Book Review

The Nonsurgical Management of Acute Low Back Pain: Cutting through the AHCPR guidelines

N Engl J Med 1998; 339:484August 13, 1998

Article

The Nonsurgical Management of Acute Low Back Pain: Cutting through the AHCPR guidelines
Edited by Erwin G. Gonzalez, with Richard S. Materson. 271 pp., illustrated. New York, Demos, 1997. $99.95. ISBN: 1-888799-13-7

The clinical-practice guidelines for the management of acute low back pain that were published in 1994 by the Agency for Health Care Policy and Research (AHCPR) are widely recognized to have been a watershed. On the one hand, they marked an important scientific accomplishment in that a rigorous evaluation of more than 10,000 published studies on the management of this ubiquitous condition was completed. On the other hand, the reaction from some quarters to the recommendations of the agency's expert multidisciplinary panel was so negative and, indeed, at times vitriolic, that the agency — and the guidelines-generating business — have not been the same since. After a coordinated attack on the agency by those who disagreed with its findings on low back pain, many of whom had vested interests in procedures found by the panel to have no evidentiary basis, the AHCPR got out of the guidelines-producing business in 1996.

This book is a critique and rebuttal of the AHCPR guidelines on low back pain, section by section, written by members and affiliates of the Association of Academic Physiatrists and based on a course offered by that organization in 1996. In introducing the book as a deliberately alternative monograph, the editors perhaps promise more than is delivered. To be sure, some of the chapters present a thoughtful challenge to the AHCPR recommendations, based largely on the authors' genuine mastery of the relevant basic biologic sciences. This expertise is helpful when, as was the case for the majority of the original guidelines, there is less than adequate evidence available on the accuracy or efficacy of a given test or treatment in terms of studies that meet the usual clinical epidemiologic standards.

There is, for example, a thorough chapter on modern imaging techniques applied to the spine and an intriguing chapter on the promise of somatosensory evoked potentials for future diagnostic use. There are also exhaustive chapters summarizing — though not necessarily critically appraising — virtually everything ever written on epidural steroid injections, diskography, diagnostic nerve-root blocks, lumbar facet-joint injections, sacroiliac-joint therapies, and trigger-point management, all by obvious proponents of these techniques. Unfortunately, the evaluation of the literature is uneven, with only a few chapters demonstrating an informed sense of the standard criteria for assessing study design and analysis. There is also a distressing lack of awareness of tertiary care referral bias, since much space is devoted to conditions that are rare in primary care. When it comes down to whether these advocates can cite any more high-quality evidence of efficacy for the treatments reviewed than the AHCPR panel could find, the answer is pretty much a resounding no. Instead, the reader is merely provided with interesting case material and many basic biologic rationales. In fact, when the AHCPR recommendations are directly commented on, there is generally more agreement than disagreement with the guidelines in terms of what is known about managing acute low back pain.

More fundamentally, however, the state of the evidence is not the key issue for the practicing experts in spinal medicine who wrote this book. The issue for them is rather what the appropriate conclusion should be when, as so often was the case for the literature the AHCPR panel reviewed, there is simply no good evidence one way or the other. The essential difference in perspective between the agency's panel and these would-be critics is laid out well in the introductory chapter by the editors and again in helpful chapters on the use of medications, physical treatments, manipulation, bed rest and exercise, and patient education. In the absence of sound scientific evidence, the authors collectively believe that clinical experience and a basic-science rationale for a test or treatment constitute an abundantly adequate basis to justify its use. This epistemological position is, they argue, in contrast to the implicit view of the AHCPR panel that “no evidence” is reason not to use tests and treatments unless they are virtually risk- and cost-free.

Surely the pragmatic position that most physicians subscribe to is that there are many occasions in clinical practice when high-quality evidence just isn't in yet, and may never be, and we are thus forced to use tests and treatments for which we have only a “promising” biologic rationale and an expert opinion based on experience — and for which we must therefore very carefully weigh the benefits, risks, and costs. To this end, most of us in primary care are grateful to the AHCPR panel for expertly summarizing a huge body of evidence on low back pain. Reassuringly, in the case of the arguments advanced in this book, there seems to be more rhetoric than reality in the authors' claims of disagreement with the specifics of the AHCPR guidelines. The contributors do present, however, a provocative exposition of their opposition to the agency's philosophy of decision making in the absence of good science — and for that they deserve recognition.

John Frank, M.D.
University of Toronto, Toronto, ON M5S 1A8, Canada