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Anesth Pain Med. 2015 July; 5(4): e29716. DOI: 10.5812/aapm.29716
Published online 2015 July 22. Review Article
Interventional Therapies for Chronic Low Back Pain: A Focused Review
(Efficacy and Outcomes)
Vikram B. Patel 1,*; Ronald Wasserman 2; Farnad Imani 3
1Phoenix Interventional Center for Advanced Learning, Algonquin, Illinois, USA
2Back and Pain Center, University of Michigan, Ann Arbor, Michigan, USA
3Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
*Corresponding author: Vikram B. Patel, Phoenix Interventional Center for Advanced Learning, Algonquin, Illinois, USA. Tel: +1-8478547246, E-mail: vikpatel1@yahoo.com
Received: May 4, 2015; Accepted: May 17, 2015
Context: Lower back pain is considered to be one of the most common complaints that brings a patient to a pain specialist. Several
modalities in interventional pain management are known to be helpful to a patient with chronic low back pain. Proper diagnosis is
required for appropriate intervention to provide optimal benefits. From simple trigger point injections for muscular pain to a highly
complex intervention such as a spinal cord stimulator are very effective if chosen properly. The aim of this article is to provide the reader
with a comprehensive reading for treatment of lower back pain using interventional modalities.
Evidence Acquisition: Extensive search for published literature was carried out online using PubMed, Cochrane database and Embase
for the material used in this manuscript. This article describes the most common modalities available to an interventional pain physician
along with the most relevant current and past references for the treatment of lower back pain. All the graphics and images were prepared
by and belong to the author.
Results: This review article describes the most common modalities available to an interventional pain physician along with the most
relevant current and past references for the treatment of lower back pain. All the graphics and images belong to the author. Although it is
beyond the scope of this review article to include a very detailed description of each procedure along with complete references, a sincere
attempt has been made to comprehensively cover this very complex and perplexing topic.
Conclusion: Lower back pain is a major healthcare issue and this review article will help educate the pain practitioners about the current
evidence based treatment options.
Keywords:Low Back Pain; Facet Joint; Sacroiliac joint; Procedures; Intradiscal Procedures, Disc Decompression; Discography; Spi-
nal Cord Stimulation; Interventional Therapies
Copyright © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM). This is an open-access article distributed under the terms of the Creative Com-
mons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material
just in noncommercial usages, provided the original work is properly cited.
1. Context
Low back pain is one of the most common ailments that
bring a patient to a pain specialist. Interventional mo-
dalities for low back pain are highly effective when used
in conjunction with other adjuvant modalities and per-
formed by properly trained physicians who are not only
well versed with the anatomy and physiology of chronic
pain but also possess the special skills necessary for per-
forming such delicate procedures. Failure of a patient to
respond to an intervention for low back pain can have
several variables. Poor patient selection (1), poor patient
compliance (2) and poorly performed intervention may
be the primary variables.
Use of fluoroscopy has revolutionized the interven-
tional treatments for chronic pain by providing excellent
guidance to the needle placement (3, 4), as well as recog-
nizing improper placements such as intravascular (using
live fluoroscopy or digital subtraction angiography (5, 6)
imaging) or unintended intrathecal placements of nee-
dles and thus avoiding morbidity in the form of injury
to the intra-spinal structures including spinal cord, nerve
roots and blood vessels.
2. Relevant Anatomy
The lumbar spine is a complex structure. It is capable
of maintaining dynamic motion of the lower back while
bearing the weight of the upper body and torso.
The lumbar spine is composed to five vertebral bodies
numbered 1 - 5 from cephalad to caudad direction. The
vertebral bodies are separated by the intervertebral discs
which provide shock absorbing function as well as flex-
ibility to the lumbar spine (Figure 1).
The lumbar vertebra is formed by the body anteriorly,
the pedicles projecting posterolaterally anterolaterally
and the laminae projecting posteromedially uniting in
the posterior aspect to form the spinous process. The
transverse processes arise from the lateral aspect bilater-
ally. The spine can be divided into anterior, middle and
posterior elements for the purpose of diagnosis as well
as treatment as depicted in the Figure 2. The anterior seg-
ment consists of the vertebral body and the interverte-
bral disc, anterior and posterior longitudinal ligaments,
the gray and white rami communicantes and the sympa-
thetic chain. The middle segment consists of the longi-
tudinal canal and its contents including the spinal cord
Patel VB et al.
Anesth Pain Med. 2015;5(4):e297162
(up to about L2 level), nerve roots, blood vessels and fatty
tissue within the canal and the neural foramina. The pos-
terior segment is made up of the vertebral body arches
made up of the pedicles, the transverse processes, the
laminae and the articular elements including the facet
(zygapophyseal) joints, ligaments and the correspond-
ing nerve and blood supply.
Figure 1. Lumbar Spine Anatomy
Figure 2. A Cross Section of the Lumbar Vertebral Level Showing the Dif-
ferent Sections of the Spine
3. Etiology of Low Back Pain
Lower back pain can arise from multiple structures in-
cluding the discs (secondary to herniation, internal disc
disruption, infection), the vertebral bodies (secondary to
vertebral fracture, infection, metastatic lesion), lumbar
nerve roots (compression due to mechanical causes from
a herniated disc or inflammation, spinal stenosis and
tethering due to post-surgical scarring), lumbar facet
joints (degeneration, inflammation, injury), muscular
components from the muscles attached to the ,lumbar
spine and the iliac crest, ligaments and the sacroiliac
joint. Multiple conditions may involve more than one
pain generators. Such conditions include scoliosis, ky-
phosis, spondylolisthesis, metastasis, post-laminectomy
syndromes, trauma etc.
Pain may also radiate posteriorly to the spinal area from
the abdominal viscera such as the aorta, the pancreas,
ovaries, intestines, kidneys etc. and such causes should
be ruled out with appropriate imaging studies (7-9).
4. Interventions
4.1. Basic Interventions
4.1.1. Trigger Point Injections
Trigger point injections are the most basic of interven-
tions which are known to help with myofascial pain (10,
11) in selected patients. Various practitioners have used
different types of medications and/or combinations of
different pharmaceutical agents (such as local anesthetic
and steroid, local anesthetic/steroid/opiate, botulinum
toxin (Botox) (12, 13) etc.). Some medications such as
Sarapin® (an extract from pitcher plant) are widely used
but do not have much supporting literature to be recom-
mended for such usage (14). “Dry needling” is also a tech-
nique used by many (15, 16) and is shown to be equally
effective as local anesthetic when combined with physi-
cal therapy. A common practice is to inject the affected
muscle at various points detected on palpation to be the
most tender (signifying the trigger points) using a small
bore needle (27 G) and about 2 - 4 mL of injectate. Immedi-
ate relief is apparent in most cases. The injections them-
selves may not provide long term relief and hence have to
be combined with proper stretching exercises which are
the main modalities to help achieve long term pain relief.
4.1.2. Epidural Steroid Injections
Epidural steroid injections have been used for past sev-
eral decades (17-19) for multiple indications for the lower
back pain (20). Initially the injections were performed
blindly without the use of imaging guidance but the
recent concerns of vascular injections (especially with
particulate steroids) have prompted a recommendation
for the use of fluoroscopic or CT guidance for these injec-
tions (21, 22). Even in experienced hands blind epidural
steroid injections result in inaccurate needle placement
in up to 30% of cases (White AH, Derby R, Wynne G Epidur-
al injections for the diagnosis and treatment of low-back
pain. Spine 1980; 5:67-86, White AH Injection techniques
for the diagnosis and treatment of low back pain. Orthop
Clin North Am 1983; 14:553-567). Aberrant injections can
occur into the multifidus muscle, subdural or subarach-
Patel VB et al.
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Anesth Pain Med. 2015;5(4):e29716
noid space. In addition intravascular injection can occur
with an incidence of 0.5 % in the lumbar region to 4% in
the thoracic region. Various approaches have been used
over the years for these injections (18, 20).
4.1.3. Lumbar Interlaminar Epidural Injection
This is the most common approach that is utilized for
“blind” injections. It utilizes a “loss of resistance to air”
(or fluid or air/fluid interface) technique to recognize the
penetration of the ligamentum flavum and thus into the
epidural space. This technique has been used for a long
time for placement of epidural catheters for labor anal-
gesia, post-operative analgesia etc. However, for a single
shot injection it is advisable to use fluoroscopic guidance
not only for proper placement of medication at the right
level but also on the right (correct) side and more impor-
tantly to avoid any vascular injection, the incidence of
which was found to be between 0.5 % in the lumbar re-
gion to 4% in the thoracic region (23). Injection of a water
soluble contrast medium is required to confirm proper
placement of the needle. A live injection of contrast un-
der fluoroscopic view is recommended to recognize
intra-vascular uptake. Digital Subtraction Angiography
(DSA) has been considered the gold standard for recogni-
tion of intravascular spread of the contrast material. Of
course it can also help one recognize an intra-thecal or
sub-dural injection as well.
4.1.3.1. Technique
The approach is usually midline or slightly paramedian
towards the site of the pathology. The fluoroscopic view
can be used to determine the appropriate level of the in-
jection between the vertebral spinous processes. An epi-
dural needle (usually an 18 G or 20 G 3.5” Touhy needle) is
utilized for accessing the epidural space. Once the needle
is within the interspinous ligament, a glass or plastic
“loss of resistance” syringe is attached to the needle. The
needle is then gradually advanced through the inter-
spinous ligament until a distinct “pop” is felt and there
is a loss of resistance to injection through the attached
syringe. The fluoroscopic view when used in a lateral
projection or a contra-lateral oblique projection would
also confirm the placement of the needle tip within the
posterior aspect of the epidural space (Figure 3). A con-
firmatory injection of water soluble contrast medium is
then carried out under live fluoroscopy to obtain an epi-
durogram. Once confirmed, the main injectate usually
comprises of a mixture of local anesthetic/normal saline
and the intended cortico-steroid, is injected gradually.
Adding normal saline or local anesthetic to the mixture
helps create adequate volume for better coverage of the
inflamed areas (Figure 3).
4.1.3.2. Evidence
As one of the oldest technique for epidural injections, it
has been studied extensively. Its use for chronic low back
pain is also one of the oldest treatments for this ailment.
In one of the recent randomized, double-blind, active-
control trial studies, Manchikanti et al. (24) found that
lumbar interlaminar epidural injections of local anes-
thetic with or without steroids might be effective in pa-
tients with disc herniation or radiculitis, with potential
superiority of steroids compared with local anesthetic
alone at 1 year follow-up. In a systematic review for lum-
bar interlaminar epidural injections, Benyamin et al. (25)
Figure 3. Lumbar Interlaminar Epidural Injection AP and Lateral Views
Patel VB et al.
Anesth Pain Med. 2015;5(4):e297164
concluded that the evidence was good for lumbar epi-
dural injections under fluoroscopy for radiculitis second-
ary to disc herniation with local anesthetic and steroids,
fair with local anesthetic only; whereas it was fair for
radiculitis secondary to spinal stenosis with local anes-
thetic and steroids, and fair for axial pain without disc
herniation with local anesthetic with or without steroids.
4.1.4. Caudal Epidural Injection
Also one of the most common injections in the treat-
ment of lower back pain, in the past a caudal approach
was usually performed without any fluoroscopic guid-
ance using just the palpable anatomical landmarks.
However it was later realized that a blind caudal injection
does not have a reliable way of entering the caudal epi-
dural space and hence it is now mainly performed using
fluoroscopic guidance (26).
This technique is especially useful in patients who have
a post-surgical spine and those with severe lumbar degen-
eration or stenosis and have a difficult to access epidural
space using midline interlaminar lumbar approach.
4.1.4.1. Technique
Caudal approach to the epidural space is best accom-
plished using a lateral view on the fluoroscope. The sacral
hiatus can be easily visualized on a lateral view follow-
ing the posterior border of the sacrum, however it may
also be absent in a small percentage of patients (27). In
some patients there may be a deficient posterior wall as
well (28), and the incidence of deficiency is found to be
higher in patients with low back pain (29). Sacral shapes
are varied in human beings. Females usually have a “C”
shaped sacrum while males normally have a “J” shape. An
epidural needle is recommended for accessing this sacral
epidural space. Once inside the sacral canal (epidural
space) the needle tip is halted at about S3 level to avoid
penetration of the dura which usually extends up to the
S2 level but can be lower. A midline approach is normally
attempted and is easier to visualize following the natal
cleft. Needle may be directed slightly laterally to either
side depending on the pathology and intended side of
the epidural space. After confirming the epidural place-
ment utilizing a small amount of contrast, the cortico-
steroid can be injected. An epidurogram is performed by
most physicians to evaluate the extent of pathology and
the spread of the injectate. A larger amount of injectate
is usually required when using a caudal approach to ef-
fectively reach the level of pathology (30, 31). The caudal
canal contains a large amount of venous plexi and intra-
vascular placement of the needle tip is not uncommon
(32), hence it is important to identify the placement with
an injection of water soluble contrast media (Figure 4).
Figure 4. Caudal Epidural Injection AP and Lateral Views
4.1.4.2. Evidence
Caudal epidural steroid for lower back pain especially
in patients with spinal stenosis has been known to be ef-
fective. In a recent extensive systematic review of litera-
ture, Parr et al. (33) found that the evidence was fair for
caudal epidural injections in managing chronic axial or
discogenic pain, spinal stenosis, and post-surgery syn-
drome, however it was good for short- and long-term re-
lief of chronic pain secondary to disc herniation or radic-
ulitis with local anesthetic and steroids. They also noted
that it was more effective than transforaminal as well as
interlaminar approaches. In an earlier review, Conn et al.
(34) had found that there was a Level II-1 or II-2 evidence
for caudal epidural injections in managing chronic pain
of post lumbar laminectomy syndrome and spinal steno-
sis. In a randomized trial Manchikanti et al. (20) found
Patel VB et al.
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Anesth Pain Med. 2015;5(4):e29716
that caudal epidural injections of local anesthetic with or
without steroids were effective in patients with chronic
axial low back pain of discogenic origin without facet
joint pain, disc herniation, and/or radiculitis.
4.1.5. Transforaminal Epidural Injection
A Transforaminal approach to injecting a steroid into
the lumbar spine is mainly used for a nerve root inflam-
mation which is the cause of radicular symptoms allow-
ing a peri-neural coverage (35, 36). Although these symp-
toms are usually presented as radiating pain to the lower
extremity, in most cases there is also a lower back pain
component. This is mostly due to the damage to the inter-
vertebral disc but can also be due to the referral pattern
of an inflamed nerve root. They have been shown by some
studies to be superior to the inter-laminar approach (37).
Hence this approach is also mentioned here for the sake
of completeness.
The approach to the intervertebral foramen is accom-
plished from a postero-lateral angle under fluoroscopic
guidance (Figure 5). The technique initially involved
placement of the needle tip inferior to the corresponding
pedicle inside the spine. However, even if the needle tip
is at the rim of the intervertebral foramen, the medica-
tion has been shown to cover the intended areas very well
thus reducing the chances of any damage to the dura or
the nerve roots (38). More recently it has been advocated
by some that placing the needle in the inferior aspect of
the foramen reduces the risk of nerve root damage as
well as penetration of any arterial component within the
foramen. An approach to this space via the inferior aspect
of the foramen (supra pedicular, retro-discal (39)) (Figure
6) is described through the so called “Kambin’s triangle”
(40, 41). Some physicians prefer to advance the needle up
to the anterior epidural space which is unnecessary as
the injectate can be deposited in the vicinity of the pa-
thology even with the tip of the needle in the postero-lat-
eral aspect of the foramen (42). If the needle is advanced
too far it has been known to enter the disc (43, 44) which
is usually protruding in most cases that need treatments.
This may theoretically lead to higher incidence of disc in-
fection if due precautions are not taken.
Figure 5. Transforaminal Injection AP and Lateral Views; Infra-Pedicular Approach
Figure 6. Transforaminal Injection AP and Lateral Views; Supra-Pedicular Approach
Patel VB et al.
Anesth Pain Med. 2015;5(4):e297166
4.1.5.2. Evidence
The evidence for transforaminal injections just for low-
er back pain without radicular component is not very
strong. However, this route has been used for adminis-
tration of steroids for decades. Most of the studies con-
ducted, included lower back pain with radicular pain.
However, considering the disc as a source of lower back
pain as well as radicular pain several studies have sug-
gested transforaminal injections prior to consideration
of a surgical intervention. Lutz et al. (45) concluded in a
study published in late 90s that fluoroscopic transforam-
inal epidural steroids are an effective nonsurgical treat-
ment option for patients with lumbar herniated nucleus
pulposus and radiculopathy in whom more conservative
treatments are not effective and should be considered be-
fore surgical intervention. In a focused review of transfo-
raminal epidural injections, Manchikanti (46) suggested
that the indications and evidence in favor of therapeutic
transforaminal epidural steroids in managing chronic
low back pain are balanced and less controversial than
diagnostic blocks and other means of administration of
epidural corticosteroids, namely, blind interlaminar epi-
dural injections.
4.2. Facet Joint Interventions
Facet joints are the most common pain generators
in the lumbar spine (47) representing anywhere from
15% to 45% of low back pain. Joint degeneration leade-
ing to facet joint hypertrophy, soft tissue infolding and
osteophyte formations (48) is the most common cause
of pain but other causes such as trauma, synovial cyst,
spondylolisthesis etc. are also known to cause facet joint
syndrome. In a post-surgical spine, the levels above and
below the surgical (fusion) level are the most common
sources for pain (49). Pain is usually felt with extension
and/or rotation of the lumbar spine especially in older
population making it less painful for the patient to
bend forward while being upright. Although a reliable
history and physical examination and radiological find-
ings of degeneration can provide enough suspicion for
these pain generators, a diagnostic block under fluoro-
scopic guidance is considered to be the most reliable
diagnostic test (50, 51) and the evidence for such blocks
is Level I or II-1.
Once diagnosed, this type of pain can be treated with
steroid injections into the intra-articular area, or by ab-
lation of the nerves supplying these joints thus making
them insensate (50).
4.2.1. Medial Branch Block
The facet joints are supplied by the medial branches of
the dorsal ramus of a spinal nerve root (Figure 7). At any
given level, a facet joint is supplied by two medial branch-
es, one from the same level and one from the level above
in case of a lumbar facets (51). Thus the L4-5 facet joint is
supplied by the medial branches of L4 as well as L3 nerve
roots. These medial branches lie in close proximity to the
bone at the junction of the transverse and superior ar-
ticular processes. The medial branch from the nerve root
at any given level lies at this junction of the lower level.
Thus the L5 medial branch (essentially the dorsal pri-
mary ramus) lies over the junction of superior articular
process and the ala of the sacrum and the L5 transverse
process houses the L4 medial branch (52).
Figure 7. Lumbar Spine Anatomy Showing the Medial Branches
4.2.1.1. Technique
An oblique view is necessary to visualize this junction
which is then superimposed over the pedicle at that
level. In a classic view depicting a “Scotty dog” image,
this point corresponds to the eye of the “Scotty” (Fig-
ure 8). For a diagnostic block of the medial branch a
very small amount of local anesthetic is advocated
and usually 0.5 mL of local anesthetic is sufficient (51).
Higher amount may lead to a false positive response.
The placement of the needle is confirmed by injecting
a very small amount of contrast medium which usu-
ally shows the spread along the groove formed by the
junction of the transverse and superior articular pro-
cesses providing an image in oblique view that looks
like a blindfold across the “Scotty dog’s” eyes (Figure 9).
A single needle technique to block multiple levels has
been advocated by some (53, 54) when it was found that
it takes less time, causes less patient discomfort and
provides the same accuracy as multiple needle tech-
nique. Ultrasound has also been utilized for facet joint
medial branch blocks with about the same accuracy as
the fluoroscopically guided blocks, confirmed with a
computed tomography scan (55).
Patel VB et al.
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Anesth Pain Med. 2015;5(4):e29716
Figure 8. Classic Oblique View Optimized for the “Scotty Dog” Image Depicting the “Eye”
Note the tangential placement of the needle for medial branch neurotomy.
Figure 9. Contrast Spread for Medial Branch Block
4.2.1.2. Evidence
The diagnostic rather than therapeutic nature of me-
dial branch blocks should be kept in mind. For a radio-
frequency ablation of the medial branches used in treat-
ment of lumbar facet joint pain, it is necessary to properly
diagnose the pain generator as the lumbar facet(s) to
achieve the best outcome. The specificity of lumbar me-
dial branch block technique was compared to CT in a ca-
daveric study by Dreyfuss et al. (56). He noted that “when
the appropriate technique is used, medial branch blocks
are target specific”.
In the past, Manchikanti et al. (57) looked at the validity of
lumbar diagnostic medial branch blocks. They concluded
that comparative local anesthetic blocks to diagnose lum-
bar facet joint pain withstood long-term follow-up in 75%
to 85% of the patients with accurate diagnosis and that
they are similar or superior to other well established inves-
tigations. In a systematic review of literature studying di-
agnostic utility of medial branch blocks, Sehgal et al. (58)
concluded that controlled comparative local anesthetic
blocks of facet joints (medial branch or dorsal ramus) are
reproducible, reasonably accurate and safe and that there
is strong evidence for controlled comparative local anes-
thetic facet joint injections or medial branch blocks in the
diagnosis of neck and low back pain and moderate evi-
dence in the diagnosis of pain arising from thoracic facet
joints. Datta et al. (50) found that the evidence for diagnos-
tic procedures for lumbar facet joint pain with controlled
local anesthetic blocks is Level I or II-1.
Patel VB et al.
Anesth Pain Med. 2015;5(4):e297168
4.2.2. Intra-Articular Facet Joint Injections of Steroids
Intra-articular injection of steroids for lumbar facet joint
(Figure 10A) related pain has recently been losing favor
amongst the pain physicians while radio-frequency ab-
lation has gained more acceptance probably because of
the evidence available at this time, which found limited
evidence for intra-articular injections and fair to good evi-
dence for radio-frequency neurotomy (59). Even so, many
physicians still perform this procedure in select cases.
For example a patient who is not a candidate for radio-
frequency due to a pace-maker or a spinal cord stimulator.
4.2.2.1. Technique
The image guidance for the intra-articular space remains
essentially the same as medial branch block, although the
obliquity and cephalo-caudad angulations may vary de-
pending on the target level. The needle is advanced within
the facet joint after the view is optimized similar to the me-
dial branch block. A curved needle helps steer the tip of the
needle into the intra-articular space with ease and single
pass through the tissue. A small amount of contrast is in-
jected to confirm the placement. Usually less than 0.5 mL
is injected. Sometimes the contrast may spill over into the
epidural space from the joint capsule through a pars in-
terarticularis defect, capsular foramina or a burst capsule
and even into an adjacent facet joint (60, 61) which may be
present in some individuals (Figure 10B). The amount of
steroid injected should also be minimal as the joint (espe-
cially an inflamed joint) does not have much space which
normally has a capacity between 1 to 1.5 mL. About 10 mg of
methylprednisolone or equivalent steroid is injected.
4.2.2.2. Evidence
As mentioned before, intra-articular injections for lum-
bar facets do not have strong evidence. In a systematic
review, Datta et al. (50) noted that there was a level III
(limited) evidence for intra-articular injections. This was
recently reinforced by Falco et al. (59) in 2012. CT guid-
ance for lumbar facet joint injections has also been stud-
ied for therapeutic as well as diagnostic utility. Schleifer
et al. (62) found that CT-guided facet joint infiltration is
a good method for treatment and diagnosis of lumbar
facet joint syndrome. Similarly, ultrasound (U/S) guid-
ance has also been recently promoted extensively for
lumbar facet joint interventions. Yun et al. (63) found
that U/S-guided injections in patients with lumbar facet
syndrome are as effective as fluoroscopically guided in-
jections for pain relief and improving activities of daily
living. After studying the effectiveness of lumbar facet
joint injections as well as radio-frequency denervations,
it has been recommended by Civelek et al. (64) that the
first choice should be the facet joint injection and if the
pain reoccurs after a period of time or the injection is
not effective, radio-frequency procedure should be used
for the treatment of chronic lumbar pain. They noticed
that over short term, the joint injection was more effec-
tive than radio-frequency. However in midterm follow-up
radio-frequency had more satisfying results.
4.2.3. Radiofrequency Ablation of the Medial Branches
A successful medial branch diagnostic block is followed
by radio-frequency ablation of the same medial branch-
es. As mentioned previously, for a diagnostic injection, a
very small amount of local anesthetic is injected at each
level of the medial branch block to avoid any spillage of
the local anesthetic into the epidural space, which may
provide a false positive result. The duration of pain relief
has to correspond to the type of local anesthetic injected.
It may be advisable to perform the diagnostic medial
branch blocks twice using different local anesthetics and
see if the results are consistent.
Figure 10. A, B: Lumbar Intra-Articular Facet Joint Injections
Patel VB et al.
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Anesth Pain Med. 2015;5(4):e29716
4.2.3.1. Technique
As noted earlier, the lumbar facet joints are innervated
by two medial branches for each level hence it is required
that both of these medial branches be neurolysed to
achieve complete sensory denervation of each joint. The
currently practiced method was first described by Shealy
(65, 66). The needle tip chosen for these procedures is 10
mm active tip on a 10 cm radio-frequency needle, usually
of 20 G or 22 G size, some practitioners even use an 18 G
needle for a bigger lesion. A curved needle is preferable
as it can help steer the needle tip to the target with a sin-
gle pass through the tissue, minimizing tissue trauma as
well as provide maximum contact and proximity to the
medial branch. To achieve optimal results, the needle is
placed tangential to the target point parallel to the nerve
to be addressed (rather than perpendicular (67), allowing
maximal contact with the nerve (Figure 11A - D). This can
be achieved by making the skin entry point of the needle
at least 1 level below the intended level of the targeted
medial branch. The placement of the needle tip is con-
firmed with fluoroscopic imaging in antero-posterior as
well as lateral views. The tip of the needle on lateral view
should not encroach upon the neural foramen to avoid
any risk of damaging the exiting nerve-root. A sensory
stimulation (usually at ≤ 0.5 V for lower back and nega-
tive for lower extremity radiation at 1V) as well as motor
stimulation (usually up to 3V eliciting multifidus muscle
stimulation with absent lower extremity muscle stimula-
tion) is then carried out to confirm the proximity of the
needle to the medial branch as well as to rule out any
proximity to the exiting nerve-root. However, it should
be noted that a sensory stimulation may also be per-
ceived by the patient even if the needle is just within the
muscle tissue (50), hence a correlation with fluoroscopy
is necessary. After confirmation of proper placement of
the needle, injection of local anesthetic + a small amount
of steroid is carried out to minimize procedural pain and
post-procedural discomfort. The injectate should not
have any effect on the lesion generation and may actually
help extend the lesion (68, 69). A radio-frequency lesion
is then carried out for 60 - 90 seconds (70, 71) at 60 - 800
Celsius. Recent studies have suggested that even placing
the needle tip perpendicular to the nerve provides simi-
lar results using a larger needle (72).
Figure 11. A, B, C and D, Radiofrequency of L5-S1 Level, AP and Lateral Views
Note the tangential angles of the needles and the L5 medial branch (dorsal ramus) ablation over the ala of the sacrum.
Patel VB et al.
Anesth Pain Med. 2015;5(4):e2971610
4.2.3.2. Evidence
Therapeutic effectiveness of radiofrequency ablation
of the medial branches for treatment of lumbar facet
joint pain has been well studies and established. In the
early part of this century, during a double blind placebo
controlled trial, Leclaire et al. (73) found that although ra-
diofrequency facet joint denervation may provide some
short-term improvement in functional disability among
patients with chronic low back pain, the efficacy of this
treatment had not been established. Several other stud-
ies have shown better outcomes overall. In a prospective
randomized double blind trial, van Kleef et al. (74) found
that RF for lumbar facet joint denervation results in a
significant alleviation of pain and functional disability
in a select group of patients with chronic low back pain,
both on a short-term and a long-term basis. In a system-
atic review of the literature, Falco et al. (59) found that
there good evidence for the conventional RF for the treat-
ment of Spine chronic lumbar facet joint pain resulting
in short-term and long-term pain relief and functional
improvement. It efficacy for pain of facet joint origin in
spondylolisthesis was also recently studied by Klessinger
(75) , who found that radiofrequency neurotomy for the
facet joint pain is a rational, specific non-operative ther-
apy in addition to other non-operative therapy methods
with a success rate of 65%. For post-surgical facet joint
pain he found 58.8% success rate for the lumbar facet
joint related pain using radio-frequency neurotomy (76).
4.3. Sacroiliac Joint Interventions
Sacroiliac joint is the joint between the lateral aspect
of the sacrum and the ilium (Figure 12A and B). It is a
true synovial joint but has limited mobility. It differs
from other joints in that it has fibro-cartilage as well as
hyaline cartilage. It provides stability to the pelvis and
has a very irregular articular surface (77). Most of the
cephalad portion of this joint is covered posteriorly by
the posterior superior iliac spine at the end of the iliac
crest. The joint can be accessed in its inferior 1/3rd to
1/5th portion under fluoroscopic guidance. The joint has
several ligaments around it to help it stabilize. The main
ligaments are the long and short sacro-iliac ligaments
and sacro-spinous ligament posteriorly and the ante-
rior sacroiliac ligament, sacro-tuberous ligament, Ilio-
lumbar ligament and lumbosacral ligament anteriorly.
The sacro-iliac joint is well innervated with nociceptive
fibers (77) in its capsule and surrounding ligaments as
well as intra-articular area. It has been reported to have
nerve supply from ventral rami of L4 and L5, superior
gluteal nerve, and the dorsal rami of L5, S1 and S2 (77, 78).
However, there is also evidence that it is only supplied
by the dorsal rami (77).
Figure 12. A and B, Anatomy of the SI Joint (Courtesy Gray’s Anatomy Online)
The SI joint articular surface is highlighted in the left image.
Patel VB et al.
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The sacroiliac joint pain is more common in females
due to the shape of pelvis as well as ligamentous laxity.
It is more common after age of 30 (except due to trauma)
and is a significant source of pain if the lumbar fusion is
carried to the S1 segment. The prevalence of sacro-iliac
joint pain is 16% - 30% of all chronic lower back pain (79).
The pain is mainly felt in the gluteal region but may radi-
ate to the groin, abdomen and the lower extremity, usu-
ally above the knee (79).
4.3.1. Intra-Articular Injections of Steroid
4.3.1.1. Technique
The sacroiliac joint is technically more difficult to access
than most other joints. This is because of the anatomi-
cal shape of the joint, which has an irregular articular
surface unlike most other synovial joints (77) and super-
imposition of the iliac crest over the joint. “Blind” injec-
tions are not recommended as they have a high failure
rate (successful in only about 12% of blind injections) of
accessing the joint (4). The best approach to the joint for
an intra-articular injection is through the lower 1/3rd or
1/5th of the joint. In some individuals the lower 1/3rd can
be seen clearly in a straight antero-posterior view on fluo-
roscopy but in most patients the fluoroscopic view has to
be adjusted to clearly visualize the joint space. A slight tilt
from cephalad to caudad direction and a slight oblique
rotation towards the contra-lateral side will “open up”
the lower joint space. Once the needle is beyond the liga-
ments and into the joint space, a lateral fluoroscopic view
will confirm the depth of the needle and its placement
within the joint space.
After confirming the position, a small amount of con-
trast should be injected and a proper placement will
show a linear spread of the contrast within the joint
(Figure 13A and B). It should be kept in mind that the soft
tissues within the joint may be inflamed and occupying
the higher than normal joint space, hence the spread of
the contrast may not be ideal and it may start pooling
into the inferior cusp of the joint capsule. However, such
spread should remain confined within the joint and cap-
sule space and should not show horizontal spread within
the ligaments. A small amount of steroid in then injected
along with some local anesthetic. The joint can only ac-
commodate about 1.0 mL of injectate without disrupting
the joint capsule (80).
Ultrasound guidance has been recently advocated
strongly for the sacroiliac joint injections and can help
eliminate the use of fluoroscopy and may also be useful
for patients who cannot be subjected to radiation (e.g.
pregnant patients) (81-83). The procedure can be time sav-
ing and simple in experienced hands.
4.3.1.2. Evidence
Although this is one of the most common procedures
performed by pain physicians as well as general practi-
tioners, the evidence for intra-articular steroid injection
for sacroiliac joint pain is not very strong. In a recent sys-
tematic review, Hansen et al. (84) found that the evidence
for intra-articular injection of steroids is poor for short
as well as long term relief. This could be because of litera-
ture deficiency with well controlled randomized studies.
However, the diagnostic accuracy for intra-articular in-
jections was found to be good by Simopoulos et al. (85).
Overall, the evidence for diagnostic accuracy for sacro-
iliac joint pain was found to be Level II-2 (86).
Figure 13. A and B: Sacroiliac Joint Intra-Articular Injection Antero-Poste-
rior and Lateral Views
Note the angle of the needle in lateral view, parallel to the joint.
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4.4. Neuroablative Procedures for the Sacroiliac Joint
4.4.1. Cooled Radio-Frequency Ablation (RFA)
4.4.1.1. Technique
Steroid injection in a degenerated or unstable sacro-
iliac joint may not provide a long term relief and hence it
may be necessary to perform neuroablative procedures.
The nerves supplying the joint are not adherent to the
bone along their paths and remain ‘floating’ higher than
the bone surface. Conventional radio-frequency proce-
dures do not always succeed in ablating these nerves due
to this anatomical fact. Hence the cooled radio-frequency
is considered as it can generate a large spherical lesion
(Figure 14) from the tip of the needle and can cover the
intended nerves. The procedure is time consuming as
multiple lesions at the posterior sacral foramina need
to be made. The positions of the nerve fibers are variable
around the lateral aspect of the foramina. 3 lesions are
generated at each level as well as a lesion for the L5 me-
dial branch at the level of the ala of the sacrum.
Under antero-posterior view, a 27 G spinal needle is
placed within the posterior sacral foramen to mark the
center of the foramen. This may require some optimiza-
tion of the fluoroscopic view with slight tilt and rotation.
After this, the cooled radio-frequency probes are placed
at 2, 4, 7 o’clock positions to generate the lesions. This
procedure is repeated at S1, S2, S3 and S4 levels to cover
the entire nerve supply to the sacro-iliac joint.
Figure 14. The Image Showing the Spherical Lesions Created by Cooled RF
Lesioning and the Targeted Areas Around the Posterior Sacral Foramina as
Well as the L5 Lesion Targets
4.4.1.2. Evidence
The steroid injection for sacroiliac joint do not have
a strong evidence for reducing pain but they do pro-
vide good diagnostic function which should then be
followed by a neuroablative procedure. The difficulty
in covering the entire complex nerve supply for this
joint had led to poor outcomes overall in the past, but
the recent advances such as a cooled RF procedure has
provided much better outcomes. In a recent systematic
review, Hansen et al. (84) found the evidence to be fair
overall, which was the best outcome of all the interven-
tions for SI joint. In the first short case study Kapural
et al. (87) found that majority of patients with chronic
SI joint pain experienced a clinically relevant degree of
pain relief and improved function following cooled RF
of sacral lateral branches and dorsal ramus of L5 at 3
- 4 months follow-up. Stelzer et al. (88) recently found
that cooled RF procedure showed promising, durable
improvements in pain, quality of life, and medication
usage in a large European study population, with bene-
fits persisting in some subjects at 20 months after treat-
ment. Patel et al. (89) found that in their randomized
placebo controlled study, the treatment group showed
significant improvements in pain, disability, physical
function, and quality of life as compared with the sham
group. The duration and magnitude of relief was con-
sistent with previous studies, with benefits extending
beyond 9 months.
4.4.2. Thermal Radio-Frequency Ablation
4.4.2.1. Technique: (Conventional Method)
Radiofrequency (RF) ablation for the sacroiliac joint
is a bit different than for the facet joints. The supply-
ing nerves are not adherent to the bone as is the case
with the facet joints. They are relatively floating above
the bone within the tissue and have varied locations
around the posterior sacral foramina on their way to
the joint. Near the joint over the medial border of the
joint, they are relatively closer to the bone prior to en-
tering the joint itself. Conventional RF targets this area
for ablation. The lesions are created using a bi-polar
technique. Two RF needles are placed along the medial
border of the joint approximately 5 mm apart and a le-
sion is created (Figure 15).
The inferior needle is then moved cephalad to the previ-
ously placed needle in a “leap frog” manner for the subse-
quent lesion (90). A series of such lesions is created along
the entire medial border of the joint. The technique re-
quires multiple needle punctures as well as a longer time
to finish the procedure.
4.4.2.2. Evidence
RF lesioning for the sacroiliac joint should have the
same evidence for efficacy (90) as cooled technique but
does not, basically because conventional RF needle po-
sitioning may not cover the dorsal branches very effec-
tively due to their anatomical location. Nevertheless,
radio-frequency (both pulsed as well as thermal) has
been used in treatment of the SI joint pain and has been
found to be effective. The bipolar technique described
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Anesth Pain Med. 2015;5(4):e29716
above is thought to be technically simpler and provides
adequate pain control for at least short term (91). Vallejo
et al. (92) found that pulsed RF denervation of the later-
al branch of the medial branch of L4, posterior primary
rami of L5, and lateral branches S1 and S2 is an effective
treatment for some patients with SIJ pain unresponsive
to other forms of therapy with > 70% patients reporting
good to excellent pain relief ranging from 6 to 32 weeks.
Figure 15. Antero-Posterior and Lateral Views of the RF Lesioning for the SI Joint at the Edge of the Medial Joint Border of the Joint Using the “Leap Frog”
Technique
4.4.2.3. Technique: (Simplicity III®)
This procedure utilizes a probe with multiple contacts
for RF (Figure 16). The probe itself is curved to match the
sacral curvature and is inserted in the cephalad direction
with a slightly lateral angulation following the natural
curve of the sacrum and the tip is advanced up to the up-
per aspect of the sacrum. Once in place, the lesions are
generated with a single push of a button and multiple
needle insertions are not required.
4.4.2.4. Evidence
Not much literature has been published for this proce-
dure. In a recent poster presentation by Mehta et al. (93),
all their patients in the study had a reduction in their
pain scores at one, two and six months post-procedure
compared to baseline. No complications were reported
during this period and in their opinion, SIJ RF denerva-
tion with the Simplicity III system is a safe and effective
treatment modality for SIJ pain.
4.5. Advanced Interventions for Low Back Pain
4.5.1. Procedures for the Intervertebral Disc
4.5.1.1. Diagnostic Discography
The lumbar intervertebral disc can be a source of sig-
nificant pain in human beings. The pain is usually re-
lated to the annular tears and extrusion of the nuclear
material towards the outer 1/3rd of the disc (94). The
damaged disc shows neuropeptide Y and substance P
only up to the depth of 0.5 to 0.9 mm in the annulus and
except for this area, a normal disc is without any inner-
vations (95, 96). As the name suggests, this procedure
is purely diagnostic (97) and has little or no prognostic
value (98). The test is also thought to be of low specific-
ity (99). Even with a positive test, there are numerous
other variables that determine the outcome of a surgi-
cal procedure and hence it should only be considered
for diagnostic purposes. The results may also be influ-
enced by the subject’s emotional and psychological pro-
file (100). The procedure remains controversial due to
these facts. However, it can add to the diagnostic value
for identifying a patient’s pain generator where no ap-
parent source can be located on radiological studies
(101). The best diagnostic value is obtained by combin-
ing various studies along with the patient’s history and
physical examination (102).
A post-discogram computerized tomography scan pro-
vides a better understanding of the disc damage and
whether the nuclear material is extruded of contained
and also any disruption of the annulus causing leakage
of the injected contrast outside the disc (103). The pos-
sible contrast distribution and its correlation has been
classified (Dallas Classification) providing a basis for
quantifying the disc damage in terms of annular disrup-
tion (104).
Patel VB et al.
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Figure 16. Simplicity® Probe for SI Joint RF Lesioning (Courtesy Neuro-
therm)
Figure 17. Entry Point for the Discogram With Optimized View for the
L4-5 Disc
The articular elements of the inferior level bisect the end-plate of the level
above in an ideal view.
4.5.1.1.1. Technique
The basic concept is to place a needle within the nucleus
of the intervertebral disc and inject the contrast material
in a controlled graduated manner and pressurize the
disc to simulate the normal pain producing situations
in a given patient such as sitting, leaning forward etc.
which increase the intra-discal pressure (105, 106). The
pressures are measured at the tip of the needle (107) to
reflect the inherent pressure within the disc (opening
pressure), pressure when pain is felt (pain pressure),
maximum pressure generated (maximum pressure)
and the amount of pain felt (usually a numeric rating
pain scale) by the patient as well as the total amount of
contrast injected (108). Along with the intensity of pain,
the concordance of pain is also considered as an impor-
tant parameter. A painful disc that generates concordant
pain is considered to be the main pain generator for the
patient’s back pain. Occasionally patient may also feel
radicular symptoms as the disc may bulge out due to in-
ternal pressure and irritate the exiting nerve root. Exces-
sive pressure generation during a discogram can lead to
disc disruption in a previously un-ruptured disc and even
compression of the intra-spinal structures and should be
avoided (109, 110).
The safest route to the center of the disc is from the
postero-lateral approach under the nerve root. With this
angle, the needle can avoid touching the exiting nerve
root and thus avoid any pain that might interfere with
the interpretation of the test.
The procedure can be performed under CT guidance as
well as fluoroscopy (more common). The intended disc
is “squared” off so that the X-rays pass parallel to the disc
and the superior as well as inferior end-plates do not
have parallax. The cephalo-caudad angulation differs
depending on the level of the targeted disc. Usually at
L3-4 level the disc is almost squared off in an antero-pos-
terior view, whereas at lower levels it requires progres-
sively more cephalo-caudad angulation and the upper
levels a slightly more caudo-cephalad angulation. After
appropriate angulation based on the target disc level,
the c-arm is turned oblique so that the articular ele-
ments are approximately bisecting the end-plate above.
The entry point for the needle is marked just anterior to
the superior articular process (SAP) of the inferior verte-
bral body (Figure 17).
The choice of needles is sometimes based on the phy-
sician’s training. A single needle technique is used by
many where a 22 G spinal needle is inserted using the
above approach up to the middle of the disc within
the nucleus. A dual needle technique uses a 20 G intro-
ducer needle up to the outer rim of the annulus and a
curved discography 25 G needle through it (Figure 18).
This technique may help reduce contamination and
may help reduce any chance of infection within the disc
(Discitis), although it is very rare. Although there are
no good studies proving that a double needle technique
is safer, it may be because a very low incidence of disci-
Patel VB et al.
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Anesth Pain Med. 2015;5(4):e29716
tis. Regardless, it is prudent to maintain proper asepsis
throughout the procedure. The technique utilized by
this author uses a double needle technique, Duraprep®
prep, Ioban® drape and a complete body drape. Addi-
tionally the performer is fully scrubbed, gowned and
gloved similar to a surgical procedure. The patient re-
ceives IV antibiotics as well as antibiotic within the in-
jected contrast material. The author’s method is to mix
up 1 gm of cephazolin in 10 mL PFNS. Use 9 mL of this
mixture IV and the 1 mL is then further mixed with 19 mL
of contrast to make 20 mL of injectate which will then
contain 5 mg cephazolin per mL. The dual needle sets
are 20 G 3.5 or 5 inch introducer needle, 25 G 6 or 8 inch
discography needle (Figure 18). The longer needles are
necessary for the L5-S1 disc in most patients. The intro-
ducer needle is inserted in the manner described above
and the discography needle (curved) is then introduced
through the introducer to reach the center of the disc.
The curved needle helps maneuver the needle tip to its
desired location without multiple attempts. Especially
at the L5-S1 level, when an optimal oblique angle cannot
be achieved (due to the iliac crest obstructing the entry)
a curved needle can help with proper central placement
of the needle tip. Once in position, a manometric sy-
ringe with the injectate is attached to the needle. Some
newer syringes have a digital manometer attached to
them. A controlled injection of the contrast is then car-
ried out measuring the pressures during injection (Fig-
ure 19 A and B). Most discography syringes have a gradu-
ated injection rate and can inject a very small amount
with each turn of the plunger. This helps reduce exces-
sive pressure generation and uncontrolled amount of
injection material. A pressure graph can be printed out
with some syringes. Pressures such as opening pres-
sure (pressure at which the contrast is first seen enter-
ing the disc), pain pressure (pressure at which patient
complains of any type of pain), maximum pressure are
recorded (Figure 20A and B). The severity of pain as well
as the concordant nature of pain is noted. A post-disco-
gram CT scan can help identify any extra-discal spread
of the contrast and helps identify the condition of the
annulus of the disc and show if the disc is internally her-
niated (Figure 21A and B). Further treatment options are
based on these findings.
Figure 18. Dual Needle Set for Diagnostic Discography
Note the curved inner needle. This curve helps negotiate the needle with-
in the nucleus so that the tip is positioned centrally within the disc. The
curvature is reduced significantly as the needle exits the introducer
Figure 19. A and B, Dual Needle Discography
Note that even though the introducer needle is inferior to the center of the disc, the inner needle can achieve a central location of the tip due to the cur-
vature, thus eliminating the need for re-introduction of the needle.
Patel VB et al.
Anesth Pain Med. 2015;5(4):e2971616
Figure 20. A and B, Printed Data From a Discography Procedure Showing Graphical as Well as Numeric Readings
120
100
80
60
40
20
0
0:20
1:00
1:40
2:20
time
Pts Time
(m:s)
TTL Press
psi
Diff Press
psi
Volume
mL
psi
1
1
2
-
-
P max
V max
00:00
00:11
-
-
00:11
00:10
28
95
-
-
101
88
28
95
-
-
101
88
00.25
02.00
-
-
02.00
02.00
The leads are confirmed to be in the posterior epidural space with a lateral view.
Figure 21. A and B, Post Discogram CT Scan Image Showing Annular Disruption
Figure 22. A and B, Intradiscal Electrothermal Treatment (IDET)
Compare to the fluoroscopic image on the right taken during the procedure.
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4.5.1.1.2. Evidence
The diagnostic utility of a properly performed provoca-
tion discogram with manometric measurements is well
established. However, it should be noted once again that
a discogram is not intended for prognostic purposes and
cannot predict the results of a procedure including sur-
gery. There is a positive correlation between a history of
low back pain and a high intensity zone on an MRI and
a higher rate of positive discography (111). Derby et al.
(112) had found that patients with chronic low back pain
had a significantly lower pain tolerance than asymptom-
atic subjects during a pressure-controlled manometric
discography. They concluded that pressure-controlled
manometric discography using strict criteria may dis-
tinguish asymptomatic discs among morphologically
abnormal discs with Grade 3 annular tears in patients
with suspected chronic discogenic LBP. In a systematic
review, Manchikanti et al. (113) found that based on con-
trolled evaluations, the lumbar intervertebral discs have
been shown to be sources of chronic back pain without
disc herniation in 26% to 39%. The review indicated the
strength of evidence as Level II-2 for the diagnostic accu-
racy of lumbar provocation discography utilizing inter-
national association for the study of pain (IASP) criteria.
4.6. Therapeutic Interventions
4.6.1. Disc Decompression
Several methods for decompressing a painful inter-
vertebral disc are available to an interventional pain
physician. It is prudent to try one of these percutane-
ous methods prior to a surgical option in an attempt to
avoid surgery and possible post-surgical complications
(114-116). The evidence suggests that surgically treated pa-
tients with herniated discs have a similar outcome after
10 years post-surgery. However, about 25% of patients un-
dergo at least one more repeat surgery which was about
the same for non-surgically treated patients requiring
first time surgery (117). Same study also found that im-
provement in the patient’s predominant symptom and
work and disability outcomes were similar regardless of
treatment received. The controversy regarding an open
vs. percutaneous disc decompression continues and
there is “considerable evidence that surgical discectomy
provides effective clinical relief for carefully selected pa-
tients with sciatica due to lumbar disc prolapse that fails
to resolve with conservative management” (118). Never-
theless, a contained disc herniation is a pain generator
with minimal surgical options other than a percutane-
ous decompression and steroid injections.
A disc that generates concordant pain during a properly
performed manometric, provocation discogram and also
shows that the herniation is contained and not extruded
can be de-compressed by percutaneously removing part
of the nucleus. This helps reduce the pressure within the
disc and hence irritation of the outer third of the annulus
which contains the pain fibers. The procedure itself uses
almost the same approach to the disc as a discogram. Var-
ious methods are available to remove part of the nucleus,
thereby reducing the pressure within the disc so that
the bulge is reduced. This can help alleviate the pressure
upon a nerve root and help with radicular pain and/or
help prevent progression of the nuclear material to the
outer level of the annulus, helping with discogenic low-
er back pain. Several methods for decompressing a disc
with internal contained herniation (as evidenced with
a properly conducted diagnostic discogram and a post-
discogram CT scan) have been studied. At least 4 different
methods are available and have been utilized extensively.
These include a DeKompressor®, a coblation wand, laser
assisted decompression and automated percutaneous
device for decompression.
4.6.1.1. Technique
The technique for decompression is essentially the
same with various modalities. Usually a large bore tro-
car is introduced within the disc and advanced up to its
center through a postero-lateral approach percutane-
ously. The access is similar to performing a discogram.
The fluoroscopic image is optimized per level and the
cephalad-caudad angulation may vary with each level
with highest angulation at the L5-S1 level. The higher lev-
els at L2-3 and above require an opposite angulation with
a more caudad-cephalad tilt. The obliquity of the fluoros-
copy also varies according the level and should be rotated
such that the articular elements of the lower level nearly
bisect the vertebral end-plate of the upper level on the
image. With this optimized image the entry point is simi-
lar to the discography entry point at the anterior border
of the superior articular process of the inferior vertebral
body. Once the introducer trocar is in place at the center
of the disc the actual decompressing element is then in-
troduced under fluoroscopic view and decompression
carried out. In case of the DeKompressor®, a high speed
rotating element which is a battery operated self-con-
tained unit, is introduced and multiple passes are made
under live fluoroscopy. A live image is advisable to avoid
penetrating the anterior annulus and thus entering the
vital abdominal structures. The procedure extracts small
amount of the nuclear material which can be visualized
and sent for pathological study to ascertain its nature.
Usually the unit is operated for about 1 minute and the
material examined for its volume. A small amount of
nuclear material is extracted which is sufficient to reduce
the intra-discal pressure and can help with discogenic
pain. Nucleoplasty using the coblation technique is a
similar procedure with nearly identical technique. How-
ever, it requires bigger equipment which then provides
radio-frequency energy to ablate and then coagulate
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Anesth Pain Med. 2015;5(4):e2971618
the material. The ablation phase literally vaporizes the
tissue with heat at 400 - 700 centigrade by breaking
the bonds between the molecules. This gaseous mate-
rial then escapes through the cannula. The bulk of the
nucleus is thus reduced and the intradiscal pressure is
decreased. Multiple passes are made by rotating the co-
blation wand under live fluoroscopic view.
4.6.1.2. Evidence
In a systematic review of literature, Singh et al. (119)
concluded that one of the commonly used disc extrac-
tion unit (DeKompressor®) provided only a level III
evidence for efficacy using United States Preventive
Services Task Force (USPSTF) criteria. In another review,
Manchikanti et al. (120) studied another device for nu-
cleoplasty and considering pain relief as the primary
outcome measure, found that there was a level II-3
evidence for mechanical lumbar percutaneous disc
decompression with nucleoplasty in the treatment of
leg pain. However, there was no high quality evidence
available in managing axial low back pain. Lierz et al.
(121) showed in a relatively small group of patients that
there was a significant reduction of pain overall from
7.3 to 2.1 after a year. A reduction of analgesic use was
also observed after disc decompression using a DeKom-
pressor® wand.
With Coblation® nucleoplasty, Singh et al. (122) found
that overall, 75% of patients indicated a decrease in
their numeric pain scores at 12 months with a statis-
tically significant reduction in numeric pain scores.
The results indicated that disc decompression using
Coblation® (Nucleoplasty) was a safe and efficacious
procedure for reducing discogenic low back pain with
or without leg pain. A long term evaluation of this pro-
cedure was carried out by Zhu et al. (123). In a 2 year
study, they found that nucleoplasty may have satisfac-
tory clinical outcomes for treatment of protruded lum-
bar intervertebral disc for as long as two-year follow-up
with significant improvement in their VAS scores.
LASER has also been used to treat the disc with mini-
mally invasive technique. During a systematic review
of literature, Singh et al. (124) noted that the level of
evidence for percutaneous lumbar laser discectomy
(PLLD) is II-2 for short- and long-term relief which was
found to be equivalent to automated percutaneous
lumbar disc decompression. In a more recent study,
Zhao et al. (125) concluded that target percutaneous
laser disc decompression (T-PLDD) can significantly de-
crease pain and improve function of patients who have
extruded but non-sequestered lumbar intervertebral
disc herniation.
4.6.2. Thermal Annular Procedures
The thermal procedures for the annular disruptions
have evolved within the past two decades. This tech-
nique has been used extensively by interventional pain
physicians to treat a disrupted annulus of the disc. In
the past, attempts were made to use radiofrequency
ablation for the outer annulus to treat discogenic low
back pain caused due to annular disruption with poor
outcomes. This was thought to be due to lack of mois-
ture within the disc which is necessary for radiofre-
quency to generate heat. To overcome this problem, a
flexible heating element was devised to be introduced
within the disc and guided to the posterior annulus at
the nuclear-annular junction through a small cannula.
This was the first type of device that was used and is
called IDET® (IntraDiscal Electrothermal Therapy) (Fig-
ure 22A and B). IDET® is thought to decrease discogenic
pain by 2 different mechanisms: thermal modification
of collagen fibers and destruction of disc nociceptors.
Disctrode® is a similar device that provides heating ele-
ment to achieve similar results. Cooled radiofrequency
has also been used to treat annular disruptions. It is
claimed that such a lesion is larger and also avoids heat-
ing up the intra-spinal tissue and thus help minimize
the risk of damaging the exiting nerve root during the
procedure.
4.6.2.1. Technique
Technique varies according to the procedure. How-
ever, the standard approach to the disc remains largely
unchanged. The use of IDET® requires passing a flex-
ible heating element through the introducer cannula
(Figure 22A and B) and placing it between the nucleus
and the annulus in the posterior part of the disc. The
passage of the heating element requires proper angle
of the cannula in the disc and a certain finesse to avoid
breaking it. Once in place, the equipment delivers elec-
trical energy to heat up the element and raise the intra-
discal temperature to 900 C. In a recent cadaveric study
the temperatures generated by IDET have been found
to be safe for the intra-spinal structures and did not
appear to be high enough to cause any nerve damage
(126).
Procedure for cooled radio-frequency procedure re-
quires placement of dual introducers through bilateral
postero-lateral approaches. The tips of the main RF ele-
ments are positioned at the nuclear-annular junction
(Figure 23A and B) where the equipment delivers radio-
frequency through a water cooled probe on each side.
4.6.2.2. Evidence
In one of the earlier studies, Saal (127) showed that
patients with low back pain of discogenic origin
whose symptoms had failed to improve with aggres-
sive non-operative care demonstrated a statistically
significant and clinically meaningful improvement
on the short form health survey (SF-36) and the visual
analog scale (VAS) scores at a minimum follow-up of 1
Patel VB et al.
19
Anesth Pain Med. 2015;5(4):e29716
year after IDET. However, Freeman et al. (128), in a ran-
domized, double-blind placebo controlled trial found
that although the IDET procedure appeared safe with
no permanent complications, no subject in either
arm met criteria for successful outcome. Further de-
tailed analyses showed no significant change in out-
come measures in either group at 6 months. This study
demonstrated no significant benefit from IDET over
placebo. Pauza et al. (129) published the results of a
randomized placebo controlled trial for discogenic
low back pain showing that patients in both groups
(treated and sham) exhibited improvements, but mean
improvements in pain, disability and depression were
significantly greater in the group treated with IDET.
More patients deteriorated when subjected to sham
treatment, whereas a greater proportion showed im-
provements in pain when treated with IDET. They con-
cluded that IDET appeared to provide worthwhile re-
lief in a small proportion of strictly defined patients.
Similar method was used with Disctrode ® which also
uses a thermal element to coagulate the outer annulus.
In a randomized double-blind controlled trial for this
procedure, Kvarstein et al. (130) found that a 6-month
analysis did not reveal any trend towards overall effect
or difference between active and sham treatment for
the primary endpoint: change in pain intensity (0 - 10),
after 12 months the overall reduction from baseline
pain had reached statistical significance, but there was
no significant difference between the groups, hence
they would not recommend intra-annular thermal
therapy with the discTRODE® probe.
Cooled radiofrequency had been studied initially at
the Cleveland Clinic. Kapural and Mekhail (131) pub-
lished an initial report of a patient showing that biac-
uplasty procedure showed significant improvement
in patient functional capacity, and pain scores also im-
proved after 6 months. Later in a follow up study (132),
he concluded that patients showed improvements in
several pain assessment measures after undergoing
IDB (intradiscal Biacuplasty®) for discogenic pain.
More recently in a randomized, placebo controlled
trial for IDB (133), after 6 months, patients in the IDB
group exhibited statistically significant improvements
in physical function, pain, and disability compared to
the sham group. It was concluded that IDB should be
recommended to select the patients with chronic dis-
cogenic low back pain. In a comparative study of cooled
versus traditional radiofrequency ablation of the later-
al branches for sacroiliac joint pain, Cheng et al. (134)
did not find any significant univeriable relationship be-
tween radiofrequency techniques and the duration of
pain relief and concluded that cooled radiofrequency
does not provide longer relief from the sacroiliac joint
pain. This study demonstrates that a larger lesion pro-
duced by cooled radiofrequency is not superior to a
properly conducted conventional lesion. However, the
precision required in the placement of a conventional
needle may not be that critical with cooled radiofre-
quency due to a larger lesion being generated.
Recently, Helm et al. (135) did a systematic review of lit-
erature to study the thermal annular procedures (TAP)
and found that the evidence is fair for IDET® and poor
for DiscTRODE®. They did not comment on Biacuplas-
ty® as the studies were not published yet.
Figure 23. A and B, Biacuplasty® Procedure With Cooled Radiofrequency
The entry point is at the posterolateral annulus and the thermal element
is guided through the introducer at the annular-nuclear junction with
the final position in the posterior aspect of the disc.
Patel VB et al.
Anesth Pain Med. 2015;5(4):e2971620
Figure 24. A, B, C and D: Spinal Cord stimulator Lead Placement for Low Back Pain as Well as Radicular Pain in a Post-Laminectomy Pain Patient Using a
Dual Lead Configuration
The lesion is generated between the tips of the probes and provides a near complete coverage of the posterior annulus.
4.6.3. Intrathecal Infusion Devices
Intrathecal infusions have been used for pain for de-
cades. This modality was mainly offered to cancer pain
patients in the past, but since the mid-1990s it has gained
widespread utilization for non-cancer pain as well. The
procedure involves placement of a catheter within the
dural sac providing precisely measured doses of medica-
tions directly into the spinal fluid. The device itself is im-
planted in a sub-cutaneous pocket, usually created in the
anterior abdominal wall. There are computerized pumps
of varied capacities available for implant which can be
programmed precisely to deliver various amounts of the
injectate. Various other pumps are also available that are
capable of delivering a fixed amount of injectate but can-
not be programmed. These pumps operate mechanically
and commonly utilize a refrigerant under pressure. To
change the dosage, one has to alter the concentration of
the drug being delivered. The efficacy of opiates delivered
in this manner provides not only a significant reduction
in the amount of medication required for adequate anal-
gesia, but also helps reduce the incidence of side effects
due to systemic effects of opiates. United States food and
drug administration (FDA) has currently approved only
morphine sulphate, ziconotide (the only non-opiate
drug approved for chronic pain) and baclofen (for cen-
trally originating spasticity) for such use in these devices
for pain and floxuridine and methotrexate for treatment
of cancer (136). Although not approved by FDA, several
medications have been successfully used for infusion.
These include fentanyl, sufentanil and local anesthetics
such as bupivacaine.
4.6.3.1. Technique
The delivery method for intra-thecal infusions ranges
from simple external infusion pumps connected to the
Intrathecal catheters placed percutaneously to highly
sophisticated computerized, programmable pumps that
are implanted sub-cutaneously. The technique for place-
ment of an implantable intrathecal infusion devise is
relatively simple but requires surgical skills. Procedure
can be performed under spinal or general anesthesia. The
access to the intra-thecal space is achieved using a large
bore needle placed percutaneously at the mid-lumbar re-
gion. A flexible styleted catheter is then passed through
this needle and guided under fluoroscopic view to the
thoraco-lumbar junction region. Once the catheter is in
place, it is tunneled sub-cutaneously from the midline in
the back to the front in the lower abdominal area using
a tunneling device. A sub-cutaneous pocket is then sur-
gically created in the anterior abdominal wall and the
infusion devise is placed within this pocket and option-
ally secured. The catheter is also surgically secured to the
inter-spinous ligament to prevent migration. External
infusion devices are preferred for a relatively short term
use and for terminally ill patients.
4.6.3.2. Evidence
Long term effect of this modality has been associated
with significant complications. Intrathecal granuloma
formation at the tip of the catheter has been known to
cause spinal cord compression. Although studies show-
ing the incidence are not in abundance, several case re-
ports have been published in the recent past (137-141). In
a systematic review that we conducted in 2009 (142) we
found that despite the high costs of chronic non-cancer
pain, it had been claimed that there was lack of evidence
for intrathecal infusion systems for the use in chronic
non-cancer pain and the cost effectiveness of these sys-
tems had been questioned in improving pain and func-
tion. The level of evidence for intrathecal infusion sys-
tems indicated either Level II-3 or Level III (limited) for
non-cancer pain. We also noted that limitations of that
study included paucity of literature, lack of quality evi-
dence, and lack of randomized trials. Earlier in 2004 Deer
et al. (143) published “Intrathecal drug delivery for treat-
Patel VB et al.
21
Anesth Pain Med. 2015;5(4):e29716
ment of chronic low back pain: report from the National
Outcomes Registry for Low Back Pain”. They had found
that at 12-month follow-ups, implanted patients experi-
enced reductions in numeric back and leg pain ratings,
improved Oswestry scores, and high satisfaction with
the therapy. Smaller patient groups have been studied
for various low back pain diagnoses. Lara et al. (144) stud-
ied 30 patients with failed back surgery syndrome and
found that intrathecal infusion of morphine is a useful
and safe tool for long-term treatment of chronic nonma-
lignant pain. Anderson and Burchiel (145) prospectively
studied 40 patients with chronic non-cancer pain and
concluded that continuous intrathecal morphine can be
safe and effective therapy for severe non-malignant pain
among carefully selected patient population and can re-
sult in improvement of long term areas of daily function.
In another small study, Kumar et al. (146) concluded that
in their experience, the administration of intrathecal
opioid medications for nonmalignant pain is justified in
carefully selected patients. The common conclusion in
these and several other studies is that the patient selec-
tion has to be carefully made in order to obtain a success-
ful outcome.
Newer drugs approved for use in implanted pumps may
provide better outcomes. Ziconotide is one such drug
that has been well studied. Rauck et al. (147) found that
Ziconotide is a potential therapeutic option for chronic
refractory neuropathic pain. Lynch et al. (148) concluded
that Ziconotide is a therapeutic option for treatment of
severe chronic pain in patients who have exhausted all
other agents, including intrathecal morphine, and for
whom the potential benefit outweighs the risks of seri-
ous neuropsychiatric adverse effects and of having an im-
planted device. In a clinical update, Pope and Deer (149)
suggested that Concomitant use of Ziconotide and mor-
phine is an option when considering use of FDA-labeled
intrathecal drugs in those resistant to monotherapy.
4.6.4. Spinal Cord Stimulation (SCS)
Spinal cord stimulation solely for lower back pain is
an indication not yet approved by FDA. However, several
articles have been published that show its efficacy. Most
patients with failed back surgery syndrome have a com-
bination of low back pain as well as radicular leg pain.
Majority of the studies have been done on patients with
lower back as well as leg pain and thus a quality study is
lacking for lower back pain alone. Nevertheless, SCS has
been extensively used alone or in combination with oth-
er interventions including intrathecal infusion devices to
achieve satisfactory pain relief in a patient with chronic
pain. This modality has been shown to be more effective
and less costly in the long term compared to the other
interventions or conservative management of a patient
with chronic low back pain (150, 151). However, careful pa-
tient selection is necessary for optimal outcomes and it
may not be cost effective in certain patient populations
such as workers’ compensation patients (152) and the ini-
tial high procedural cost may not be offset by lower cost
of subsequent care.
4.6.4.1. Technique
The described technique for coverage of low back pain is
similar to the lead placements for post laminectomy syn-
drome with radicular pain. Usually two leads are placed
(153) but several practitioners have been using more than
two leads. Additionally multi contact surgical leads are
also available. These leads are paddle shaped and have
multiple arrays of contacts providing better coverage
and deeper penetration of the applied current.
The permanent and sometimes temporary lead place-
ment procedure is performed with strict aseptic precau-
tions similar to a surgery in an operating room. Some
practitioners place the temporary lead in clean rather
than sterile rooms. The percutaneous method involves
placing an introducer needle in the upper lumbar epi-
dural space usually at L1-2 level (Figure 24A - D). The nee-
dle needs to be angulated cephalad to facilitate the pas-
sage of the lead smoothly into the epidural space. Loss
of resistance technique is utilized to identify the entry of
the needle into the epidural space. The stimulator lead(s)
is then introduced and guided in the posterior epidural
space under fluoroscopic guidance and advanced in the
paramedian area up to the T8-T9 level under very light
sedation and local anesthesia at the entry point. At this
point the patient is confirmed to be wide awake and re-
sponsive to commands. The lead is then connected to a
temporary external stimulator and the pattern of stim-
ulation established to cover the affected painful area. A
second (and sometimes a third) lead is also placed in a
similar manner. For the trial stimulation, these leads are
then secured to the skin at the entry point and patient
is allowed to go home with the stimulator connected ex-
ternally. Usually the trial period may vary between physi-
cians from 3 to 10 days. It is thought that a shorter trial
period may reduce therapeutic failures, risk of infection
as well as the cost of therapy (154). The temporary leads
are removed after the trial period and the patient may
receive a permanent implant if the trial was effective in
relieving the pain.
The permanent placement of leads is similar to the trial
placement. After the leads are satisfactorily positioned
and tested for the stimulation pattern, they are tunneled
through the subcutaneous area to the implantable pulse
generator (IPG) placed in a subcutaneous pocket created
below or above the beltline posteriorly in most cases. The
lead(s) is then secured to the interspinous ligament us-
ing an anchor device. Recent advances in the design of
these anchoring devices have simplified the anchoring
process and may provide a more secure method as com-
pared to the past methods. Most of the modern IPGs are
rechargeable and are relatively small in diameter and
thin requiring only a small subcutaneous pocket. Vari-
ous systems have various options for programming the
Patel VB et al.
Anesth Pain Med. 2015;5(4):e2971622
system. An external programmer/controller can program
the implanted IPG remotely. It is said that covering the
lower back for pain is relatively more difficult and hence
multiple leads and contacts are necessary. Surgically
placed leads require a laminotomy performed under
general anesthesia and hence the patient response to the
initial stimulation is not possible. A minimally invasive
laminotomy for paddle lead placement has been studied
under spinal anesthesia as well and that method may be
preferable as the patient can be awake and responsive
during the testing phase as the stimulation is carried out
at a level higher than the block (155). However, a percu-
taneous trial followed by a surgical placement may pro-
vide better stability during the initial period when lead
migration is more common. Newer systems are avail-
able for percutaneous as well as surgical placements and
tend to overcome several of these difficulties in covering
lower back with a stimulator. One of the newest systems
can place an array of stimulator leads, or a narrow paddle
lead percutaneously. In a recent article Deer et al. (156)
described this method of placement of a paddle lead via
a minimally invasive percutaneous method, as well as
complex cylindrical arrays with a single needle entry to
the epidural space. The device functioned successfully
and presented a safe option for placing paddle leads and
complex arrays. It’s safe use has been corroborated by
Loge et al. (157) in a series of 34 patients. The method is
safe and effective as well as has a low migration rate (158).
4.6.4.2. Evidence
In a review article, Epstein and Palmieri (159) found
that there is strong evidence for efficacy and cost effec-
tiveness of spinal cord stimulation in the treatment of
pain associated with intractable angina, failed back sur-
gery syndrome, and complex regional pain syndrome.
Clinical studies revealed a success rate of from 50% to
70% with spinal cord stimulation, with decreased pain
intensity scores, functional improvement and decreased
medication usage. In a relatively small study of 41 pa-
tients with predominantly lower back pain, Ohnmeiss
and Rashbaum (160) noted that majority of patients were
satisfied with the results of SCS and would have the pro-
cedure again knowing what their outcome would be. In a
prospective multicenter study, Burchiel et al. (161) found
that Spinal cord stimulation can be an effective therapy
for management of chronic low back and extremity pain.
They included more than 200 patients with lower back
and leg pain. All the pain and quality-of-life measures
showed statistically significant improvement during
the treatment year using VAS, McGill Pain Questionnaire,
Oswestry Disability Questionnaire, Sickness Impact Pro-
file, and the Back Depression Inventory. Another study
published recently in this journal, looking also at a com-
bination of lower back and leg pain (162) showed that
a hybrid, surgically placed lead in failed back surgery
patients, is capable of alleviating both low back and leg
pain. Stimulator placement is a costly procedure and the
initial argument was against such treatment but it has
been found to be more cost effective than conventional
medical management (CMM) of chronic pain in several
studies. Taylor and Taylor (163) noted that in selected pa-
tients with FBSS, SCS is cost effective both as an adjunct
to CMM and as an alternative to reoperation. Bala et al.
(150) performed a systematic review of cost effectiveness
of SCS in FBSS patients. They found that SCS is both more
effective and less costly in the treatment of FBSS in terms
of pain reduction in the long-term. Compared to repeat
spinal surgery, spinal cord stimulation is more effective
in the treatment of persistent radicular pain and it obvi-
ates the need for re-operation (164). This study did not ad-
dress low back pain issues in these patients, but consid-
ering the fact that most failed back surgery patients also
have back pain along with radicular symptoms, it may
be an effective choice for improving their life style and
productivity. North et al. (165) also studied the efficacy
of spinal cord stimulation compared to other interven-
tional modalities and found that SCS had a statistically
significant advantage over reoperation after 6 months. A
systematic review published by Frey et al. (166), although
not just for lower back pain but post-laminectomy syn-
drome as a whole, showed the evidence to be Level II-1
or II-2 for clinical use on a long-term basis for relieving
chronic intractable pain.
4.6.5. Peripheral Nerve Field Stimulation (PNFS) for Low
Back Pain
Peripheral nerve field stimulation is a relatively newer
modality utilizing the neuromodulation technique.
While spinal cord stimulation alone often may be able
to provide coverage for axial low back pain at the time of
placement, constant adjustments to the programming is
required over time period to achieve adequate coverage
for pain (167). Including peripheral nerve field stimula-
tion along with spinal cord stimulation provides a bet-
ter outcome for control of chronic pain which is axial in
nature.
4.6.5.1. Technique
Technique for placement of leads for peripheral nerve
field stimulation is simpler than a spinal cord stimula-
tor placement. Peripheral nerve field stimulation for low
back pain has been most commonly studied for failed
back surgery syndrome (FBSS) pain and involves place-
ment of multiple stimulator leads within the sub-cutane-
ous space in the lumbo-sacral region. The leads surround
the painful aspect of the lower back and are commonly
used in conjunction with centrally placed SCS leads. With
no clear guidelines for appropriate depth for placement
of these leads, it is difficult to achieve reproducible re-
sults. Observing that a shallower placement may be too
painful and lack efficacy and a placement too deep may
Patel VB et al.
23
Anesth Pain Med. 2015;5(4):e29716
be uncomfortable including muscle contractions, Abe-
jon et al. (168) used radiofrequency stimulation probe
to identify the appropriate depth of the leads to help
achieve proper depth of placement.
4.6.5.2. Evidence
In one of the larger and early prospective observational
studies, Verrills et al. (169) found that in 100 consecutive
patients receiving peripheral nerve field stimulation
(PNFS) for the treatment of chronic intractable pain, an
overall 72% of patients reduced their analgesic use fol-
lowing PNFS and showed a significant reduction in their
disability determined by the Oswestry Disability Index.
Bernstein et al. (170) studied a group of 20 patients with
chronic low back and leg pain syndromes who had failed
conventional therapies. These patients underwent im-
plantation of a combination of traditional SCS (epidur-
ally) and PNFS (around the field of maximum intensity of
lumbar pain) if the trial stimulation showed more than
50% of improvement in their pain. Majority of patients
found the combination better in controlling their over-
all pain rather than either modality alone. Another small
but prospective study by Mironer et al. (171) studied two
groups of 20 patients each. In the first part 20 patients
were implanted with SCS and PNFS. They selected the best
program out of three: SCS alone, PNFS alone, or both to-
gether. In the second part another 20 patients with the
same implanted leads were selecting between three pro-
grams: SCS and PNFS separately, SCS as anode and PNFS
as cathode, or in reverse. They concluded that communi-
cation between SCS and PNFS provided wider coverage
of axial pain and simultaneous use of SCS and PNFS in-
creased the efficacy of both methods for axial back pain.
More recently, in a small study, Reverberi et al. (172) placed
octapolar as well as quadrapolar leads for spinal cord as
well as peripheral nerve field stimulation and found that
when used in conjunction with spinal cord stimulation,
PFNS provided a significant reduction in opiate intake
as well as reduction in the disability and pain after one
year. Yakovlev et al. (173) showed that in a small group of
patients with post-laminectomy syndrome (PLS) suffer-
ing from low back pain, four vertically orientated leads
provide an effective treatment option for patients with
PLS after multilevel surgical procedures with intractable
low back pain who had failed conservative treatment af-
ter 12 months follow up. In a retrospective study, Burgher
et al. (174) studied sub-cutaneous lead placements on
patients with axial low back pain and found that was a
promising therapy for axial neck and back pain based on
a small cohort of patients. They used ultrasound to assist
with electrode placement at the most appropriate depth
beneath the skin. While inter-lead stimulation had been
preferred by patients in published reports, they did not
find it clearly influenced pain relief.
Although these studies show a significant advantage of
using sub-cutaneously placed leads for PFNS along with
SCS for axial low back pain, a larger prospective random-
ized study is still lacking.
4.6.6. High Frequency Stimulation for Low Back Pain
Conventional spinal cord stimulation can be more ef-
fective in decreasing low back pain if a higher frequency
of stimulation is utilized. The placement of the leads and
the rest of the procedure remains essentially the same,
except the difference in programming. Such high fre-
quencies do not produce paresthesiae. The frequency can
be achieved up to 10 kHz with the use of certain SCS sys-
tems. It is shown in an animal study that delivery of high
frequency current (3 - 50 kHz) to the region of epidural
nerve root or nerve root entry inhibits afferent nocicep-
tive input and therefore may be an alternative to tradi-
tional spinal cord stimulation without sensory paresthe-
siae as neuronal activation cannot occur at frequencies in
this range (175).
4.6.6.1. Technique
Technique for the placement of these leads is the same
as a conventional SCS.
4.6.6.2. Evidence
Recent literature has shown significant success with
this method for SCS. Van Buyten et al (176) studied eighty
three patients with back pain and treated them with a
dual eight-contact leads placed percutaneously. Patients’
pain ratings, disability, sleep disturbances, and satisfac-
tion were assessed for up to six months. Seventy-four per-
cent of patients had greater than 50% back pain relief at
six months. There were significant improvements in Os-
westry disability score and sleep, and reductions in pain
medication use. This was achieved without the sensation
of paresthesiae and results confirmed a favorable safety
and efficacy profile of the high-frequency SCS system. In
a smaller study, Tiede et al. (177) found that patients with
predominant back pain reported a substantial reduction
in overall pain and back pain when trialed with high-
frequency spinal cord stimulation therapy. To confirm
these findings, Perruchoud et al. (178) compared the ef-
fects of high frequency stimulation to a sham group in a
double blind study with patients who were already stable
on conventional spinal cord stimulation therapy. They
noted that the mean benefit of high frequency vs. sham
was not statistically significant and it appeared that the
effect of HFSCS and sham is equal and only the order in
the sequence, not the nature of the treatment, seems to
dictate the effect.
Another newer and emerging technology in this field is
dorsal root ganglion stimulation. Proper long term stud-
ies are yet to be seen in the published literature although
several are ongoing at this time. The future for neuro-
stimulation is much more promising than ever due to
newer technology and advances in electronic technol-
Patel VB et al.
Anesth Pain Med. 2015;5(4):e2971624
ogy. Use of an accelerometer has also been emerging to
regulate the amount of stimulation based on a patient’s
position.
5. Conclusions
Low back pain is a major health problem in the civi-
lized nations. One of the reasons may be the prevalence
of inactivity in this population. Disorders of the lumbar
spine are among the most common medical problems in
western countries, affecting up to 80% of people at some
time during their lives (179). Although initially managed
by oral analgesics, low back pain can get severe enough
to require light to heavy opiate medications. Opiates for
lower back pain do not have much convincing evidence
and compared to interventional therapies, they have
fewer efficacies not only in controlling pain but also im-
proving function. Several modalities for controlling low-
er back pain in specific conditions are available to a pain
practitioner. Not only do they help reduce or even elimi-
nate the use of systemic analgesics, but also improve
functional capacities as evidenced in abundance of pub-
lished literature. Proper diagnosis is definitely the first
step towards providing proper treatment options. Sev-
eral modalities may be required in most of the patients.
Various treatment options, when combined, provide the
best outcomes such as combining physical therapy, psy-
chological modalities, and medications along with inter-
ventional procedures.
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