre-existing) neurological compromise, as it requires time (generally 3 weeks) to

develop the needle EMG abnormalities. EMG is minimally invasive, and has no long-term adverse effects (although it is somewhat painful), and it is costly. To result in reliable measures, it must be performed by a practitioner well skilled in the appropriate anatomy and testing procedures.
Strength of Evidence

There are no RCTs regarding the use of electromyography. (There is one guideline and eight other studies in this summary)

Epidural Steroid Injections (Lumbar) - Recommendations
Recommended for Acute and Sub-Acute Radicular Pain Syndromes (including Sciatica) (Insufficient Evidence (I))

An epidural glucocorticosteroid injection is an option for acute or subacute radicular pain syndromes. Its purpose is to provide a few weeks of partial pain relief while awaiting spontaneous improvement.


An epidural steroid injection may cause short-term improvement which may assist in successfully accruing sufficient time to ascertain if conservative care will succeed. An “option” means there should be no requirement that a patient receive and fail treatment with epidural glucocorticosteroids, especially repeated injections, prior to discectomy.


Each injection should be scheduled separately and the effects of each evaluated before scheduling a series of 3 injections. Medications most often used in the RCTs were triamcinolone and methylprednisolone combined with an anesthetic (most often bupivacaine). There are no head-to-head comparisons of different medications to ascertain the optimum medication(s) and/or dose(s).

Indications for Discontinuation

A second epidural steroid injection is not recommended if following the first injection there has been resolution of the symptoms of the acute radicular pain syndrome, particularly resolution of leg symptoms, or a decrease in symptoms to a tolerable level. If there has been no response to a first epidural injection, there would be no recommendation for a second injection. In patients who respond with a pharmacologically appropriate 3 to 6 weeks of temporary, partial relief of leg pain, but who then have a worsening of leg pain and function, and who are not (yet) interested in surgical discectomy, a repeat epidural steroid injection is an option. Generally, there are not benefits beyond 3 injections for a given episode of radicular pain. Patients

requesting a fourth injection should be counseled for discectomy or considered to have chronic radicular symptoms for which epidural steroids are not recommended.


Recommended for Acute Spinal Stenosis (Insufficient Evidence (I))

Epidural glucocorticosteroid injections are an option as a second-line treatment for acute flare-ups of spinal stenosis, although the evidence is less robust than it is for herniated discs.


Symptoms of spinal stenosis of at least 1 to 2 months duration with prior treatment that has included NSAIDs and progressive exercise.


Each injection should be scheduled separately and the effects of each evaluated before additional injections are scheduled, rather than scheduling a series of 3 injections.

Indications for Discontinuation

Resolution of the symptoms of spinal stenosis or decrease in symptoms to a tolerable level.

Not Recommended for Acute, Sub-Acute and Chronic Low Back Pain (Limited Evidence (C))

Epidural glucocorticosteroid injections are not recommended for acute, subacute, or chronic LBP in the absence of significant radicular symptoms.

Epidural glucocorticosteroid injections are not recommended for acute, subacute, or chronic LBP in the absence of significant radicular symptoms.
They are also not recommended as first- or second-line treatment in individuals with LBP symptoms that predominate over leg pain. They are not recommended as treatment for any chronic problem.

Epidural glucocorticosteroid injections are performed in an attempt to deliver the active medication as close to the target tissue as possible, whether most commonly a herniated disc or spinal stenosis. (Abdi 2007; Cannon 2000; Delport 04) The three approaches most commonly used are caudal, interlaminar, and transforaminal. (Abdi 07; Manchikanti 03; Boswell 07; Gordon 80) This is performed as an interlaminar epidural injection in which the injection is placed immediately adjacent to the dural sac in the posterior spinal column with subsequent diffusion to the herniated disc or other offending structure. Fluoroscopic guidance has been shown to improve the accuracy of injection placement, as blind targeting has been shown to be 77% accurate. (Manchikanti 04) It is the least technical of these procedures. Complications occur, are rare, but in rare cases may be serious. These include infection (meningitis, epidural abscess, etc.) and hemorrhage related to penetration of an anatomical variant artery. A resulting epidural hematoma may compress the nerve or spinal cord (Abdi 07) and generally requires emergency surgery. Suppression of the pituitary-adrenal axis does occur. (Kay 94) Transforaminal injections most closely target the usual sites of pathology and inflammation and use the least volume of agent.

Transforaminal epidural injections (aka selective nerve root injections) accomplish the same task, except the needle is placed along the nerve root in closer proximity to the herniated disc or impinged neurologic structure. (Abdi 07; Botwin 02) These are technically more difficult. Transforaminal injections are generally performed under fluoroscopic or CT guidance. (Lutze 97) Transforaminal injections also necessitate better diagnostic precision to ensure the closest proximity to the affected level via the injection. (Manchikanti 03) A technique has been described using electrical stimulation to assist with nerve root identification. (Haynsworth 03) As these injections are most frequently performed as a combination of a glucocorticoid with an anesthetic, they are considered to be both diagnostic and therapeutic. (Samanta 04) The technical performance of these injections, including the precision of placement of medication using fluoroscopic guidance, is reportedly a significant aspect related to the efficacy of these injections. (Cannon 00) Uncontrolled data suggest psychological factors may be associated with treatment failure, (Hopwood 93) but that is not a universal finding. There are radiation exposure concerns for fluoroscope operators and patients that should be addressed. (Botwin Arch PMR 02) Serious complications are rare in the RCTs

reviewed, but have occurred and include intraspinal abscesses and meningitis. (Butler 05; Gaul 05)


Systematic reviews have arrived at contradictory conclusions. Those with the highest standards for evidence have generally not found glucocorticosteroid injections to be a cost effective treatment. Most of the RCTs have studied blind interlaminar epidural injection. Fluoroscopic guidance may improve results; however, that theory has not been directly tested.

Glucocorticosteroid injections have been evaluated in moderate to high-quality studies. All four high-quality studies that evaluated patients in the 4 to 6 week timeframe demonstrated that these injections are helpful to reduce short-term leg and back pain ratings for those with herniated intervertebral discs. (Arden 05; Karppinen 01; Price 05; Carette 97) Data also appear to mostly show that benefits of a single injection disappear by approximately 6 weeks. There is poor evidence for long-term benefits. The evidence does not suggest that these injections change function or the need for surgery. Importantly, there is good evidence that it is the natural history of symptoms from a herniated disc to trend towards resolution over time. (Price 05; Gibson 07) Thus, it should be recognized that the purpose of these injections for acute radicular pain syndromes is perhaps best stated as “buying time” through a period of natural recovery that decreases the patient’s pain while shrinkage or resorption of the herniated disc occurs.

Since the relief from epidural steroid injections is brief, and since by definition chronic non-specific back pain and chronic radicular pain with or without prior back surgery are chronic problems, epidural steroid injections are not recommended as a transient treatment for these long-term problems. There also is no quality evidence that accomplishing these injections earlier in the course of the syndrome results in any improvement in the condition. On the contrary, there is some evidence inferred from the published studies suggesting it may make no difference. (Price 05) There is also limited evidence in two moderate-quality RCTs that these injections help symptoms of spinal

stenosis, (Wilson-MacDonald; Fukusaki 98) though again on a short-term basis.

Technique may be important as well as the anatomical approach chosen. (Cannon 00)

However, there is insufficient evidence presently to recommend one technique over the other for an initial approach (caudal vs. interlaminar vs. transforaminal), other than to note that there is evidence that endoscopy for steroid injection has not been shown to be beneficial. (Dashfield 05) Although it is suspected that fluoroscopic or CT guidance for these injections is helpful, there is not sufficient evidence for guidance on that topic.

Although three studies used a series of up to 3 injections over 6 weeks, (Arden 05; Price 05; Carette 97) there is no quality study that performed 3 injections without an assessment after each injection to determine whether an additional injection was appropriate and recommended. Most studies utilized one injection. Thus, there is no quality evidence to support or require a series of 3 injections. There is no evidence that there is a limit of 3 in a year or lifetime, although if there is no clear benefit, then repeated injections are not recommended.

Current practice in the U.S. is generally to obtain an MRI or CT prior to an epidural injection. However, there is evidence that this is not necessary, and at least three of the trials appeared to solely rely on the clinical examination to address the level targeted with subsequent epidural glucocorticosteroid injection. (Arden 05; Price 05; Butterman 02) Additional studies may be needed to determine whether imaging is required or not, as if it is not necessary, it can be eliminated and markedly reduce the cost of this intervention.

Epidural glucocorticoid injections are invasive, have a low risk of adverse effects, (Price 05) and are costly. The number needed to achieve partial pain relief at 3 weeks was 11.4, but there was no benefit from Weeks 6 to 52. (Price 05) They are an option in acute radiculopathy, but as a second-line treatment after prior treatment with NSAIDs, possibly a short course of an oral corticosteroid and a suggested waiting period of at least 3 weeks.

Strength of Evidence

There are 12 high- and moderate-quality RCTs incorporated in this analysis. (There are 12 systematic reviews, three guidelines, seven low-quality RCTs, and two other studies in the Appendix.)


Diagnostic Facet Joint Injections - Recommendations
No Recommendation for Chronic Low Back Pain (Insufficient Evidence (I))

One diagnostic facet joint injection may be recommended for patients with chronic LBP that is significantly exacerbated by extension and rotation or associated with lumbar rigidity and not alleviated with other conservative treatments (e.g., NSAIDs, aerobic exercise, other exercise, manipulation) in order to determine whether specific interventions targeting the facet joint are recommended. Repeated diagnostic injections in the same location(s) are not recommended.

No Recommendation for using Diagnostic Facet Joint Injections (Intraarticular and Nerve Blocks) for Chronic Low Back Pain (Insufficient Evidence (I))

One diagnostic facet joint injection may be recommended for patients with chronic LBP that is significantly exacerbated by extension and rotation or associated with lumbar rigidity and not alleviated with other conservative treatments (e.g., NSAIDs, aerobic exercise, other exercise, manipulation) in order to determine whether specific interventions targeting the facet joint are recommended. Repeated diagnostic injections in the same location(s) are not recommended.

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