ACUTE PHASE (first two weeks):
What is the evidence for MRI?
Richard Herzog et al. reported on consensus recommendations regarding MRI indications for low back pain. Because most patients with lumbar and radicular pain spontaneously improve, it is more appropriate to wait until symptoms have persisted for approximately 7 weeks without improvement despite proper care before performing MRI. For the present, the choice between CT and MRI for lumbar stenosis depends on issues such as costs reimbursements access to equipment skill of radiologist and patient safety.
What is the evidence for bed rest and physical therapy?
Antti Malmivaara and al. have shown in a controlled trial that among patients with acute low back pain, continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises.

M. Nordin, M. Campello, in a systematic review of the literature, did not find evidence of clinical benefit from active exercises in the acute phase of low back pain.
SUBACUTE PHASE (two weeks to three months):
Which treatment would offer the quickest return to recovery with fewest potential adverse effects?
A general overview of lumbar disc prolapse showed that the eventual outcome would be the same regardless of intervention. Although some treatments offered a better short-term prognosis in term of speed of recovery of speed, other factors such as costs and potential risks need to be taken into account.
We usually consider several further management options in treating acute radicular back pain: epidural corticosteroid injection, chemonucleolysis, and discectomy. The ultimate decision in this case would still require an individualized approach that is determining which option would be most suitable for this particular patient under these particular circumstance. Accordingly, the clinical question that we posed was which of these three treatments would offer the patient the quickest return to recovery with fewest potential adverse effects?
The evidence
Epidural corticosteroid injection:
Watts and Silagy, performed a meta-analysis of the efficacy of epidural injections, using 11 suitable good quality trials involving 907 patients. They reported a definite beneficial outcome (pain relief >75%) in the short term (<60 days) and long term (12 months) in comparison with placebo. The odds ratio for improvement in pain was 2.79 (95% confidence interval 1.92 to 4.06) in the short term and 1.87 (1.31 to 2.6S) in the long term. Adverse effects were few, (<2.5%) and transient (dural tap, headache, increased pain). Details of a reanalysis of this study are given on the BMJ website. Carette et al, in a randomized controlled trial involving 158 patients, also reported a short-term improvement on the leg pain and sensory deficits caused by a herniated lumbar disc, but this form of treatment did not reduce the need for surgery in the future. They reported very few adverse effects.
Chemonucleolysis:
Nordby, et al reviewed studies of chemonucleolysis with chymopapain. These included 135 000 patients studied between 1982 and 1991, and showed that long-term improvement in sciatic pain was maintained. Adverse effects of chemonucleolysis were infrequent (<0.1%) but may be more serious (that is, anaphylaxis, infections, bleeding problems, and neurological deficits than those associated with epidural injections.
Discectomy:
McCulloch reviewed studies of macrodiscectomv and microdiscectomy for lumbar disc prolapse. These showed high-success rates (80-96%) and indicated that short-term success was particularly good when clinical findings and radiological findings agreed. However, the long-term results were only slightly better than those achieved with conservativ non-surgical management. There was no important difference between macrodiscectomy and microdiscectomy disce and although adverse events were few, these were more serious than those seen with epidural injections.
Discussing the evidence with the patient
Choosing between epidural corticosteroid injection, chemonucleolysis, and discectomy: Applying the evidence
The evidence obtained was discussed with the patient. He had the choice between an epidural injection, which might produce only shirt term relief and not obviate the need for future intervention and a more interventional procedure with a higher success rate but a greater risk of adverse (albeit small). He opted for lumbar epidural injection that was performed. He noticed a considerable improvement within a week and was able to continue with his demanding work schedule.
What is the evidence for physical therapy and exercises?
The evidence
Exercise and physical therapy:
The task Force found no evidence that any exercise technique has therapeutic value in the treatment of acute cases of low back pain (duration less than 1 week). Most studies conclude that physical activity is a valuable therapeutic approach to chronic LBP (pain lasting more than 12 weeks) even there is no consensus on the specific technique intensity or active intervention. No specific active technique or method is superior to another.
  • Discussing the evidence with the patient
  • Applying the evidence
Therefore, the clinical question that we posed was which of available interventions would prevent the patient from developing recurrent or turning into chronic LBP?

Applying the evidence
A program of spinal exercises was discussed with the patient looking at physical rehabilitation modalities and results to be achieved. The patient was followed up intermittently and was given advice and care for his lumbar spine
What are the risk factors for developing chronic LBP?
CHRONIC PHASE (more than three months)

Because of the patient's concerns about pain and quality of life, it was decided to reassess the usual approach and evaluate evidence for choosing between treatment options.
  • What medical treatments can we still offer?
  • What is the evidence for physical rehabilitation?
  • What is the evidence for spine fusion?
J. Turner et al reported thefollowing through meta-analysis: Indications for lumbar spine fusion for the disorders reviewed are not scientifically established. There is a wide range of satisfactory outcomes, in part depending on the study design. The average 68% success may overestimate the actual clinical results due to study design flaws and the possibility of publication bias. There is little support for one fusion technique over the others and randomized controlled trials are necessary to compare fusion with other surgical and non-surgical approaches.
R. Deyo also reported that data fail to support the hypothesis that lumbar spine fusion reduces the rate for future back surgery. There are likely to be clinical subsets of patients namely spondylolisthesis and spinal stenosis who may benefit from fusion.

PERTINENT INFORMATION
Pertinent features of the acute and subacute phase
  • Fit, young patient
  • Lumbar disc prolapse L5-SI
  • Minimal neurological signs
  • Non-progressive condition
  • Main symptom of pain
  • No response to conservative management
  • Absence from work could have serious consequences
Pertinent features of the chronic phase
  • Recurrent episodes of low back pain with occasional radiating pain.
  • Low back pain persisted despite three epidural injections and lumbar brace.
  • Activities of daily living have been quite limited over the past month.
  • There was no motor or sensory loss with minimal neurological signs.
  • Plain X-rays of the lumbar spine revealed stage II degenerative L5-S1 inter-vertebral disc and stage I degenerative L4-L5 inter-vertebral disc.
  • MRI of the lumbar spine revealed L5-S1 right hand side posterior-lateral extruded disc in contact with S1nerve root and rupture of the inter-vertebral ligament.
Pertinent features regarding management
  • Conservative management of sciatica may fail to bring relief, and a more invasive treatment is required
  • Evidence shows that an epidural injection of corticosteroids produces short-term relief; adverse effects are few and not usually serious
  • Chemonucleolysis or discectomy have higher success rates but a greater risk of more serious adverse events
  • Long term results after surgery are only slightly better than non-surgical intervention
  • Patients require an individualized approach using best evidence and the application of clinical art and expertise
  • Indications for lumbar spine fusion for the disorders reviewed are not scientifically established. There is a wide range of satisfactory outcomes, in part depending on the study design. Data fail to support the hypothesis that lumbar spine fusion reduces the rate for future back surgery.
REFERENCES
  1. Saal JA. Natural history and non operative treatment of lumbar disc herniation. Spine 1996; 21 (suppl 42): 2-9S.
  2. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine, how to practice and teach EBM. London Churcllill Livingstone, 1997.
  3. Richard J. Herzog. Concepts in Spine Care. MRI use in patients with Low Back Pain or radicular pain. 1995 Spine Vol20, N16:1834-8
  4. Antti Malmivaara et al. The treatment of acute low back pain - bed rest, exercises or ordinary activity? N. Engl. J. Med. 1995;332:351-5
  5. Watts RW, Silagy CA. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth. Intens. Care 1995; 23:564-9.
  6. Carette S. Le Claire R, Marcoux S , Morin F. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N. Engl. J. Med. 1997; 336: 1634-40.
  7. JP Valat et al Indice prédictif de l'évolution chronique des lombalgies aiguës. Elaboration par l'étude d'une cohorte de 2487 patients. Rev Rhum. 2000;67(7):528-535
  8. Nordby EJ, Fraser RD, Javid MJ. Chemonucleolysis. Spine 1996; 21: 1102-5.
  9. McCulloch JA. Focus issue on lumbar disc herniation: macro and micro discectomy. Spine 1996; 21 (suppl 42): 45-56S.
  10. M. Nordin, M; Campello. Physical therapy exercises and the modalities