Musculoskeletal lower back pain - Emerging treatments

Tanezumab

Tanezumab is a humanized monoclonal antibody that binds to nerve growth factor, which regulates the growth and function of sensory neurons. In randomized controlled trials, tanezumab significantly improved low back pain intensity, compared with placebo.[174][175] However, advisory committees of the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have rejected approval of tanezumab, concluding that its benefits in patients for whom use of nonsteroidal anti-inflammatory drugs or opioids is ineffective or inappropriate did not outweigh its risks. The tanezumab osteoarthritis clinical trial program has been discontinued.

High-level laser therapy

One systematic review reported that compared with control, high-level laser therapy reduced pain intensity and improved function for people with low back pain.[176]

Radiofrequency neurotomy (radiofrequency denervation)

There is a paucity of evidence for the use of radiofrequency neurotomy in people with nonspecific low back pain. The results of systematic reviews and meta-analyses including people with low back pain with an underlying causes are mixed, suggesting that radiofrequency is of no benefit or is more effective than placebo in patients with chronic low back pain.[177][178][179] A subsequent meta-analysis found that, in chronic low back pain arising from the facet joints, radiofrequency neurotomy significantly reduced pain over 12 months in patients who responded to a diagnostic nerve block (compared with sham procedures or epidural nerve blocks).[180] Overall quality of evidence was very low to moderate.[177][178][179] In patients with vertebrogenic low back pain there is moderate quality evidence that nerve radiofrequency ablation reduced pain and disability in most patients.[181]

Thermal annular procedures

Thermal annular procedures, such as percutaneous biacuplasty, use heat to ablate part of an intervertebral disk annulus. One systematic review found strong evidence that percutaneous biacuplasty effectively treats chronic, refractory discogenic back pain.[182] The procedure reduced pain at 6 months and 12 months compared with placebo or usual medical care.[182]

Injection therapy and dry needling

Injection therapy is controversial. An early Cochrane review found insufficient evidence to support the use of injection therapy in subacute and chronic lower back pain.[183] One meta-analysis found moderate evidence that dry needling of myofascial trigger points, particularly when administered in combination with other therapies, can alleviate pain intensity and functional disability in patients with low back pain.[184]

Peripheral nerve field stimulation

Peripheral nerve field stimulation involves implanting electrodes in the back, connected to a neurostimulator under the skin. It is intended to mask back pain by modulating transmission of pain signals to the brain. Data regarding efficacy (quality and quantity), safety, or follow-up are limited.[185] Evidence from systematic reviews and meta-analysis does not support the use of spinal cord stimulation for the management of low back pain outside of a clinical trial.[186] In the UK, stimulation of lumbar muscles for refractory nonspecific chronic low back pain should only be used with special arrangements for clinical governance, consent, and audit or research.[187]

Extracorporeal shockwave therapy (ESWT)

There is evidence to suggest that ESWT can improve lumbar function and reduce pain in people with low back pain, but may only be effective in the short term.[188][189][190]

Transcutaneous electrical nerve stimulation (TENS)

Evidence to support TENS as an adjunct for managing chronic back pain is lacking.[191]