Intended for healthcare professionals

Rapid response to:


NICE recommends early intensive management of persistent low back pain

BMJ 2009; 338 doi: (Published 27 May 2009) Cite this as: BMJ 2009;338:b2115

Rapid Response:

NICE guideline on low back pain are flawed

Dear Sir

We, as a group of Consultants in Pain Medicine received with
incredulity and dismay the new NICE (National Institute of Health and
Clinical Excellence) guidelines on the treatment of early persistent low
back pain.

NICE has decided that for back pain lasting between 6 weeks and one
year that the following options be considered; osteopathy, acupuncture,
psychological therapy and surgery. The NICE Committee consisted of,
amongst others , a psychologist, a chiropractor, an acupuncturist and a
spinal surgeon, but there was no one on the committee who was an
experienced Pain Physician. It appears that the NICE committee’s
conclusion on early low back pain reflect the personal bias of the
committee members.

An example of this is that NICE specifically dismiss the role of
spinal injections in treatment of early low back pain, preferring instead
to recommend spinal fusion surgery before spinal injections. Whilst we
accept that fusion surgery has a limited role in some patients, to exclude
less invasive and less risky procedures such as spinal injections, which
can benefit patients and avoid the risk of major surgery, seems
idiosyncratic and distorted at best and deeply disturbing at the worst.
We believe that a consequence of these NICE guidelines is a grave risk
that many thousands of patients will undergo unnecessary spinal fusion
operations, when much less invasive injections would have been helpful

We as a group of Consultants in Pain Medicine including previous and
current presidents of the specialist association were alerted to the draft
NICE guidelines and we urgently wrote presenting the wealth of data
supporting the role of spinal injection and other therapy in helping
people with low back pain. We were rebuffed and told we had to submit our
concerns about the guidelines through a ‘registered Stakeholder’.
Notwithstanding the bureaucratic hurdles that were in place , we
submitted our concerns about what we felt was a distorted opinion of the
evidence and in particular emphasised the positive outcomes of the
randomised controlled trials of injection therapy. To our dismay, our
submission and this data has been utterly ignored. Yet acupuncture and
spinal fusion, which have far less reliable data to support them, have
been included.

We draw attention the past record of NICE's decision making in the
respect of the drug treatment of early Alzheimer's’ and some cancer
treatments which have provoked public and professional outrage and note
the serious questions which have been raised about the lack of
transparency in the decision making process of NICE.

Because of these new guidelines patients will continue to experience
unnecessary pain and suffering and their rights to appropriately
individually tailored treatment have been removed on the basis of a
flawed analysis of available evidence. We believe the guidelines do not
reflect best practice, remove patient choice and are not in our
patients’ best interests.

Dr Rajesh Munglani, Dr Sanjeeva Gupta, Dr Jonathan Richardson, Dr
Chris Wells, Dr Charles Gauci, Dr Glynn Towlerton, Dr Andrew Lawson, Dr
AR Cooper, Dr Manohar Lal Sharma. Dr Tony Hammond, Dr Stephen Ward, Dr
Wisam Ali, Dr Daniel W Wheeler, Dr Mark Abrahams, Dr Mark Sanders, Dr
Dalvina E Hanu-Cernat, Dr.F.D.O. Babatola, Dr M. Murali-Krishnan, Dr Yadi
Jayran-Nejad, Dr Thomas Smith, Dr Andrea M R Harvey, Dr Jones Kurian, Dr
Andrew StClair Logan, Dr. Liz Garthwaite, Dr. Don Jones, Dr J C Burnell,
Dr P.N.Colling, Dr. Marcia Schofield, Dr Dimitri Leschinskiy, Dr K E
Tighe, Dr Ian Wilson, Dr Vanessa Hodgkinson, Dr. S. Kanakarajan, Dr Wisam
Ali, Dr. Zahid Waheed, Dr Adam Masters., Dr Rokas Tamosauskas, Dr Raju
Bhadresha, Dr M. Murali-Krishnan, Dr Nick Roberts, Dr Sujann Singh, Dr
Simon Tordoff. Dr.Sridevi Ramachandran, Dr Mark Dale, Dr Nick Padfield. Dr
R Iyer, Dr Andrew Ravenscroft, Dr Joseph Azzopardi . Dr Ilan Leiberman. Dr
David Conn. Dr Amgad Ragheb, Dr FE LuscombeAll Consultants in Pain
Medicine through out the United Kingdom.

Competing interests:
None declared

Competing interests: No competing interests

31 May 2009
Rajesh Munglani
Consultant in Pain Medicne
West Suffolk Hospital IP33 2QZ