The World Federation of Neurosurgical Societies (WFNS) Spine Committee is developing a pioneering hub of information in spinal health, guiding both patients and medical professionals. Its guidelines and recommendations have allowed for crucial steps in enhancing knowledge and improving the diagnosis and treatment of common but frequently debilitating spinal conditions.
Millions of people worldwide suffer from lower back pain, a condition that has long been the focus of medicine. A study from the WFNS Spine Committee explores the complexities of acute low back pain and lumbar disc herniation, providing insight into the underlying causes, risk factors, and range of clinical manifestations. The guidelines provide a timely and essential resource for healthcare providers in a world where sedentary lifestyles have led to increasing cases of lower back pain.
One of the hallmarks of the WFNS Spine Committee's guidelines is its emphasis on precise and efficient diagnoses. By synthesizing the latest research and clinical evidence, the guidelines provide a roadmap for healthcare practitioners to navigate the complexities of identifying low back pain. From detailed clinical assessments to advanced imaging techniques, the recommendations equip clinicians with the tools to unravel the mystery of lower back pain and initiate targeted interventions. These WFNS recommendations differ from previous efforts in that they are made not only for countries in the West but for the whole world.
After developing and publishing guidelines about cervical trauma, spinal cord injury, lumbar spinal stenosis, osteoporotic spine fractures, thoracolumbar spine Trauma, and cervical spondylotic myelopathy, the WFNS Spine Committee has now developed recommendations regarding Lower back pain and Lumbar disc herniation. This was achieved after a gross literature search between 2012 and 2022, and a consensus meeting. We reviewed up-to-date information to reach an agreement during two consensus meetings. The first meeting was conducted live in Karachi in May 2022, and the second in Istanbul in September 2022.
Both meetings aimed to analyze a preformulated questionnaire through preliminary literature review statements. This analysis was based on the current evidence base to generate recommendations through a comprehensive voting session. The Delphi method was utilized to administer the questionnaire to preserve a high validity. Consensus was achieved when the sum for disagreement or agreement was ≥66 %. Each consensus point was clearly defined, with evidence strength, recommendation grade, and consensus level provided.
The ten papers in the following pages are guidelines for almost all aspects of “Lower Back Pain” and “Lumbar Disc Herniation”. The WFNS Spine Committee was able to formulate several key recommendations to guide clinical practice.
The incidence and prevalence of acute LBP are high, particularly in high-income countries. This is felt to be at least partially due to demographic shifts with an aging population and lifestyle changes, higher rates of obesity and physical inactivity. Acute LBP significantly impacts on quality of life and ability to work, resulting in increased direct and indirect costs worldwide. Early diagnosis and appropriate management of acute LBP are recommended to prevent the pain from becoming chronic.
Ten final consensus statements address the clinical and radiological diagnosis of acute LBP, including which clinical conditions cause acute LBP and how we can distinguish between the different causes of LBP (including discogenic, facet joint, sacroiliac joint, and myofascial pain). The most important step within this diagnosis is evaluating the necessity of radiologic investigation, as well as its timing and the appropriate type of imaging modality.
Imaging should only be a routine diagnostic tool if red flags are present. In fact, routine imaging for acute LBP can have a negative effect as it may reveal incidental radiographic findings that exacerbate the patient's anxiety. Once indicated, magnetic resonance imaging (MRI) is considered to be the gold standard technique for confirming a suspected LDH or other disorders.
The role of medication, physical medicine, and rehabilitation in the management of acute LBP is the subject of our following paper. We advocate for a uniform approach to treating these patients, including proper patient education and the use of medicines with proven efficacy and minimal side effects. First-line pharmacologic agents are acetaminophen and NSAIDs; Cox 2 inhibitors are preferred due to fewer side effects. Muscle relaxants may be used for spasms. Opioid use should be minimized due to side effects and dependence. Continued activity, rather than bed rest, is recommended, and lumbar spine orthotics may be used to reduce pain and augment functional status. Thermotherapy, cryotherapy, TENs, and acupuncture may all be adjuncts to improve acute LBP.
Up-to-date evidence regarding the role of injections and surgical management for acute low back pain highlights significant heterogeneity. Despite the dearth of evidence on the topic, epidural injections are considered efficacious for providing short-term and intermediate pain relief, and surgical interventions are reserved for patients failing conservative measures.
The topic of our following paper is how to prevent acute back pain from becoming chronic. Maintaining an average body weight, avoiding obesity, and remaining physically active are factors that can help. Early psychological assessment of patients with back pain and appropriate intervention for abnormalities may help reduce chronic back pain.
The lifetime risk for symptomatic LDH is 1–3%; of these, 60–90 % resolve spontaneously. Risk factors for LDH include genetic and environmental factors, strenuous activity, and smoking. Clinical tests, including manual muscle and sensory testing, supine straight leg raise, are recommended for use in diagnosing lumbar disc herniation with radiculopathy.
In the absence of cauda equina syndrome, motor, or other serious neurologic deficits, conservative treatment should be the first line of treatment for LDH. NSAIDs may significantly improve acute lower back and sciatic pain caused by LDH. A combination of activity modification, pharmacotherapy, and physical therapy provides good outcomes in most LDH patients.
The WFNS Spine Committee's guidelines on LDH cover four main topics: (1) the role and timing of surgery in first-time LDH; (2) the role of minimally invasive techniques in LDH; (3) the extent of disk resection in LDH surgery; (4) the role of lumbar fusion in the context of LDH. Surgery for LDH is recommended for failure of conservative treatment, cauda equina syndrome, and progressive neurological impairment, including severe motor deficits. In such cases, early surgery is associated with faster recovery and may improve patient outcomes. Minimally invasive techniques have short-term advantages over open procedures, but there is insufficient evidence to recommend for or against a specific surgical procedure. Sequestrectomy and standard microdiscectomy demonstrated similar clinical results in pain control, recurrence rate, functional outcome, and complications at short and medium-term follow-ups. Lumbar fusion is not recommended as a routine treatment for first-time LDH, although it may be considered in specific patients affected by chronic axial pain or instability.
Recurrence after disc herniation surgery may be considered a surgical complication. Its incidence is approximately 5 % and is different from the overall re-operation incidence. There are multiple risk factors predicting LDH recurrence, including smoking, younger age, male gender, obesity, diabetes, disc degeneration, and the presence of lumbosacral transitional vertebrae. The level of lumbar microdiscectomy surgery and the amount of disc material removed do not correlate with the recurrence rate. Minimally invasive discectomies may have higher recurrence rates, especially during the surgeon's learning period. High-quality studies are needed to determine if activity restriction, weight loss, smoking cessation, and muscle-strengthening exercises after primary surgery can help prevent the recurrence of LDH. The best treatment option for recurrent disc herniation is still being discussed. While complications of minimally invasive techniques may be lower than open discectomy, outcomes are similar. Fusion in recurrent disc herniation should only be considered when spinal instability and/or spinal deformity are present. Clinical outcomes and patient satisfaction after recurrent surgery are inferior to those after initial discectomy.
The WFNS Spine Committee provides standardized definitions of cauda equina, cauda equina syndrome (CES), conus medullaris, and conus medullaris syndrome. We advocate for using the Lavy et al classification system to categorize different types of CES and recommend urgent MRI in all patients with suspected CES, considering the low sensitivity of clinical examination in excluding CES. Surgical decompression for CES is recommended within 48 h, preferably within less than 24 h.
Further research is necessary to tackle the relative scarcity of good quality scientific evidence about patients with Lower back pain and lumbar disc herniation. WFNS Spine Committee will continue to endeavor to teach, train, guide, and inspire spine surgeons worldwide.
The WFNS Spine Committee's “Lower Back Pain and Lumbar Disc Herniation Guidelines” are a milestone in spinal healthcare, offering a comprehensive and evidence-based roadmap for clinicians worldwide. In an era where the prevalence of lower back pain continues to rise, the dissemination and implementation of these guidelines holds the promise of improving patient outcomes and enhancing the efficiency of healthcare delivery. This may ultimately alleviate the societal impact of this condition. The WFNS Spine Committee's guidance will provide a compass for both practitioners and patients on the journey toward spinal health and well-being.