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Three Part Question

[In patients with intractable low back pain] are [intraspinal or epidural opioids better than routine care or placebo] at [reducing pain and increasing global functioning]

Clinical Scenario

A 45 year old man is seen with a 4 year history of severe low back pain. He has undergone well conducted periods of rehabilitation under the care of chiropracters and physiotherapists with no success. Diagnostic imaging has revealed no isolated lesion as a cause of his back pain. He is depressed with his degree of disability and you are concerned for his mental and physical health. He was managing with NSAIDs, paracetamol and codeine but has recently had a severe GI bleed as a result of the NSAIDs and is very reluctant to take them again. You have read about long term epdural infusions of opitates and wonder if they might help your patient.

Search Strategy

Medline 1966-June 2005 OVID on ATHENS
[back pain.mp. or exp Back Pain/ or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.] and [exp Injections, Spinal/ or intrathecal.mp. or exp ANALGESIA, EPIDURAL/ or epidural.mp.] and [opiates.mp. or exp Narcotics/] limit to human, english, abstracts and therapy (sensitivity)

Search Outcome

Medline
40 citations of which none were comparator trials against placebo or routine care. A number of case reports and uncontrolled case series were identified, but these were considered to be of too biased to answer the three part question.

Comment(s)

For the patient with chronic back pain in whom normal treatments have failed it is difficult for the clinician to know where to go next. Many of these patients are referred to pain clinics for palliative procedures. In cancer patients the use of intraspinal infusions of opiaites is a well known technique so it perhaps unsurprising that their use has been advocated in severe chronic back pain. Although a number of uncontrolled case series were identified on the search the lack of a control group makes the interpretation of the results impossible. In addition many of the studies examine patients with back pain persisting after failed surgery, such patients represent a subgroup not relevant to this BET. Comment from current textbook authors on the subject suggests that evidence for the therapy is lacking.

Clinical Bottom Line

There is a lack of evidence for the management of chronic low back pain with intraspinal opioids.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.