Article

Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain

American Society of Interventional Pain Physicians, Paducah, KY 42001, USA.
Pain physician (Impact Factor: 3.54). 02/2007; 10(1):7-111.
Source: PubMed

ABSTRACT

The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States.
To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices.
Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes.
The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate).
Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief.
These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."

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Available from: James Giordano, May 16, 2014
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    • "Epidural steroid spinal injections administered via a translaminar or transforaminal route to target specific nerve roots have been shown to provide up to 6 months of pain relief, though long-term benefits are variably effective, and complications as well as side-effects, like anxiety, cataracts and stomach ulcers, may compound the unreliability of the intervention[ 124 ]. According to a literature synthesis[125]examining facet joint nerve blocks, evidence for therapeutic lumbar intraarticular facet injections was moderate for both short and long-term improvement, and limited for cervical facet joint injections. Evidence for cervical medial branch blocks was moderate. "

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    • "For lumbar spine, there are three approaches for epidural steroid injections, namely: transforaminal, interlaminar and caudal. According to systematic reviews, successful evidences of caudal epidural steroid injections in spinal stenosis are limited [5,6]. Fluoroscopic guided transforaminal epidural steroid injection (TFESI) has several advantages such as the accuracy, specific targeting, and safety with low volumes of injectate. "
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    • "Spinal injections are an important tool in the diagnosis and therapy of spinal disorders. Periradicular injections, also termed nerve root-blocks or perineural injections, are used despite their controversial evidence successfully by orthopaedic surgeons, radiologists, neurosurgeons and pain interventionalists for decades in the diagnosis and therapy of nerve root irritation due to intervertebral disc herniation, zygapophysial joint hypertrophy and spondylolisthesis [1,2]. The performing interventionalists are using different types of imaging for a safe injection guidance, ie. "
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