Five Back Pain Treatments to Avoid

Five Back Pain Treatments to Avoid

Five common tests and treatments for back pain may be unnecessary, ineffective or increase the risk of complications, according to new recommendations from the North American Spine Society (NASS), a group that represents more than 8,000 physicians who specialize in spinal care.

bigstock-Hand-holding-hip-with-visible--29205395“Because back pain is so prevalent and debilitating, desperate patients flock to their spine specialists’ offices armed with advice and anecdotes from well-meaning family, friends and online sources,” said F. Todd Wetzel, MD, a professor in the Department of Orthopedic Surgery and Sports Medicine at Temple University School of Medicine in Philadelphia.

“We hope this list of recommendations will help spine care providers and their patients cut through the noise and make informed care decisions together.”

The five things that doctors should not do in the absence of “red flags” that might indicate a more serious problem are:

  • Don’t recommend bed rest for more than 48 hours when treating patients with low back pain.
  • Don’t perform elective epidural spinal injections without imaging guidance.
  • Don’t use advanced imaging (such as an MRI) of the spine within the first six weeks in patients with non-specific acute back pain.
  • Don’t use bone morphogenetic protein (a compound that stimulates bone formation) for routine anterior cervical spine fusion surgery.
  • Don’t use electromyography (EMG) and nerve condition studies to determine the cause of axial lumbar, thoracic or cervical spine pain.

NASS says the effectiveness of the tests and treatments has never been proven or can lead to life threatening complications. Medical conditions that could justify having the treatments include a history of trauma, unintentional weight loss, immunosuppression, history of cancer, intravenous drug use, steroid use, or osteoporosis.

The list was created by a multidisciplinary task force appointed by NASS that studied scientific evidence, existing clinical practice guidelines, and expert opinion. The final list was approved by the NASS Board of Directors.

“The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what evidence-based care they need, and what we can do to reduce waste and overuse in our health care system,” said Richard Baron, MD, president and CEO of the ABIM Foundation.

Epidural steroid injections (ESI) have become one of the most common treatments for back pain, with nearly 9 million spinal injections in the U.S. in 2011. Studies have shown the procedure often gives only short term pain relief and has high failure rates for conditions such as sciatica.

Spinal shots given without imaging to help place the needle can puncture the spinal membrane and cause arachnoiditis, a chronic inflammation of the spine.

“Elective spinal injections, such as epidural steroid injections, should be performed under imaging guidance using fluoroscopy or CT (cat scan) with contrast enhancement to ensure correct placement of the needle and to maximize diagnostic accuracy and therapeutic efficacy. Failure to use appropriate imaging may result in inappropriate placement of the medication, thereby decreasing the efficacy of the procedure and increasing the need for additional care,” NASS states in its guidelines for the procedure.

But some who suffer from arachnoiditis say ESI’s aren’t worth the risk, even with imaging.

“The multitude of risks attributed to epidural steroid injections outweighs the transient benefits. Risks include arachnoiditis, meningitis, stroke, paralysis and death to name a few,” says Terri Anderson, who had over 20 spinal injections to treat a ruptured lumbar disc and now suffers from arachnoiditis.

“Fluoroscopy, while advocated as a safety measure, cannot prevent neurologic injury, nor guarantee that the injection will not inadvertently violate the dura and deposit the steroid in the intrathecal space or spinal cord and permanently damage delicate neural tissues.”

The NASS’s list of treatments and tests to avoid is part of Choosing Wisely, an initiative of the ABIM Foundation to encourage physicians to be better stewards of health care resources and to help their patients make better choices in their treatment.

Authored by: Pat Anson, Editor

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Kimberly Miller

I have suffered from FMS for several years. As a result of this disease and it’s manifestations, I take numerous medications. None of the typical fibromyalgia drugs have helped me. I have developed interstitial cystitis and restless legs syndrome, both considered comorbidities of fibromyalgia. I also suffer from idiopathic peripheral neuropathy.

I am in pain from these conditions daily. It has changed my life to the point where small things like taking a shower seem monumental in scope. I have no energy and the more I move, the worse feel. Doctors, hesitant to prescribe narcotics, are forever pushing these fibromyalgia drugs that do not work.

Please research this godawful scourge or a disease and find us something useful.

Thanks for reporting on this controversial and difficult topic, Pat. I’ve long struggled, as millions of other countrymen and women have, with the mad dog of pain and depression attendant to it. Your piece warns those of us desperate enough to seek epidural and other spinal injections for relief from the mad wolf of prowling pain to be extra careful with decisions we make and after making a decision to be careful enough to entertain some level of skepticism. It’s a bit like the matador entering the ring with certain knowledge that a misstep brings him/her a step closer to oblivion, and the trouble there is that oblivion in the face of the mad wolf seems, over time, to be an acceptable risk.

In my opinion, it the attendant risk should be carefully examined and discussed with a trusted other so as to be as clear as possible about a potentially life altering decision. Thanks for bringing this to our attention again.


I can’t put much credence in an article that lumps all low back pain together. There are too many variables. Doctors need to understand they don’t get a script to follow - they have to figure out what is wrong and treat accordingly - and for God’s sakes - listen to what your patient is telling you.

Gary Kersey

Low back pain is one of those problems that can have many, many causes. One must NOT keep thinking inside the box if they are going to solve their low back pain issue. I’ve treated back pain for OVER 30 years. I’ve seen many success stories…but…there is no simple formula for everyone. There are over a hundred causes for back pain. If one chooses to only consider one or two approaches to their own personal back issues, they are really narrowing the field. Usually, in most cases someone with low back pain will need to combine more than one approach in a synergistic fashion to solve the problem. Again, that “magic bullet/instant cure” sounds wonderful, but probably not practical.


I’ve been struggling with LBP in the L4/L5 level since 1998. Around 2002, it had finally become 24/7. Standing for too long feels like someone shoving spikes into my back. Yet, all tests show are just slightly arthritic and, bulging without impingement. I had so many epidurals, chodal (I can never remember the spelling on that one) shots and facet joint injections. Not a single one did any good. Most caused a flare to higher pain levels for 24 hours. The only thing that actually helped, was getting a radio frequency ablation. In 2010, I slipped a disc in that area. Bad enough to need surgery, as it was impinging a nerve this time. I still have problems in that area. Physical therapy is the only thing that has any affect on it. I have to do stretches every so often to help stretch out the muscles in my legs and back. I should be doing them daily but, that is a struggle for me.

I still have no idea why I get LBP. Even when I’ve completed my full physical therapy regiment, I still get the pain in my low back. Standing for too long still feels like someone shoving a spike in my back and moving it around.