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 treatment. A recent systematic review2 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 management strategies. The authors1 recommend that most patients with acute low-back pain can be managed with analgesia and physiotherapy; however, recent evidence shows that stratified care is superior to a general approach.3
The authors1 state that magnetic resonance 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 Physicians.4 Kennedy and Baerlocher1 tout the potential benefits 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 authors1 promote vertebroplasty as an effective treatment for painful, acute vertebral compression fractures, and cite an open-label trial.6 When vertebroplasty has been evaluated in randomized trials with a sham surgery control group, resulting in blinding of patients, no specific effect for vertebroplasty has been shown.7
The literature does not support the use of selective root block for low-back pain.8 The authors1 advocate the use of radiofrequency denervation or ablation for low-back pain with nerve-root involvement, and cite a trial9 that showed no difference between radiofrequency 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 specific effect associated with radiofrequency facet joint denervation for chronic low-back pain.10