Minimal invasive therapeutic interventional procedures in the spine: an evidence-based review. Surg Technol Int

Scientific Committee, Back Care Network, Athens, Greece.
Surgical technology international 02/2008; 17:259-68.
Source: PubMed


This chapter evaluates the current evidence on common minimally invasive therapeutic spinal procedures based on the Levels of Evidence and Grades of Recommendation developed by the Centre for Evidence-Based Medicine (Oxford, United Kingdom). The results of the evaluation of current clinical evidence allow the following recommendations to be made: epidural adhesiolysis performed repeatedly every 3 months to 4 months is effective in the "post lumbar laminectomy" syndrome; epidural steroid injections may provide only short-term relief from pain in lumbar radiculopathy but have no long-term effect; selective nerve root injections of corticosteroids have no therapeutic effect on the long-term natural history of radiculopathy symptoms; intra-articular facet joint injections of corticosteroids have no therapeutic effect on lower back pain (grade of recommendation: A). Furthermore, percutaneous vertebroplasty and balloon kyphoplasty provide immediate pain relief from osteoporotic spinal fractures but no significant long-lasting benefit (grade of recommendation: B). Finally, there is limited evidence (grade of recommendation: C) of the value of medial branch (facet) neurotomy, sacroiliac joint injection of steroids, and intradiscal electrothermal therapy, as well as of the advantages of percutaneous endoscopic lumbar discectomy over open microdiscectomy. As the level of evidence is generally low, more prospective randomized-controlled studies are needed to establish the value of the considered methods.

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    • "Datta et al. [10] concluded that although there is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, the evidence for therapeutic lumbar intraarticular injections is level III (limited). Furthermore, an earlier study [11] found that intra-articular facet joint injections containing corticosteroids seemed to have no additional therapeutic effect on lower back pain compared to injections of anesthetic alone. It has even been suggested that intra-articular facet joint injections may be no better than placebo for chronic lumbar spine pain [12]. "
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    ABSTRACT: To determine whether data obtained from patients returning postal questionnaires accurately reflect how patients receiving imaging-guided lumbar facet injections respond. Seventy-eight patients receiving lumbar facet joint injections who returned an outcomes questionnaire (responders) were age and gender matched with 78 patients who did not return the postal questionnaire (non-responders) after facet joint injections. Baseline numerical rating scale (NRS) pain data were collected. NRS and Patients' Global Impression of Change (PGIC) data were collected 1 month after injection by postal questionnaire or telephone interview. Differences in NRS scores were calculated using the unpaired t-test. One level injection patients were compared to patients having ≥2 levels injected using the paired and unpaired t-test. The proportion of patients reporting significant improvement in each group was calculated. NRS scores were significantly improved compared to baseline (p = 0.0001). Thirty-eight percent of responders were significantly improved compared to 50 % of non-responders. Patients having ≥2 levels injected reported significantly higher baseline NRS scores, but by 1 month there was no difference in NRS scores between groups. Patients returning postal questionnaires report a less favourable outcome. Telephone interview patients having injections at more than one level have better outcomes. MAIN MESSAGES : • Patients returning postal questionnaires report worse outcomes after facet injection. • Method of data collection should be considered when reporting treatment outcomes. • Patients receiving facet injections at more than one level report greater levels of pain reduction.
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    ABSTRACT: Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.
    Regional anesthesia and pain medicine 05/2013; 38(3):175-200. DOI:10.1097/AAP.0b013e31828ea086 · 3.09 Impact Factor
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    ABSTRACT: The modern era of minimally invasive spine surgery has its roots in percutaneous techniques developed in the mid-twentieth century. The widespread application of minimally invasive techniques seen today is predicated on technologic developments of only the past 10 years, however. This article reviews the development of minimally invasive spinal surgery as it has evolved for the cervical, thoracic, and lumbar spine. Each new development has sought to equal or improve on the effectiveness demonstrated by comparable open surgical techniques while reducing iatrogenic tissue trauma and resultant postoperative pain and disability, to produce overall better outcomes for patients.
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