Advances in treatment for this common ailment

Lower back pain is something nearly everyone experiences, and its pathology derives from the spine, intervertebral disks, and surrounding soft tissues.

In research cited by the WHO, the lifetime prevalence of common low back pain is between 60% and 70% in industrialized nations. In any year, between 15% and 45% of adults experience back pain. The prevalence of common back pain is highest among people aged 35 to 55. And, the number of people experiencing back pain will only increase due to the deterioration of intervertebral disks as the population ages.

Although back problems are among the most frequent complaints to doctors, lower back pain, in particular, is notoriously difficult to treat, with limited effective interventions emerging. It doesn’t help that back pain is the subject of widely held myths and misconceptions. 

Let’s take a closer look at cutting-edge interventions that offer some hope for those experiencing back pain.

What's the evidence?

Although multifarious treatment modalities exist for back pain, there are few evidence-based treatment options, according to a review article published in American Family Physician.

There's "moderate evidence" to support the short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and topiramate for mechanical low back pain, the authors wrote. However, “There is little or no evidence of benefit for acetaminophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain.”

Anti-nerve growth factor monoclonal antibodies

Nerve growth factor (NGF) is necessary for neuron survival and the moderation of pain and nociceptor activity in adults. Preclinical and clinical studies have demonstrated the role NGF plays in acute and chronic pain, including chronic lower back pain. NGF blockade with anti-NGF monoclonal antibodies (anti-NGF mAb) is receiving attention for the treatment of chronic lower back pain and related conditions.

According to the authors of a review published in the Journal of Pain Research, “Accumulating pieces of evidence have demonstrated that anti-NGF mAb therapy (ie fasinumab and tanezumab) ameliorates different chronic pain conditions, especially OA, CLBP (chronic lower back pain), and neuropathic pain. Moreover, the analgesic efficacy of these anti-NGF antibodies is potentiated by the reduction of adverse effects associated with conventional pharmacological pain therapies (NSAIDs and opioids)."

Therefore, anti-NGF mAb therapy may serve as an alternative non-opioid therapeutic choice for pain management. However, more research is warranted to understand the levels of analgesic effect, duration, immunogenicity, and potential adverse events of anti-NGF mAbs.

Concerns about adverse events have arisen in patients treated with large joint osteoarthritis. In clinical trials, patients treated with anti-NGF antibodies have exhibited negative side effects including rapidly progressive osteoarthritis and joint fractures. The authors of the review stressed that in patients with osteoarthritis and other chronic pain syndromes, further studies elucidating possible risk factors are required.

In March 2021, the FDA Arthritis Advisory Committee and the Drug Safety and Risk Management Advisory Committee expressed concerns that tanezumab “is not sufficient to mitigate the risk of RPOA and would not ensure that the benefits of tanezumab outweigh the risks of RPOA.” Of note, stopping the drug doesn’t stop RPOA from further damaging joints.

Disconcertingly, tanezumab can destroy healthy joints, and risks are elevated in those taking the biologic with NSAIDs. The FDA also noted that the biologic can result in self-limited mononeuropathy such as carpal tunnel syndrome. Ultimately, no final decision has been made on the drug’s application.

Intracept

This recently developed surgical procedure involves intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. In a randomized controlled trial published in Spine Journal, 140 patients with chronic lower back pain for greater than 6 months were randomized to receive either radiofrequency ablation or continued standard care. The team measured clinical outcomes using questionnaires during follow-up visits. 

The intervention was so effective during interim analysis that early crossover from the control arm was recommended. The investigators noted that “patients in the treatment arm were found to have higher satisfaction than in the control arm. This further demonstrates the role of this novel therapy in the treatment of a specific subtype of chronic LBP.” Importantly, no adverse events were related to the Intracept delivery system, but patients did experience adverse events from surgery.

Intracept works by targeting vertebrogenic pain, which is an emerging clinical concept. A plethora of studies indicate that vertebral endplates are a source of lower back pain, with endplate nociceptors originating from the basivertebral nerve. Intriguingly, this nerve was only first described in 1998. 

Of note, intraosseous radiofrequency ablation was performed with a unilateral transpedicular delivery system. Treatment was performed in as many as four nonconsecutive vertebrae from levels L3 to S1.

Bottom line

Unfortunately, there is no magic bullet for treating lower back pain. Even promising newer treatments, such as monoclonal antibodies, carry risks of joint destruction. Intracept does appear to offer hope to those with this debilitating condition, however, it is a surgical procedure, with inherent risks. Unfortunately, many other conventional treatments don’t work.

The best way to deal with back pain is to prevent it by avoiding repetitive tasks, lifting mindfully, and practicing good posture. You may also want to consider strengthening and stretching your back muscles through exercise.