Interventional Techniques: Evidence-Based Practice Guidelines in the Management of Chronic Spinal Pain

Pain Physician 2007; 10:7-111 • ISSN 1533-3159

Guidelines

Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain

Mark V. Boswell, MD, PhD, Andrea M. Trescot, MD, Sukdeb Datta, MD, David M. Schultz, MD, Hans C. Hansen, MD, Salahadin Abdi, MD, PhD, Nalini Sehgal, MD, Rinoo V. Shah, MD, Vijay Singh, MD, Ramsin M. Benyamin, MD, Vikram B. Patel, MD, Ricardo M. Buenaventura, MD, James D. Colson, MD, Harold J. Cordner, MD, Richard S. Epter, MD, Joseph F. Jasper, MD, Elmer E. Dunbar, MD, Sairam L. Atluri, MD, Richard C. Bowman, MD, PhD, Timothy R. Deer, MD, John R. Swicegood, MD, Peter S. Staats, MD, Howard S. Smith, MD, PhD, Allen W. Burton, MD, David S. Kloth, MD, James Giordano, PhD, and Laxmaiah Manchikanti, MD

Background: 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.

Objective: 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.

Design: 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.

Methods: 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).

Results: 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, From: American Society of for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid Interventional Pain Physicians. injections is strong for short-term and moderate for long-term improvement in managing lumbar Address Correspondence: nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain ASIPP, 81 Lakeview Drive secondary to lumbar post laminectomy syndrome and spinal stenosis. Paducah, KY 42001 The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, E-mail: [email protected] Funding: None. the evidence is strong for short-term relief and moderate for long-term relief. Conflict of Interest: None. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for Author affiliation information is long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. listed in alphabetical order on pages 74 and 75. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic Free Full manuscript: low back pain, whereas for annuloplasty the evidence is limited. www.painphysicianjournal.com www.painphysicianjournal.com Pain Physician: January 2007:10:7-111

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. Conclusion: 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.” Key words: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions, epidural injections, epidural adhesiolysis, discography, radiofrequency, disc decompression, vertebroplasty, kyphoplasty, spinal cord stimulation, intrathecal implantable systems

Contents 5.2 Provocation Discography 1.0 Introduction 5.3 Transforaminal Epidural Injections 1.1 Purpose or Selective Nerve Root Blocks 1.2 Rationale 5.4 Sacroiliac Joint Blocks 1.3 Importance 1.4 Population and Preferences 6.0 Therapeutic Interventional Techniques 1.5 Implementation and Review 6.1 Facet Joint Interventions 1.6 Application 6.2 Epidural Injections 1.7 Focus 6.3 Epidural Adhesiolysis 1.8 Technology 6.4 Sacroiliac Joint Interventions 1.9 Methodology 6.5 Intradiscal Therapies 6.6 Percutaneous Disc Decompression 2.0 Chronic Pain 6.7 Vertebral Augmentation Procedures 2.1 Definitions 6.8 Implantable Therapies 2.2 Prevalence 2.3 Spinal Pain 7.0 Evaluation and Management 2.4 Chronicity 7.1 Evaluation 2.5 Health and Economic Impact 7.2 Medical Necessity Management

3.0 Structural Basis 8.0 Delivery of Interventional Technology 3.1 Facet or Zygapophysial Joints 8.1 Facet Joint Injections and Medial Branch Blocks 3.2 Intervertebral Disc 8.2 Medial Branch Neurotomy 3.3 Dorsal Root Ganglion 8.3 Epidural Injections 3.4 Sacroiliac Joint 8.4 Percutaneous Adhesiolysis 3.5 Postlaminectomy Syndrome 8.5 Spinal Endoscopic Adhesiolysis 3.6 Spinal Stenosis 8.6 Sacroiliac Joint Injections 8.7 Sacroiliac Joint Radiofrequency Neurotomy 4.0 Interventional Techniques 4.1 Mechanism of Action 9.0 An Algorithmic Approach

5.0 Diagnostic Interventional Techniques 10.0 Conclusion 5.1 Facet or Zygapophysial Joint Blocks

www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

1.0 Introduction chronic pain conditions are considered as either 1.1 Purpose acute recurrent problems that are characterized by Evidence-based clinical practice guidelines for in- periods of quiescence punctuated by flare-ups, or terventional techniques in the management of chron- chronic diseases, like diabetes or hypertension, re- ic spinal pain are statements developed to improve quiring long-term treatment with ongoing care. On quality of care, patient access, treatment outcomes, the basis of advances in imaging, neural anatomic appropriateness of care, efficiency and effectiveness, findings, new discoveries in chemical mediation, the and achieve cost containment by improving the cost- development of precision diagnostic and therapeu- benefit ratio (1-4). tic injection techniques, and reported non-operative treatment successes, the importance of intervention- 1.2 Rationale al techniques in managing chronic spinal pain has Interventional pain management is an emerg- been defined. ing specialty. Consequently, the problems faced by Many guidelines, systematic reviews, Cochrane this specialty may be disproportionate compared to Reviews, and other articles pertaining to intervention- established specialties. Interventional pain manage- al pain management have been published (1-4,9-82). ment is also faced with increased utilization. The data Neither cancer pain nor spine surgery guidelines may for interventional techniques in the Medicare popula- be applied to manage chronic spinal pain. The debat- tion shows that from 1998 to 2005, overall growth in ed quality of the systematic reviews, guidelines, and interventional techniques has been 179%, increasing policies, along with non-applicability across the popu- from 1,406,417 procedures in 1998 to 3,925,467 pro- lations, bias, with alleged major shortcomings, result- cedures in 2005 (5,6). Extrapolation of the Medicare ing in potentially harmful healthcare implications for statistics suggests that 4 times as many procedures are patients in the United States have been highlighted performed in the general U.S. population. (1-4,9-97). Consequently, the American Society of In- Available evidence documents a wide degree of terventional Pain Physicians (ASIPP) has developed an variance in the definition and the practice of interven- ongoing process of evidence synthesis and guideline tional pain management (1-6). Application of inter- preparation and appropriate updating since 1999 ventional techniques by multiple specialties is highly (1-4). The interventional techniques guidelines and variable for even the most commonly performed pro- opioid guidelines developed by the American Soci- cedures and treated condition(s) (6). ety of Interventional Pain Physicians have been listed National Uniform Claims Committee (NUCC) (7) on the AHRQ/NGC website (98,99). ASIPP guidelines defined interventional pain management as the disci- have been developed with rigorous quantitative and pline of medicine devoted to the diagnosis and treat- qualitative methodology with literature review and ment of pain and related disorders by the application synthesis. of interventional techniques in the management of This is the fourth revision and update of guide- subacute, chronic, persistent, and intractable pain, in- lines to address the issues of systematic evaluation dependently or in conjunction with other modalities and ongoing care of chronic or persistent pain. Pri- of treatments. marily, these guidelines provide information about Medicare Payment Advisory Commission (Med- the scientific basis of recommended procedures. The PAC) (8) described interventional techniques as guidelines, properly applied, should increase compli- minimally invasive procedures including percuta- ance, dispel misconceptions, contribute to appropri- neous precision needle placement, with placement ate patient expectations, and facilitate the relation- of drugs in targeted areas or ablation of targeted ship between patients, physicians, and the payers. nerves; and some surgical techniques such as laser or endoscopic discectomy, intrathecal infusion pumps 1.4 Population and Preferences and spinal cord stimulators, for the diagnosis and The population covered by these guidelines in- management of chronic, persistent or intractable cludes all patients suffering with chronic spinal pain pain. eligible to undergo commonly utilized and effective interventional technique(s). A treatment plan must be 1.3 Importance established taking into consideration the evidence, Many of the causes of spinal pain and other patient preferences, and risk-benefit ratio.

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1.5 Implementation and Review facet joint blocks, provocative discography, sacroiliac The dates for implementation and review were joint blocks, and transforaminal epidural injections or established: selective nerve root blocks. ♦ Effective date – February 1, 2007 Therapeutic interventional techniques in- ♦ Expiration date – January 31, 2009 clude facet joint interventions which encompass ♦ Scheduled review – April 1, 2008 intraarticular injections, medial branch blocks, and medial branch neurotomy; sacroiliac joint interven- 1.6 Application tions, including sacroiliac joint blocks, and radio- These guidelines are intended for use by inter- frequency neurotomy; epidural injections including ventional pain physicians and other physicians trained caudal epidural injections, interlaminar epidural in interventional pain management. However, these injections, and transforaminal epidural injections; guidelines do not constitute inflexible treatment rec- epidural adhesiolysis including percutaneous adhe- ommendations. It is expected that a provider will es- siolysis, and spinal endoscopic adhesiolysis; intradis- tablish a plan of care on a case-by-case basis, taking cal therapies including intradiscal electrothermal into account an individual patient’s medical condi- therapy (IDET) and radiofrequency posterior an- tion, personal needs, and preferences, and the phy- nuloplasty; percutaneous disc decompression with sician’s experience. Based on an individual patient’s automated percutaneous lumbar discectomy, per- needs, treatment different from that outlined here cutaneous laser discectomy, nucleoplasty and de- could be warranted. These guidelines do not repre- compression utilizing mechanical high RPM device sent a “standard of care.” or DeKompressor technology; vertebral augmen- The goal of these guidelines is to provide practi- tation techniques including vertebroplasty and tioners and payors information to determine whether kyphoplasty; and implantable therapies, which in- the available evidence supports the notion of a “stan- clude spinal cord stimulation and intrathecal drug dard” for interventional techniques. “Standard” re- administration systems. fers to what is applicable to the majority of patients, These guidelines also describe evaluation and with a preference for patient convenience and ease of management services, delivery of interventional tech- administration without compromising the treatment nology, and an algorithmic approach to diagnosis and efficacy or morbidity (100). It is essential to recognize management of chronic spinal pain. the difference between “standard” and “standard of care,” as utilized by a legal definition. 1.9 Methodology In developing these guidelines, all types of evi- 1.7 Focus dence are utilized. The methodology utilized was These updated and revised guidelines focus on a the best scientific approach available with compre- range of interventions that are the essential elements hensive evidence synthesis. Further, if an evidence- of effective management of chronic spinal pain. It is based approach failed to provide adequate levels of recognized that management of chronic spinal pain evidence, consensus and expert opinions have been takes place in a wide context of healthcare settings, utilized. Those approaches have been described involving multiple specialists, and multiple tech- in separate publications (86,87,93,101-118). These niques which also include non-interventional tech- guidelines include both patient and physician focus niques. Consequently, the decision to implement a to understand the issues and the guidelines easily, particular management approach should be based so that appropriate care may be provided and the on a comprehensive assessment of the patient’s over- guidelines may be followed in an overall manage- all health status, medical requirements, and patient ment plan. preferences. While an evidence-based approach may seem to enhance the scientific rigor of guideline development, 1.8 Technology recommendations may not always meet the highest These guidelines describe multiple interventional scientific standards. Evidence-based medicine is de- techniques available in the management of chronic fined as the conscientious, explicit, and judicious use spinal pain, both diagnostic and therapeutic. of current best evidence in making decisions about The diagnostic interventional techniques include the care of individual patients (103).

10 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

1.9.1 Practice of Evidence-Based Medicine ♦ Multidisciplinary process of development The practice of evidence-based medicine requires ♦ Flexibility and adaptability the integration of individual clinical expertise with ♦ Cost-effectiveness of treatments the best available external evidence from systematic ♦ Appropriate dissemination research. Decisions that affect the care of patients ♦ Evaluation of implementation and impact of should be made with due weight accorded to all valid, guidelines relevant information. This includes valid and relevant ♦ Appropriate revision of the guidelines on a regu- clinical evidence derived from randomized, controlled lar basis trials, and all types of evidence, patient preferences, As recommended by the National Health and and resources. Thus, it is emphasized that no one sort Medical Research Council (113) and Shaneyfelt et al of evidence should necessarily be the determining fac- (93), the present guidelines include the following: tor in decision-making. All implies that there should 1. Documentation of the purpose of the guidelines be an active search for all that is valid, relevant infor- 2. Description of the natural history of chronic spinal mation and that an assessment should be made of the pain and treatments and various interventional accuracy of information and the applicability of the techniques that are available evidence to the decision in question (85,86,87,112). 3. Identification of various conditions where recom- 1.9.2 Guidelines mendations might not apply Clinical practice guidelines present statements of 4. Detailed description of the probable outcomes best practice based on a thorough evaluation of the 5. Maintenance of flexibility and comprehensive na- evidence from published studies on the outcomes of ture of the guidelines treatment. In these guidelines, multiple methods used 6. Description of the support services required for for collecting and evaluating evidence are applied for each potential treatment a wide range of clinical interventions and disciplines 7. Inclusion of the information for consumers and to a wide range of interventional procedures, both di- clinicians, on all special clinical training or equip- agnostic and therapeutic. ment that is needed The guidelines are based on the practice of evidence- 8. Cost-effectiveness and cost comparisons of vari- based medicine which is based on four basic contingen- ous options cies originally defined evidence-based practice (112). 9. Reference to the type and strength of evidence ♦ First, the recognition of the patient’s problem and on which recommendations are based the construction of a structured clinical question. 10. Documentation of certainty or uncertainty of any ♦ Second, the ability to efficiently and effectively conclusions search the medical literature to retrieve the best 11. Documentation of the economic appraisals used available evidence to answer the clinical question. in formulating the guidelines ♦ Third, critical appraisal of the evidence. 12. Acknowledgment of consensus-based recommen- ♦ Fourth, integration of the evidence with all as- dations whenever applied pects of individual patient decision making to de- 1.9.4 Mechanism of Development of Guidelines termine the best clinical care of the patient. A policy committee, with broad representation, 1.9.3 Development of Guidelines consisting of academic and clinical practitioners rec- In the development of these clinical practice ognized as experts in one or more interventional tech- guidelines, multiple resources were utilized to cre- niques of concern and representing a variety of practic- ate principles for developing guidelines. Of particu- es and geographic areas, were included and convened. lar importance are the National Health and Medical This committee formalized the essentials of guidelines. Research Council criteria (113) with 9 basic principles This was followed by formulation of a series of poten- as follows: tial evidence linkages, representing conclusions and ♦ Outcomes (survival rates to quality-of-life attri- statements about relationships between clinical inter- butes) ventions and outcomes. The elements of the guideline ♦ Best available evidence (according to its quality, preparation process included literature searches, litera- relevance and strength) ture syntheses, systematic review, consensus evaluation, ♦ Appropriate systems to synthesize the available open forum presentations, and blinded peer review. evidence (judgment, experience and good sense) Descriptions of evidence synthesis and guideline

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2.0 Chronic Pain preparation are described in multiple documents (84,86,87,101-118). In addition, multiple systematic, 2.1 Definitions narrative, and/or best evidence synthesis reviews per- Chronic pain is a complex phenomenon. Conse- taining to interventional techniques have been con- quently, it is difficult to define. A combination of defi- sidered and included. In synthesizing the evidence, nitions is utilized (1-4): systematic reviews, randomized clinical trials, ob- ♦ Pain that persists beyond the usual course of an servational studies, and diagnostic accuracy studies acute disease or a reasonable time for any injury were evaluated utilizing reporting criteria and qual- to heal that is associated with chronic pathologic ity evaluation criteria. For a particular technique, processes that cause continuous pain or pain at if at least 10 randomized trials were not available, intervals for months or years nonrandomized or observational studies were also ♦ Persistent pain that is not amenable to routine included. pain control methods 1.9.5 Level of Evidence ♦ Pain where healing may never occur Systems for grading the strength of a body of evidence are much less uniform and consistent than 2.2 Prevalence those for rating study quality. Consequently, the The prevalence of chronic pain in the adult popu- guideline committee designed levels of evidence lation ranges from 2% to 40%, with a median point from Level I through Level V, modified from vari- prevalence of 15% (119). Persistent pain has been re- ous publications (Table 1) (86,87,104-108,114,116- ported with an overall prevalence of 20% of primary 118). care patients, with approximately 48% reporting

Table 1. Designation of levels of evidence

Level I Conclusive: Research-based evidence with multiple relevant and high-quality scientific studies or consistent reviews of meta- analyses.

Level II Strong: Research-based evidence from at least 1 properly designed randomized, controlled trial; or research-based evidence from multiple properly designed studies of smaller size; or multiple low quality trials.

Level III Moderate: a) Evidence obtained from well-designed pseudorandomized controlled trials (alternate allocation or some other method); b) evidence obtained from comparative studies with concurrent controls and allocation not randomized (cohort studies, case-controlled studies, or interrupted time series with a control group); c) evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group.

Level IV Limited: Evidence from well-designed nonexperimental studies from more than 1 center or research group; or conflicting evidence with inconsistent findings in multiple trials.

Level V Indeterminate: Opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees.

12 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

back pain (120). The literature also has consistently the administration or type of treatment, with only 5% described the high prevalence of chronic pain in chil- to 10% of patients developing persistent back pain. dren, adults and the elderly with associated functional However, this concept has been questioned, as the disability (119-126). In an evaluation of the prevalence condition tends to relapse, so that most patients will and determinants of pain and pain-related disability in experience recurrent episodes. Modern evidence has urban and rural setting in Southeastern Ontario, 76% shown that chronic persistent low back pain and neck reported some pain over the past 6 months (127). High pain in children, adults, and elderly are seen in 25%- pain intensity with low pain interference was seen in 60% of patients, one year or longer after the initial 26% (Grade II) and high pain intensity with high pain episode (141-167). interference was seen in 17% (Grades III and IV). Of those reporting pain, 49% reported chronic pain (i.e., 2.5 Health and Economic Impact pain for a minimum of 90 days over the past 6 months) Spinal pain is associated with significant econom- which represented 37% of the sample. In children it ic, societal, and health impact (168-200). Estimates was shown that the prevalence of any pain within the and patterns of direct healthcare expenditures among previous 6 months was 70%, while chronic pain was individuals with back pain in the United States have reported by 14%, and 7% of the children suffered reached $90.7 billion for the year 1998 (184). On av- with Grade III or Grade IV pain with high intensity as- erage, individuals with back pain incurred healthcare sociated with moderate to severe disability (126). expenditures about 60% higher than individuals with- Chronic pain with the involvement of multiple re- out back pain ($3,498 versus $2,178). In the United gions is a common occurrence in more than 60% of States, it was estimated that the cost of treatment in patients (123,128-130). the first year after failed back surgery for pain was approximately $18,883 in 1997 (193). Further, annual 2.3 Spinal Pain healthcare cost incurred by chronic pain patients, ex- Among chronic pain disorders, pain arising from cluding cost for surgical procedures, may range from various structures of the spine constitutes the majority $500 to as high as $35,400, with the average ranging of problems. The lifetime prevalence of spinal pain has from $12,900 to $18,883 annually (193,194). However, been reported as 54% to 80% (1-4,119,122,125,131- the majority of these costs are associated with disabil- 137). Annual prevalence of chronic low back pain ity compensation, lost productivity, and lost tax rev- ranges from 15% to 45%, with a point prevalence of enue. Disability secondary to spinal pain is enormous 30% (124,125,131,133). Studies of the prevalence of (179,184,186,196-197). In the United Kingdom, low low back pain and neck pain (131,133) and its impact back pain was the largest single cause of absence from on general health showed 25% of patients reporting work in 1988 and 1989 and accounting for 12.5% of grade II to IV low back pain (high pain intensity with all sick days and over £11 billion in direct and indirect disability) vs 14% with neck pain. The studies evaluat- costs in 2000 (195). ing chronic low back pain estimated the average age Among the various factors contributing to costs related prevalence of persistent low back pain in ap- in the United States, workers functional impairment, proximately 15% in children, adolescents, and adults, activity limitations, reduced quality of life, disabil- and 27% in the elderly (119,124-127). Historically, ity, underemployment, reduced work productivity even though back pain research has primarily focused and direct medical costs have been described (180). on younger, working adults, there is clear evidence Among the United States workers, back pain exacer- that back pain is one of the most frequent complaints bations and lost productive time (LPT) costs evaluation in older persons (119,124,138), and is an independent showed back pain in workers between 40 to 65 years correlate of functional limitations (124,139), perceived of age costs employers an estimated $7.4 billion per difficulty in performing daily life activities (140), and a year. Workers with back pain exacerbations account- risk factor for future disability. ed for 71.6% of this cost. It was also estimated that back pain related LPT in workers 18 to 65 years of age 2.4 Chronicity costs employers $19.8 billion per year (180). Moreover, Conventional beliefs are that most episodes of 50% of the annual cost of the back pain-related LPT in low back pain will be short-lived, with 80% to 90% these workers was associated with pain exacerbation of attacks resolving in about 6 weeks irrespective of (179). However, these estimates do not capture other

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costs associated with the work force “ripple effect,” smoking, drug dependence, and other comorbidities such as the potential hiring and training of replace- such as heart disease, diabetes, thyroid disease, etc. ment workers, impact of coworkers’ productivity, and (177,197-200,217). The prevalence of comorbidities, forfeiture of leisure time (179). analgesic use, and healthcare service use, varied by Frequent use of opioids in managing chronic non- the number of back pain episodes with the highest cancer pain has been a major strain on US health care in patients with more than 6 episodes of back pain. (99,177,178,181,199-208). With the majority of patients Diabetes, rheumatoid arthritis, anxiety, psychotic ill- receiving opioids for chronic pain combined with in- ness, depression, and use of opiates and nonsteroi- creased production of opioids, costs of opioid use have dal anti-inflammatory agents were associated with been much higher even when patients were not abus- significant incremental increases in costs. In a study ing. Evaluation of direct costs of opioid abuse in the of cardiovascular risk factors for physician-diagnosed insured population in the United States showed pre- lumbar disc herniation (197), cardiovascular risk fac- scription drug claims for opioids of approximately 20%, tors significantly and independently were associat- whereas opioid abusers had drug claims of almost 60% ed with symptomatic lumbar disc herniation. Thus, (99, 201). Mean annual direct healthcare costs of the physical and psychological comorbidities and mea- total prescription bill for opioid abusers were more sures of analgesic use are associated with chronicity, than 8 times higher than for non-abusers with $15,884 increased healthcare utilization, and costs. Given the for abusers versus $1,830 for non-abusers. association of comorbidities and exploding costs for Costs of abuse and addiction are enormous (204). patients with spinal pain, specifically low back pain, Multiple investigators (204) have shown a prevalence management approaches that are effective across of drug abuse in 18% to 41% of patients receiving chronic illnesses may prove to be beneficial. opioids for chronic pain. Between 1992 and 2002, the 3.0 Structural Basis population of the United States increased by 13%. The number of prescriptions written for non-controlled Chronic spinal pain is a multifactorial disorder drugs increased by 57% and the number of prescrip- with many possible etiologies. The biopsychosocial tions filled for controlled drugs increased by 154% model, which emerged in the 1980s, views chronic spi- (200, 201, 206). In addition, there was a 90% increase nal pain as a biopsychosocial phenomenon, in which in the number of people who admitted to abusing biological, psychological and social factors dynami- controlled prescription drugs during the same period. cally interact with each other. In the 1990s, the bio- Comorbidities among patients with spinal pain psychosocial approach dominated chronic spinal pain are substantial (206). Opioid abusers, compared with management, at least among academicians, with the non-abusers, had significantly higher prevalence rates introduction of “psychosocial” approaches. Medically for a number of specific comorbidities including non- unexplained pain is the subject of controversy with opioid poisoning, hepatitis, psychiatric illness, and numerous publications in the medical literature (218). pancreatitis, which were approximately 78, 36, 9, and Modern technology, including magnetic reso- 21 times higher, respectively, than that of non-abusers nance imaging (MRI), computed tomographic axial (206). scanning (CT), neurophysiologic testing, and compre- Psychological and physical comorbidities and risk hensive physical examination with psychological eval- factors are common in spinal pain. There is extensive uation, can identify the cause of low back pain in only evidence associating chronic pain and psychopathol- 15% of patients in the absence of disc herniation and ogy (199, 209-216). Consequently, unrecognized and neurological deficit (1-4, 219-227). untreated psychopathology can interfere with the The majority of painful conditions include various successful management of chronic pain and patient types of pain originating from the spine with pain in rehabilitation, can be predictive of poor surgical out- the neck, upper back, mid back, low back, and upper comes, and may increase pain intensity and disability, or lower extremities. It was postulated that, for any thus serving to increase pain related dysfunction, dis- structure to be deemed a cause of back pain (224): ability, and costs (209). A multitude of physical ele- ♦ The structure should have a nerve supply ments also lead to increased morbidity and mortal- ♦ The structure should be capable of causing pain ity along with increased costs in spinal pain patients. similar to that seen clinically, ideally demonstrat- These include lack of fitness, poor health, obesity, ed in normal volunteers

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♦ The structure should be susceptible to diseases or ing substance P and calcitonin gene-related peptide injuries that are known to be painful (264-279). ♦ The structure should have been shown to be a Neurophysiologic studies have shown that facet source of pain in patients, using diagnostic tech- joint capsules contain low-threshold mechanorecep- niques of known reliability and validity. tors, mechanically sensitive nociceptors and silent no- Kuslich et al (228) identified intervertebral discs, ciceptors (264-283). Inflammation leads to decreased facet joints, ligaments, fascia, muscles, and nerve root thresholds of nerve endings in facet capsules as well dura as tissues capable of transmitting pain in the as elevated baseline discharge rates (264,277-279, low back. Facet joint pain, discogenic pain, and sacro- 284-286). Biomechanical studies have shown that lum- iliac joint pain also have been proven to be common bar and cervical facet joint capsules can undergo high causes of pain with proven diagnostic techniques (1- strains during spine-loading (264,287-298). 4,23,32-36,46,48-50,128,129,229,230). In contrast, ver- Based on controlled diagnostic blocks of facet tebrae, muscles, and ligaments have not been proven joints, in accordance with the criteria established by to be common sources of spinal pain with proven the International Association for the Study of Pain diagnostic techniques. In one prospective evaluation (IASP) (299), facet joints have been implicated as re- (229), consecutive adult patients with intractable low sponsible for spinal pain in 15% to 45% of patients back pain (who had failed conservative therapy) of with low back pain (128,129,230,300-308), 36% to 67% undetermined etiology (by medical history, physical of patients with neck pain (128,129,309-312), and 34% examination, x-ray, CT, MRI, EMG/NCV) had pain from to 48% of patients with thoracic pain (128,129,313). facet joint(s) in 24%, combined lumbar nerve root and facet disease in 24%, combined facet(s) and sacroiliac 3.2 Intervertebral Disc joint(s) in 4%, lumbar nerve root irritation in 20%, in- The human intervertebral disc (IVD) is a unique ternal disc disorder in 7%, sacroiliac joint in 6%, and structure, composed of two major regions — the out- sympathetic dystrophy in 2%. In a second study (230), er ring, called the annulus fibrosus (AF), and the inner the relative contributions of various structures in pa- part, called the nucleus pulposus (NP), with a transi- tients with chronic low back pain who failed to re- tional zone that merges these two regions together spond to conservative modalities of treatments (physi- (314-316). Even though it is controversial whether or cal therapy, chiropractic and drug therapy), with lack not the lumbar intervertebral discs receive innerva- of radiological evidence to indicate disc protrusion or tion, early studies failed to demonstrate nerve fibers radiculopathy, were evaluated utilizing controlled, or nerve endings within the discs (317-320). Conse- comparative, double diagnostic blocks. In this study, quently, it has been concluded that the lumbar discs 40% of the patients were shown to have facet joint lack innervation (317,321-323). In subsequent studies, pain, 26% discogenic pain, 2% sacroiliac joint pain, it was reported that in a normal intervertebral disc, the and possibly 13% segmental dural/nerve root pain. nucleus pulposus is devoid of nerve fibers, whereas the No cause was identified in 13% (229) and 19% (230) outer annulus fibrosus contains an extensive network of the patients. of sensory nerve fibers (243,317,324-330). Since then, it has also been demonstrated that a variety of free 3.1 Facet or Zygapophysial Joints and complex nerve endings were present in the outer The facet or zygapophysial joints are paired diar- third of the annulus (315,317,331-344). Nerve endings throdial articulations between posterior elements of in degenerated discs have been found in the deeper adjacent vertebrae (231). Spinal facet joints have been layers of the annulus fibrosus; in some studies, nerve shown to be a source of pain in the neck and referred endings have been found extending even into the pain in the head and upper extremities (232-236); up- nucleus pulposus (314,334-337). The nerve fibers have per back, mid back and referred pain in chest wall been found both in anterior and posterior parts of the (237, 238); as well as the low back and referred pain in disc specimens following a vascularized zone of granu- the lower extremity (239-244) in normal volunteers. lation tissue (334). The ingrowth of nerve endings has Facet joints are well innervated by the medial been suggested to be the pathoanatomic correlate to branches of the dorsal rami (245-264). Neuroanatom- the dull chronic ache, which is exacerbated by the me- ic studies have demonstrated free and encapsulated chanical loading of the spine that is experienced by nerve endings in facet joints, as well as nerves contain- patients with chronic low back pain and which is often

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referred to as discogenic pain (314). In a quantitative in response to inflammation. This subgroup is respon- analysis of the innervation of the intervertebral disc sible for sensitizing the DRG to NGF and is present in in a sheep model, there was no significant difference the painful IVD. NGF may play an important role in between endplate and annulus innervation densities discogenic back pain (350,371-374). The nucleus pulp- (344). The endplate innervation was concentrated osus is a biologically active tissue that can respond to centrally adjoining the nucleus. The richest area of pro-inflammatory stimuli (374). innervation was in the periannular connective tissue. The first to create widespread interest in the disc Consequently, these authors (344) concluded that in as a source of pain in American literature were Mixter the sheep, the lumbar intervertebral disc has a meager and Barr (364) with their 1934 hallmark description of innervation, which is concentrated in the periannular the herniated nucleus pulposus. However, soon after, connective tissue and the central endplate. However, Mixter and Ayers (370) in 1935 demonstrated that ra- they also stated that receptor threshold is more closely dicular pain can occur without disc herniation. Sub- related to nociceptive function than innervation den- sequently, numerous investigators (229,230,367,352- sity. This innervation also has been demonstrated to 354,375-377) have described pain syndromes cervical and thoracic intervertebral discs, synonymous emanating from the lumbar intervertebral disc with- to lumbar discs. However, these have not been studied out mechanically compressing neural structures. Con- well (325,327,330,331,333,338-351). These nerve fibers sequently, the pathophysiology of spinal radicular transmit both nociceptive and non-nociceptive infor- pain is a subject of ongoing research and controversy mation (243,246,325,330,331,333,338,339,348,352- and discogenic pain has assumed a major role as a 354). In addition, many of these nerve fibers, identifi- cause of nonspecific low back pain, beyond the more able by immunochemistry, are accompanied by blood specific disc herniation. Thus, in addition to the me- vessels; this process of neovascularization is associated chanical component, inflammation of the compressed with inflammation. Neural structures that express nerve root is an important factor in the pathophysiol- substance P and have the morphology of nociceptive ogy of radicular and discogenic pain (377-385). Other nerve terminals are found in the nucleus of painful proposed etiologies include neural compression with discs; this may distinguish painful versus painless disc dysfunction and vascular compromise (386-390). While degeneration (349). neurotoxicity has been attributed to many agents in- Degeneration of the intervertebral disc is associ- cluding phospholipase A2 (PLA2), metalloproteinases, ated with the development of fissures in the outer an- and interleukin-6, both prostaglandin E2 (353,380- nular fibrosus, which may be ingrown by vascular tissue 384,391-396) and tumor necrosis factor (TNFα) have and nerve endings (315,345,355). Disc cells are capable been shown to have an essential role in intervertebral of producing a complex mixture of neurotransmitters, disc-induced nerve root damage (397-400). cytokines, and other inflammatory mediators that may Cartilage oligomeric matrix protein (COMP) (401) stimulate free nerve endings (356-358). While neuro- may play a role in maintaining the normal structure transmission pathways for discogenic pain remain of the intervertebral disc. The course of macroscopic poorly understood, nociceptive neuropeptides, which degeneration in the human lumbar intervertebral disc are present within the nerve fibers in the outer annu- was described to start in the nucleus. The temporal se- lus and dorsal root ganglion, may likely play a role in quence suggests a strong correlation of cleft and tears discogenic pain transmission (315,346,359-361). formation starting with the formation of clefts in the Clinically, the intervertebral disc (IVD), depend- second decade (402). It was also shown that in rats, ing on location, can produce pain in the neck, upper by creating static and dynamic posterior instability of extremities, posterior thorax, chest wall, abdominal the cervical spine, rapid intervertebral disc degenera- wall, low back, and lower extremities (228,362-378). tion starts, which is characterized by increased apop- IVD-related pain can be caused by structural abnor- tosis and local inflammation (403). TFNα, also has been malities, such as disc degeneration or disc herniation; shown to contribute to the degenerative changes that correspondingly, biochemical effects, such as inflam- occur in the disc disease (404) as well as producing end- mation, and neurobiological processes may play a plate abnormalities related to inflammation and axon role. Nerve growth factor (NGF) dependent neurons growth (405). are the main neuronal subgroup within the dorsal The etiology of discogenic pain is unclear root ganglion (DRG), that transmit and modulate pain (225,360-406). Internal disc disruption (IDD) is a con-

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dition in which the internal architecture of the disc gested that edema in the dorsal root ganglion is the is disrupted, but its external appearance remains es- basis of the production of nerve root pain in patients sentially normal (407). IDD can be experimentally in- with disc herniation (350,356,357,371,416-434). Mech- duced by endplate damage (408). Likewise, experi- ano- and chemosensitivity of the dorsal root ganglia mentally induced annular tears can lead to adverse have been described (393,394,419-421). Experimen- and progressive mechanical changes in the disc. An- tally applied nucleus pulposus from both healthy and nular degeneration has been shown to appear at degenerative discs reduces nerve root conduction ve- an early age in lumbar discs and is clearly related to locity, suggesting a pathomechanism of neural injury back pain (409). Disrupted discs may not exhibit either (422-428). The NP can induce excitatory changes, ris- bulging or herniation. These features with a normal ing endoneurial pressures-compartment syndrome, or near normal contour of discs producing back pain, and cause intraneural thrombi in the DRG or the nerve but with no evidence of herniation or prolapse were roots (394,397,423). Anti-inflammatory agents, such described by Crock (407) in 1976 as internal disc dis- as tumor-necrosis factor alpha inhibitors, may protect ruption. It has been suggested that endplate damage against NP-induced DRG and nerve root injury (393). would precede disc degeneration (405,410). Further, diminution of blood supply in the endplate initiates 3.4 Sacroiliac Joint tissue breakdown, first in the endplate and thereaf- The sacroiliac joint is a diarthrodial, synovial joint ter in the nucleus, starting in the first half of the sec- (435-440). However, the innervation of the sacroiliac ond decade of life (402,411), with visible tears in the joint remains a subject of much debate. The lateral nucleus in the 11 to 16 year age group. The removal branches of the L4 to S3 dorsal rami are cited by some of proteoglycans from the endplate, which regulates experts as comprising of the major innervation to the the movement of solutes into and out of the disc, ac- posterior SI joint (437,441). Other investigators claim celerates the loss of proteoglycans from the nucleus that L3 and S4 contribute to the posterior nerve sup- (412). It also has been shown that reduced lumbar ar- ply (437,442,443). The innervation of the anterior joint tery blood flow may diminish nutrition through the is also controversial. The early literature asserted that endplates, leading to an increased incidence of disc the anterior sacroiliac joint is supplied by the obtura- degeneration (197,413). Discs with internal disc dis- tor nerve, superior gluteal nerve, and the lumbosacral ruption are rendered painful by either chemical no- trunk (437,443). However, more recent literature sug- ciception or mechanical stimulation. Explanted discs, gests the anterior joint is innervated by L2 through S2 obtained during posterior lumbar interbody fusion in (437,444), L4 through S2 (445), and the L5 to S2 ven- patients with lumbar discogenic pain, demonstrated a tral rami (446). In addition, some authors have sug- vascularized strip lesion extending from the NP to the gested that the anterior sacroiliac joint is devoid of AF; this lesion was accompanied by extensive innerva- nervous tissue (437,442,445). Neurophysiologic studies tion in the posterior disc (414). conducted showed mechanosensitive afferent units In a controlled study, the prevalence of pain due (437,447-450). However, it has been postulated that to internal disc disruption was reported as 39% in pain sensitivity of the sacroiliac joints may be lower patients suffering with chronic low back pain (367). than that of lumbar facet joints but higher than the Primary discogenic pain was reported in 7% (229) to anterior portions of the lumbar discs (437,449,450). In 26% (230) when no other cause was suspected. The summary the sacroiliac joint is well innervated, receiv- prevalence of cervical discogenic pain in patients with ing myelinated and unmyelinated axons capable of chronic neck pain of traumatic origin in informal stud- nociception (436-456). ies was estimated to be 20% (415). Discogenic and ra- Referral patterns of sacroiliac joint provocation dicular pain syndromes continue to pose challenges to or irritation have been published by multiple au- patients, physicians, and the society at large. thors (457-460). Sacroiliac joints have been shown to be capable of producing pain in the low back, but- 3.3 Dorsal Root Ganglion tocks, thigh, lower extremity, groin and occasionally The dorsal root ganglion (DRG) plays an impor- abdomen. Since sacroiliac joints have been shown to tant role in the mechanism of spinal pain. This holds have innervation and produce pain in normal volun- true, when the DRG itself is injured or when other teers, the prevalence of sacroiliac joint pain has also spinal structures are injured. Experiments have sug- been determined. Utilizing single diagnostic blocks,

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the prevalence of sacroiliac pain would appear to the decade, with increase for lumbar fusion of 500%, be at least 13% and perhaps as high as 30% in the from $75 million to $482 million. In 1992, lumbar fu- United States (460) and 10% in Taiwan (229). Utiliz- sion represented 14% of total spending for back sur- ing controlled, comparative local anesthetic blocks in gery; by 2003, lumbar fusion accounted for 47% of patients with low back pain in whom there was a high spending. index of suspicion for pathology, frequency of sacro- Animal models of post laminectomy syndrome iliac joint dysfunction was established as 18.5% (461), demonstrate paraspinous muscle spasms, tail con- 10% (230), or 26.6% (462) in suspected patients. High tractures, behavioral pain behaviors, tactile allodyn- prevalence may be seen in patients with post-lumbar ia, epidural and perineural scarring, and nerve root fusion pain (463-465). In a prospective series of 40 pa- adherence to the underlying disc and pedicle (490- tients with persistent low back pain after a technically 496). Speculated causes of postlaminectomy syn- successful fusion, with single diagnostic blocks, a 35% drome include acquired stenosis, adjacent segment prevalence was demonstrated (465). degeneration, internal disc disruption, recurrent disc herniation, retained disc fragment, spondylolisthesis, 3.5 Postlaminectomy Syndrome epidural or intraneural fibrosis, degenerative disc Postlaminectomy syndrome and other synonyms, disease, radiculopathy, radicular pain, decondition- such as failed back surgery syndrome, represent a clus- ing, facet joint pain, sacroiliac joint pain, discitis, ter of syndromes following spine surgery wherein the arachnoiditis, pseudoarthrosis, segmental instability, expectations of the patient and spine surgeon are not and others (308,463-470,478-481,485,489,497-500). met (466-471). Persistent pain following spine surgery Among these, etiologies such as epidural fibrosis, is common (466-489). Since discectomies, decompres- facet joint dysfunction, sacroiliac dysfunction, in- sions, and spinal fusions and more recently, minimally ternal disc disruption, recurrent disc herniation, invasive surgical and interventional therapies, repre- and spinal stenosis can be treated by interventional sent the largest portion of the US spine market (with pain techniques (23,32-36,39,40,46,48-50,308,463- expenditures of $2.5 billion in the United States in 2003 470,489,497-500). Ultimately, many of these eti- of the estimated $3 billion for the worldwide spine ologies are interrelated. Facet joint involvement market), one may reasonably anticipate that the costs in chronic pain following lumbar surgery has been of persistent pain following spine surgery will increase shown to be present in approximately 8% to 16% of substantially (471). In the year 2002, more than 1 mil- the patients (308). Prevalence of sacroiliac joint pain lion spinal procedures were performed in the USA. following lumbar fusion has been demonstrated in a Six hundred thousand cases were not instrumented, study with a single block to be 35% (465). but 400,000 were instrumented (472-476,482). The es- Epidural fibrosis may occur following an annular timated yearly growth rate of uninstrumented cases tear, disc herniation, hematoma, infection, surgical ranged from 3% to 5%; in contrast, the growth rate trauma, vascular abnormalities, or intrathecal contrast of instrumented cases ranged from 6% to 8% (477). media (490-496,499-509). Epidural fibrosis may ac- The “spine market” may compound as much as 22% count for as much as 20% to 36% of all cases of failed annually (485). Lieberman (471) cautioned that all back surgery syndrome (FBSS) (479,480,510-512). Al- parties involved in the spine market must be vigilant ternatively, there may be a final common pathway in not letting the spine market turn into a “cancer,” with all these etiologies, which results in peripheral or even worse, allowing the “disc bulge bubble” to and central facilitation potentiated by inflammatory burst. A surgeon’s assessment of adverse post-opera- and nerve injury mechanisms (490-496). Paraspinal tive outcomes may seriously underreport a patient’s muscles may also become denervated and involved in self-assessment of surgical outcomes (478). the pathogenesis of FBSS (513). In fact, Weinstein et al (476) in a study of the Unit- ed States’ trends and regional variations in lumbar 3.6 Spinal Stenosis spine surgery from 1992 to 2003 showed that lumbar Spinal stenosis can be defined as a narrowing fusion rates have increased steadily since 1992 from of the spinal canal, resulting in symptoms and signs 0.3 per 1,000 enrollees in 1992 to 1.1 per 1,000 enroll- caused by entrapment and compression of the intra- ees in 2003. They also showed that Medicare spending spinal vascular and nervous structures (514,515). Disc for inpatient back surgery more than doubled over bulging, protrusion, and herniation in the cervical, as

18 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

well as lumbar area, combined with osteophytes and Various mechanisms of benefits for longer peri- arthritic changes of the facet joints can cause narrow- ods of time than the duration of the anesthetics used ing of the spinal canal, encroachment on the contents have been described (537-540). Among the several of the dural sac, or localized nerve root canal stenosis theories listed include the influence on sympathetic (514-520). nervous system (541); temporary abolition of sponta- The pain and disability associated with lumbar neous ectopic discharges, resulting in suppression of spinal stenosis can interfere with a patient’s lifestyle dynamically maintained central hyperexcitability, as (521). Treatment options for low back pain and neu- well as reinforcing endogenous G-protein-couple re- rogenic claudication related to lumbar spinal steno- ceptor inhibition of N-type voltage-sensitive calcium sis include surgery, but also nonoperative modalities channels (538,541); and glial inactivation (540). including conservative treatment and interventional 5.0 Diagnostic Interventional techniques. Techniques 4.0 Interventional Techniques It has been postulated that for any structure to Various types of injection techniques have been be deemed a cause of back pain, the structure should described with multiple benefits including pain relief have been shown to be a source of pain in patients, that outlasts by days, weeks, or months the relatively using diagnostic techniques of known reliability and short duration of pharmacologic action of the local validity (224). The diagnostic blockade of a structure anesthetics and other agents used. No clear-cut expla- with a nerve supply with the ability to generate pain nations for these prolonged improvements are cur- can be performed to test the hypothesis that the tar- rently available. get structure is a source of a patient’s pain. Evidence- based interventional diagnostic techniques include 4.1 Mechanism of Action facet joint blocks, discography, sacroiliac joint injec- Neural blockade has been postulated to alter or tions, and transforaminal epidurals or selective nerve interrupt nociceptive input, reflex mechanisms of the root blocks. afferent limb, self-sustaining activity of neuron pools 5.0.1 Rationale and neuraxis, and the pattern of central neuronal ac- The popularity of neural blockade as a diagnos- tivities (522). Improvements may be explained in part tic tool in painful conditions is due to multiple chal- based on the pharmacological and physical actions of lenging clinical situations, which include the purely local anesthetics, corticosteroids, and other agents. subjective nature of spinal pain and undetermined Local anesthetics interrupt the pain-spasm cycle and and uncertain pathophysiology in most painful spi- reverberating nociceptor transmission, whereas cor- nal conditions. Precision diagnostic blocks are used to ticosteroids reduce inflammation either by inhibiting clarify these challenging clinical situations, in order to the synthesis or release of a number of pro-inflamma- determine the pathophysiology of clinical pain, the tory substances and by causing a reversible local anes- site of nociception and the pathway of afferent neu- thetic effect (419,523-536). ral signals. Precise anatomical diagnosis in low back Various modes of action of corticosteroids in- pain has been described not only as elusive, but also clude membrane stabilization; inhibition of neural the diagnostic evaluation is often frustrating for both peptide synthesis or action; blockade of phospholi- physicians and patients (1-4,219-227,542-544). History, pase A2 activity; prolonged suppression of ongoing physical examination, and imaging provide limited in- neuronal discharge; and suppression of sensitiza- formation. tion of dorsal horn neurons. Local anesthetics have 5.0.2 Reliability and Validity been shown to produce prolonged dampening of C- Clinical studies of precision diagnostic techniques fiber activity. Physical effects include clearing adhe- are variable in sensitivity, specificity, accuracy and sions or inflammatory exudates from the vicinity of quality. False-positive rate (how often patients with- the nerve root sleeve. The scientific basis of some of out a condition will nonetheless have a positive test), these concepts, at least in part, is proven for spinal false-negative rate (how often a patient with disease pain management with epidural injections of be- will have a negative test), and placebo response are tamethasone and intravenous methylprednisolone crucial. Since none of the tests available in clinical (419,529-535). medicine are ideal, there is a degree of uncertainty

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regarding the accuracy of each and every diagnostic physical examination, informed consent, and appro- test as applied to an individual clinical case. priate documentation of the procedure. The accuracy of a diagnostic test is best deter- 5.0.4 Contraindications mined by comparing it to an appropriate reference Contraindications include ongoing bacterial in- standard (gold standard) such as biopsy, surgery, au- fection, possible pregnancy, bleeding diathesis, and topsy, or long-term follow-up. Tissue confirmation of anticoagulant therapy. Precautions are warranted in the presence or absence of a disease at surgery, with patients with antiplatelet or anticoagulant therapy, a biopsy, or autopsy, which has served as the accepted diabetes mellitus and artificial heart valves (557-559). gold standard across multiple medical disciplines, is not applicable to interventional pain management. 5.1 Facet or Zygapophysial Joint Blocks Consequently, most pain provocative or relieving tests Diagnostic blocks of a facet or zygapophysial used to diagnose painful conditions of the spine are joint can be performed by anesthetizing the joint by more closely related to the physical examination than injections of local anesthetic intraarticularly or on the to a laboratory test (38). Stability of the diagnosis over medial branches of the dorsal rami that innervate the a long period of time with long-term follow-up may target joint, to test whether the joint is the source of also be used as a gold standard. These facts are espe- pain. Valid information is only obtained by perform- cially true in the diagnosis of facet joint pain, disco- ing controlled blocks, either in the form of placebo genic pain, and sacroiliac joint pain. injections of normal saline or comparative local anes- In interventional pain management, a diagnostic thetic blocks, in which on two separate occasions, the blockade of a structure with a nerve supply that can same joint is anesthetized using local anesthetics with generate pain is performed to test the hypothesis different durations of action. that the target structure is the source of a patient’s The rationale for using facet joint blocks for diag- pain. Pain provocation in any structure is an unre- nosis is based on the fact that facet joints are capable liable criterion, except in provocative discography of causing pain and they have a nerve supply (245- (1-4,23,32-36,39,40,46,48-50,219,220,542-546). In an 264). They have been shown to be a source of pain ideal world, all controlled blocks would include plain patients using diagnostic techniques of known reli- cebo injections of normal saline. However, in prac- ability and validity (4-20,128,129,230,300-313). How- tical terms, it may be neither logistical, nor ethical ever, there are no specific markers of facet joint pain. to use a placebo injections of normal saline in con- Conventional clinical and radiologic techniques are ventional practice. It would be necessary to perform unreliable in diagnosing facet or zygapophysial joint three diagnostic blocks of the same structure with pain. Various patterns of referred pain described for application of placebo. Consequently, the use of two facet joints in the spine are similar to other structures local anesthetics with different durations of action, such as discs. Further, most maneuvers used in physi- on two separate occasions, has been proposed and cal examination are likely to stress several structures validated (547-550). The use of comparative local an- simultaneously, especially the discs, muscles, and facet esthetic blocks with facet joint injections has been joints, thus, failing to provide any reasonable diagnos- validated against challenge with placebo (549,550). tic criteria. The value, validity and clinical effectiveness Even then, the validity and relevance of diagnostic of diagnostic facet joint nerve blocks was also illustrat- nerve blocks has been questioned (551-555). Cohen ed by application of therapeutic modalities based on et al (556) also evaluated the causes of false-positive the diagnosis with controlled comparative local anes- diagnostic facet joint blocks. thetic blocks (30,34,50). The response was much better 5.0.3 Environment and longer lasting in patients after the diagnosis was The requirements for safe use of diagnostic inter- made with controlled comparative local anesthetic ventional techniques include a sterile operating room blocks than single blocks (13,20,21,30,51,56). The evi- or procedure room, appropriate monitoring equip- dence thus far on physical examination and diagnosis ment, radiological equipment, sterile preparation, has been controversial; demographic features, pain resuscitative equipment, needles, gowns, injectable characteristics, and other signs and symptoms may drugs, intravenous fluids, anxiolytic medications, and not correlate and are unreliable; and medical imaging trained personnel for preparation and monitoring of provides little useful information with radiographic patients. Minimum requirements include history and investigations, including magnetic resonance imaging

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(MRI), revealing only some conditions with certainty of patients with chronic low back pain (128,129, (1-4,34-36,50,128,129,300-311,544,545,560-577). 230,300-308), 34% to 48% of the patients with tho- 5.1.1 Validity racic pain (128,129,313), and 36% to 67% of the Controlled diagnostic blocks with two local an- patients with chronic neck pain (128,129,309-312). esthetics (or placebo-controlled) are the only means The data of prevalence with controlled diagnostic of confirming the diagnosis of facet joint pain. The blocks and false-positive rates in cervical, thoracic face validity of medial branch blocks has been estab- and lumbar regions are illustrated in Tables 2, 3 and lished by injecting small volumes of local anesthetic 4 respectively. and contrast material onto the target points for these 5.1.3 Intraarticular or Medial Branch Blocks structures and by determining the spread of contrast Facet joints are blocked by either injection into medium in posteroanterior and lateral radiographs the joint or by blocking the nerves that innervate the (34-36,50, 250, 252, 253). Construct validity of facet joint. Intraarticular injections require intraarticular joint blocks is important to eliminate placebo effect as placement of a needle into the target joint under the source of confounding results and to secure true- fluoroscopic control. Contrast medium is injected to positive results (544,549,550). The hypothesis that obtain an arthrogram and verify intraarticular place- testing a patient first with lidocaine and subsequent- ment. Medial branch or L5 dorsal ramus blocks, in ly with bupivacaine provides a means of identifying contrast, require anesthetizing both of the medial the placebo response has been tested and proven branches that innervate the target joint. Medial (544,547-550). branch blocks are also performed under fluoroscopic The specificity of the effect of cervical and lum- visualization. bar facet joint blocks was demonstrated in controlled The choice between intraarticular blocks and me- trials (250,252,253). Provocation response was shown dial branch blocks is to some extent preference and to be unreliable in one study (545). The false-nega- training of the physician. However, various consider- tive rate of diagnostic facet joint blocks was shown ations apply in choosing either intraarticular injection to be 8% due to unrecognized intravascular injection or medial branch blocks (544). Intraarticular injections of local anesthetic (252). False-positive rates were are more difficult and time consuming than nerve evaluated in multiple investigations (128,129,230,303- blocks because they require accurate placement of the 308,311,312,578-580). needle within the joint cavity with care not to over The validity of comparative local anesthetic blocks distent the joint. In contrast, medial branch blocks are was determined not only by short-term relief with expeditious and carry no risk of over distention. Fur- controlled diagnostic blocks, and ability to perform thermore, at times joint entry may be impossible be- movements which were painful prior to the blocks, cause of the severe age related changes or post trau- but also with application of another appropriate ref- matic arthropathy; no such processes affect access to erence standard (long-term follow-up) as described in the nerves (544). Significant leakage of intraarticular the literature (580). Utilizing the criteria established injected fluid into epidural space and spillage over to by the International Association for the Study of Pain the nerve roots has been described. With appropriate (299), false-positive rates varying from 27% to 63% in care this is minimal with medial branch blocks. Finally, the cervical spine, 42% to 58% in the thoracic spine, intraarticular blocks are appropriate if intraarticular and 17% to 50% in the lumbar spine were demon- therapy is proposed but if radiofrequency therapy is strated. Minimal effect of sedation (581-583) in cervi- proposed, medial branch blocks become the diagnos- cal and lumbar spine, and lack of influence of psychotic procedure of choice. In addition, in the past only logical factors on the validity of controlled diagnostic intraarticular injections were considered as therapeu- local anesthetic blocks of facet joints in the lumbar tic. However, recent evidence has shown that medial spine was demonstrated (584). Other variables were branch blocks have better evidence for the therapeu- also evaluated (585,586). tic effectiveness than intraarticular blocks (30,51). An 5.1.2 Prevalence additional advantage is that if the patient fails to re- Based on numerous evaluations utilizing con- spond to medial branch blocks one may proceed with trolled diagnostic blocks, facet or zygapophysial denervation procedures. Furthermore, the require- joints have been implicated as the source of chronic ments for steroids is much lower or none with medial spinal pain in 15% to 45% of heterogenous groups branch blocks compared to intraarticular injections

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Table 2. Data of prevalence with controlled diagnostic blocks and false-positive rates in cervical region

Quality Scoring # of Study Type Prevalence False-Positive Rate AHRQ QUADAS Subjects

Barnsley et al (309) 1995 4/5 13/14 50 P, DB 54% (95% CI 40%–68%) NA

27% (95% CI 15%- Barnsley et al (579) 1993 4/5 13/14 55 RCT NA 38%)

RCT, Lord et al (310) 1996 4/5 13/14 68 60% (95% CI 46%–73%) NA DB, PC 40% (95% CI 25%- Manchikanti et al (311) 2002 3/5 10/14 106 P 60% (95% CI 50%–70%) 56%) 63% (95% CI 48%- Manchikanti et al (307) 2002 3/5 10/14 120 P 67% (95% CI 58%–75%) 78%) 255 of 500 63% (95% CI 54%- Manchikanti et al (128) 2004 3/5 11/14 P 55% (95% CI 49%–61%) patients 72%) 251 of 500 45% (95% CI, 37% Manchukonda et al (129) 2007 3/5 9/14 R 39% (95% CI 32%–45%) patients - 52%)

Speldewinde et al (312) 2001 3/5 7/14 97 R 36% (95% CI 27%–45%) NA

RCT = randomized, controlled trial; P = prospective; R = retrospective; PC = placebo controlled; DB = double blind; NA = not available

Table 3. Data of prevalence with controlled diagnostic blocks and false-positive rates in thoracic region

Quality Scoring # of Study Type Prevalence False-Positive Rate Subjects AHRQ QUADAS

72 of 500 Manchikanti et al (128) 2004 3/5 11/14 P 42% (95% CI 30%–53%) 55% (95% CI 39%–78%) patients

Manchikanti et al (313) 2002 3/5 10/14 46 P 48% (95% CI 34%–62%) 58% (95% CI 38%–78%)

65 of 500 Manchukonda et al (129) 2007 3/5 9/14 R 34% (95% CI 22%–47%) 42% (95% CI 26%–59%) patients

P = prospective; R = retrospective

(30,51). However, if intraarticular inflammation is the 5.1.5 Evidence proven and sole source of pain, intraarticular injection The accuracy of facet joint nerve blocks is strong with steroid may be beneficial. in the diagnosis of lumbar and cervical facet joint 5.1.4 Cost Effectiveness pain, whereas it is moderate in the diagnosis of tho- Diagnostic facet joint nerve blocks were not evalu- racic facet joint pain. ated for cost effectiveness systematically. However, mul- 5.1.6 Safety and Complications tiple authors (229,230,587-589) described the feasibility Safety of facet joint interventions with intraarticular and cost-effectiveness of appropriately performed con- injections and medial branch blocks has been demon- trolled comparative local anesthetic blocks. strated. Though rare and minor, the common reported

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Table 4. Data of prevalence with controlled diagnostic blocks and false-positive rates in lumbar region

Quality Scoring False-Positive Rate Study # of Subjects Type Prevalence AHRQ QUADAS Schwarzer et al (300) NA 4/5 12/14 176 P 15% (95% CI 10%-20%) 1994 Subjects 38% (95% CI 30%-46%) Schwarzer et al (578) from 4/5 12/14 176 15% 1994 previous study Schwarzer et al (302) NA 1/4 12/14 63 P, SB 40% (95% CI 27%-53%) 1995 Manchikanti et al 41% (95% CI 29%-53%) 3/5 8/14 120 P 45% (95% CI 36%-54%) (303) 1999 Manchikanti et al 37% (95% CI 28%-46%) 3/5 11/14 200 P 42% (95% CI 35%-49%) (305) 2000 Average 36% I: 38% (CI Average 25% I: 22% (CI Manchikanti et al 26%-50%) II: 32% (CI 9%-35%) II: 27% (CI 3/5 10/14 180 P (304) 2000 20%-44%) III: 38% (CI 13%-41%) III: 27% (CI 26%-50%) 13%-41%) Manchikanti et al 40% (95% CI 31%, 47% (95% CI 35%, 59%) 4/5 10/14 120 P (230) 2001 49%) Gp I (<65 I: 26% CI 11%-40%) II: Manchikanti et al I: 30% CI 17%-43%) II: 3/5 8/14 years)=50 Gp II P 33% CI 14%-35%) (586) 2001 52% CI 38%-66%) (>65 years)=50 Gp I (no prior I: 44% (95% CI 31%- I: 36% (95% CI 18%- Manchikanti et al 3/5 7/14 surgery)=50 Gp II P 49%) II: 32% (95% CI 54%) II: 24% (95% CI (498) 2001 (prior surgery)=50 19%-45%) 9%-38%) Gp I (BMI<30)=50 I: 36% (95% CI 22%- I: 44% (95% CI 26%- Manchikanti et al 3/5 7/14 Gp II (BMI P 50%) II: 40% (95% CI 61%) II: 33% (95% CI (809) 2001 >30)=50 26%-54%) 16%-51%) Manchikanti et al 30% (95% CI 20%-40%) 3/5 8/14 120 P 40% (95% CI 31%-49%) (307) 2002

GI: Single region I: 21% (95% CI 14%- I: 17% (95% CI 10%- Manchikanti et al 4/5 9/14 =150 GII: multiple P 27%) II : 41%(95% CI 24%) II : 27% (95% CI (306) 2003 regions =150 33%-49%) 18%-36%)

Manchikanti et al 27% (95% CI 22%-32%) 3/5 11/14 397 of 500 patients P 31% (95% CI 27%-36%) (128) 2004 Manchukonda et al 45% (95% CI 36%-53%) 3/5 9/14 303 of 500 patients R 27% (95% CI 22%-33%) (129) 2007 Gp I: single surgery 14% (95% CI 5%-23%) 49% (95% CI 36%-63%) = 64

Gp 2: 2 surgeries 19% (95% CI 5%-33%) 50% (95% CI 30%-70%) = 32 Manchikanti et al 4/5 12/14 P (308) 2007 Gp 3: 3 or more 19% (95% CI 2%-36%) 47% (95% CI 23%-71%) surgeries = 21 Overall: 16% (95% CI Overall: 49% (95% CI Overall: 117 9%-23%) 39%-59%)

P = prospective; SB = single blind; R = retrospective

www.painphysicianjournal.com 23 Pain Physician: January 2007:10:7-111 complications of facet joint injections or nerve blocks are related to needle placement and drug administra- information about the structure and sensitivity of their tion. These complications include hemorrhage, dural lumbar intervertebral discs and to make informed de- puncture, spinal cord trauma, infection, intraarterial or cisions about treatment and modifications of activity. intravenous injection, chemical meningitis, neural trau- Although the clinical exam may demonstrate a favor- ma, paralysis, pneumothorax, radiation exposure, facet able correlation with discography or disc-related pain capsule rupture, hematoma formation, steroid side ef- (563,570,614-617), this information may not be suffi- fects, and epidural, subdural or subarachnoid spread cient to guide invasive treatment for discogenic pain. (1-4,30,34-36,50,51,559,590-610). There is a significant overlap in evoked pain patterns among discs (618). 5.2 Provocation Discography 5.2.2 Validity Discography is a procedure that is used to char- Examinations of cadaver discs typically confirm acterize the pathoanatomy/architecture of the inter- the presence of annular tears and disc degeneration, vertebral disc and to determine if the IVD is a source as revealed by discograms (619-623). Multiple authors of chronic spinal pain. Implicitly, discography is an also have investigated the accuracy of discographic invasive diagnostic test that should only be applied and CT/discographic findings based on the ability to to those chronic spinal pain patients in whom one demonstrate accurate pathology confirmed at the suspects a discogenic etiology. Discography literally time of surgery. There is a high inter- and intra-ob- means the opacification of the nucleus pulposus of server agreement in assessing discographic morphol- an intervertebral disc to render it visible under radio- ogy, i.e., the Adam’s classification (624,625). It was re- graphs (546). The commonly practiced technical and ported that the exact reproduction of pain was more evaluative components of discography include: sterile likely in ruptured or fissured discs and less likely in needle placement into the center of the IVD (nucleus degenerative discs; based on the Adam’s Classification pulposus), radiopaque contrast instillation to provoke (625), the sensitivity and specificity of intervertebral pain, radiological assessment of disc morphology, and disc morphology was 81% and 64% respectively for clinical assessment of the intensity and concordancy of pain. While many authors (626-631) demonstrated evoked pain in relation to baseline pain. Discography significant correlation with confirmation of reliabil- has been used extensively in the study of lumbar discs, ity of provocative discography, some (632,633) have somewhat less so in cervical discs, and infrequently in demonstrated poor correlation. CT scanning post-dis- thoracic discs. cography provided minimal additional information 5.2.1 Rationale (625). The validity of cervical discography was ques- Formal studies have shown that the discs are in- tioned by Holt in 1964 (634). He reported false-posi- nervated and can be a source of pain that has patho- tive discograms in a large number of asymptomatic morphologic correlates (243,317-415). Even though prison population. While multiple experiments were the specific neurobiological events involved in how conducted to refute the data of Holt in lumbar spine, discography causes pain have not been elucidated, no such experiments were conducted in the cervical sound anatomic, histopathological, radiological, and spine. Thus, the value of cervical discography still war- biomechanical evidence suggests that lumbar discog- rants further investigations. raphy may help to identify symptomatic and patho- Discography was compared with myelography, CT, logical IVDs (32,39,49,546). However, the cervical and MRI, and results of surgical and conservative manage- thoracic discs differ from lumbar discs and do not ap- ment. CT discography was reported to be more accu- pear to suffer the same pathology (546,611-613). rate than myelography (611,619,627,628,633,635-640). Discography was performed in asymptomatic On similar grounds, discography was shown to be su- volunteers without spinal pain in the cervical spine perior to plain computed tomography (636,639-642). (611), thoracic spine (612), and lumbar spine (613). It While comparing the results of discography with MRI, was shown that discographically normal discs were some found discography to be as good as MRI, even never painful in either symptomatic or asymptomatic though MRI was preferable as it was non-invasive and groups. allowed assessment of more levels with one test, with The rationale is well established for lumbar dis- minimal risk of complications and minimal discomfort cography (32,39,49,546). Discography is helpful in pa- (643,644). However, others have identified advantag- tients with low back or lower extremity pain to acquire es of discography with pain provocation, when MRIs

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were normal or equivocal (611,612,645-648). Strong at least one disc (preferably two) that do not elicit correlation was demonstrated between MR/discogra- pain upon injection, thereby serving as a control disc phy and CT/discography in assessing annular tears and (32,39,49,661-663). degeneration (642,649,650). In the cervical spine, an The validity of cervical discography has been es- MRI may have a false-positive rate of 51% and a false tablished in asymptomatic patients. However, there negative rate of 27% in predicting which cervical spine are no modern normative data that establish that levels to fuse, as compared to discography (651). The cervical discography is a specific test for cervical dis- role of discography in a normal MRI is of questionable cogenic pain (32,49,546,664,665). There is evidence value and the routine performance of discography in indicating that up to 40% of the positive cervical dis- this setting is not advised. cograms may be false-positive (415). However, others A good correlation between MRI, discography, (664) have concluded that cervical discography is a and the high intensity zone (HIZ) has been established safe and valuable technique. by some (649,650,652-658), while others have report- With thoracic discography, unfamiliar or discon- ed poor correlation and limited value of discography cordant pain may be produced in Schmorl’s nodes, (658-660). Finally, the relationship of discography to in lifelong asymptomatic individuals (612). However, outcomes, including conservative management, mini- thoracic discography may demonstrate disc pathology mally invasive surgery, and open procedures remains that is not seen on MRI (612). The value of thoracic controversial (32,39,49). discography is preliminary. While the accuracy of discography as an imaging The validity of lumbar discography has been test is high, with high specificity and sensitivity for studied extensively, yet the controversy remains the diagnosis of disc degeneration, the key question (32,39,546,663,666,667). While there are sub- with discography is whether this test is accurate for stantial number of proponents of discography the diagnosis of discogenic pain. An integral part of (32,39,49,54,67,663), multiple other investigators have the problem is the lack of an adequate reference or questioned the reliability of patients’ reports of con- gold standard. Surgical exposure can confirm the pres- cordant pain (668-673). In the modern era, the oppo- ence of disc degeneration or disruption, but it cannot nents of discography (674-683), as well as proponents definitely confirm the presence or absence of disco- (684-688) have published numerous articles against genic pain. However, the results from both surgical and in support of discography. and minimally invasive treatment of discogenic pain Carragee et al (676) performed a prospective con- in patients whose diagnosis was confirmed by discog- trolled study on patients without low back pain who raphy should provide a reference standard for disco- had undergone lumbar discography. They also reported genic pain. a prospective, controlled, longitudinal study on 50 sub- The face validity of discography has been estab- jects without low back pain who had undergone lumbar lished by injecting small volumes of contrast into the discography as well as patients with mild persistent low disc and determining concordant pain, with spread of back pain (677); performed discography in patients with the contrast medium in posteroanterior and lateral ra- and without low back pain following laminotomy and diographs and/or computed tomography. This “face” discectomy (678); performed discography in 8 patients validity can be challenged, since clinicians are relying without history of low back pain, all of whom under- on the transduction of a non-painful stimulus, pres- went iliac crest harvesting for non-lumbar procedures sure, into a painful stimulus. Nonetheless, discography (679); prospectively performed lumbar discography on may correlate with the use of frankly noxious intradis- 26 individuals, who had no history of low back pain cal stimuli. Sixty-eight percent of patients undergoing (674); performed a prospective, observational study of intradiscal electrothermal therapy reported exact re- patients with and without low back pain to investigate production of their pain in quality and location; none the relevance of the high intensity zone to discogra- reported unfamiliar pain (362). phy pain provocation (683); performed a prospective, Construct validity of the discograms is also equally longitudinal study of 100 subjects with high risk factors important to avoid a false-positive result and obtain a for serious low back pain as determined by structural true-positive response. Consequently, for a response and psychosocial characteristics (680); retrospectively to be considered positive, concordant pain must be reviewed the data of positive disc injections at low pres- produced; and for the test to be valid, there must be sures among 69 subjects with and without chronic low

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back pain (681); and attempted to test the hypothesis hen et al (690) in a retrospective review of patients that positive discography accurately identifies the low with chronic low back pain, showed that prevalence back pain illness due to a primary discogenic lesion as of discogenic pain was 65% irrespective of whether determined by clinical cure with successful arthrodesis the patients had prior back surgery or not. They also in a best case clinical setting (682). In summary, Carra- showed that needle insertion site does not affect the gee et al (674-683) state that their findings continue to percentage of positive discogram results. offer support for the conclusion that subjects with nei- Calhoun et al (691) determined that lumbar dis- ther low back pain, a chronic pain state, nor previous cography has a sensitivity of 90.3% and false-negative surgery have a low risk for low-pressure painful injec- rate of 9.7%, when surgical outcomes are used as the tions. However their studies were extensively criticized criterion standard. Pain provocation is most common by others. Despite their conclusions, their data suggests with posterior annular tears. Outcome was 89% in that truly asymptomatic patients and discs are at a neg- those patients selected for provocative discography ligible risk for discography-induced pain, at low pres- compared to those 52% for those selected by non-in- sure. In contrast, proponents have shown a different vasive imaging. picture with reliability of discography when it is per- 5.2.3 Indications formed appropriately (684-688). Much of the controversy about discography has Derby et al (684) concluded that patients with arisen because the results of discography have been “chemically sensitized” discs had significantly better used to help decide whether a certain patient should outcomes following interbody/combined fusion ver- or should not have surgery, even though patients sus posterolateral fusions. “Chemically sensitized” have usually undergone other diagnostic tests, the re- referred to those discs where in the static pressure, sults of which were either equivocal or non-diagnos- above opening static pressure, provoked familiar pain tic. Thus, discography should be performed only if the at least at less than 15 lbs. per square inch (PSI). They patient has failed to respond to adequate attempts speculated that these discs present pathological discs at non-operative care, and if diagnostic tests such as that have undergone inflammatory sensitization of MRI have not provided sufficient diagnostic informa- their annular nociceptors. Derby et al also performed tion. Generally, discography should be viewed as an pressure-controlled discography in 13 asymptomatic invasive test to be used to seek abnormalities when volunteers evaluating 43 discs (686); performed pres- results from other tests are equivocal or inconsistent, sure-controlled discography in 16 volunteers without in a patient with symptoms severe enough to require low back evaluating 55 discs and in 90 chronic low further evaluation (32,39,49). Thus, specific uses for back pain patients evaluating 282 discs (687); and per- discography include, but are not limited to: formed pressure-controlled discography in 86 chronic ♦ Further evaluation of demonstrably abnormal low back pain patients evaluating 279 discs (688). discs to help assess the extent of abnormality or O’Neill and Kurgansky (685) also evaluated subgroups correlation of the abnormality with clinical symp- of patients with positive discography. toms (in case of recurrent pain from a previously In 1968, Holt (666) reported false-positive disco- operated disc and a lateral disc herniation); grams in 37% of an asymptomatic prison population ♦ Patients with persistent, severe symptoms in in the lumbar spine. Simmons et al (667) reassessed whom other diagnostic tests have failed to re- Holt’s data (666) and pointed out that discography as veal clear confirmation of a suspected disc as the performed by Holt, although appropriate for its time, source of pain; was quite different from discography as performed in ♦ Assessment of patients who have failed to re- 1988. Walsh et al (613), in a carefully controlled series spond to surgical procedures to determine if of disc injections in asymptomatic volunteers, showed there is painful pseudoarthrosis or a symptomatic a 0% false-positive rate, refuting the findings of Holt disc in a posteriorly fused segment, or to evaluate (666). possible recurrent disc herniation; It is noteworthy that provocative discography ♦ Assessment of discs before fusion to determine if provided similar results in patients with or without so- the discs within the proposed fusion segment are matization or combinations of the psychological triad symptomatic and to determine if discs adjacent to of somatization disorder, depression, and generalized this segment are normal; and anxiety disorder (689). Over a three year period, Co- ♦ Assessment of minimally invasive surgical candi-

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dates to confirm a contained disc herniation or to discography is performed based on the history, physi- investigate contrast distribution pattern before cal examination, imaging data, and analysis of other intradiscal procedures. precision diagnostic techniques. There is no evidence Overall, discography is a useful imaging tool. In- to support discography without other non-invasive or tradiscal pathology may be missed by other studies. less invasive modalities of treatments or other preci- A post-discography CT scan may provide useful, addi- sion diagnostic injections. tional information, particularly to differentiate annu- 5.2.7 Safety and Complications lar tears from annular disruption. Based on the present Complications related to discography include literature, discography can produce pain in patients discitis, subdural abscess, spinal cord injury, vascular with mild or chronic low back pain, with a chronic pain injury, epidural and prevertebral abscess (665,692- disorder, or with no pain at all. However, discography 706). Complications are less frequent with lumbar rarely provokes pain in morphologically normal discs. discography compared to cervical discography. Lack Annular tears, particularly those extending to the out- of permanent effects from discography has been re- er annulus, are often associated with discographically ported (700-702). A review of lumbar discography provoked pain. However, degenerative disc changes and prophylactic antibiotics (703) concluded that with are not necessarily associated with pain provocation, lumbar discography using a two-needle technique whereas, progressive degeneration is associated with without prophylactic antibiotics, the risk of post dis- dissimilar and similar pain provocation. cography discitis is minimal, and there is not enough Discography cannot predict future back pain support from the literature to justify the routine use problems or disability in asymptomatic patients. of prophylactic antibiotics. They reported an overall Discography should not be used as a screening test incidence of 0.24% per patient and 0.091% per disc. for employment. Patients with persistent back pain However, other studies have shown effective preven- may have emotional and psychological problems tion of discitis with intravenous cefazolin or vanco- which can influence future outcomes and response mycin (704), and the combination of cefoperazone to therapy and the development of disability due and sulbactam (705). The administration of intradis- to chronic back pain. In subjecting a patient to discal antibiotics accidentally into the intrathecal space cography, false-positives may be reduced during dis- can have significant complications (706). cography, if only patients with normal psychomatic profiles and without other chronic pain syndromes 5.3 Transforaminal Epidural Injections or Se- or prior lumbar spine surgery are selected. However, lective Nerve Root Blocks in chronic pain this could be a major and difficult Transforaminal epidural injection (modern no- issue. menclature) or a selective nerve root block (old 5.2.4 Prevalence nomenclature) consists of injection of contrast, lo- Prevalence of pain due to internal disc disrup- cal anesthetic, or other substances around spinal tion was reported as 39% of patients suffering with nerves under fluoroscopy (1-4,33,46). Purists in- chronic low back pain (367) in the United States and sist on describing them as 2 separate and distinct 7% (229) in Taiwan. In contrast, primary discogenic techniques. However, over the years authors have pain was reported in 26% of patients suffering with used them interchangeably. Consequently, we con- chronic low back pain in the United States (230). The sidered transforaminal epidural and selective nerve prevalence of cervical discogenic pain in patients with root blocks as the same procedure. Both the pro- chronic neck pain of traumatic origin in informal stud- vocative response and analgesic response provide ies was estimated to be 20% (415). Prevalence of tho- clinically useful information (707-709). The validity racic discogenic pain has not been studied. of provocative and analgesic spinal injections was 5.2.5 Cost Effectiveness recognized as early as 1938 (707). In 1971, the val- There are no cost effectiveness studies of provoc- ue of diagnostic, selective nerve root blocks in the ative discography available in the literature. preoperative evaluation of patients with negative 5.2.6 Evidence or inconclusive imaging studies and clinical findings The evidence for cervical and thoracic discogra- of root irritation was reported (708). Nerve blocks phy is limited. The evidence for lumbar discography were utilized to diagnose the source of radicular is strong for discogenic pain provided that lumbar pain when imaging studies suggested possible com-

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pression of several nerve roots (708,710-732). The Comparative local anesthetic blocks that have been relief of usual symptoms following the injection shown to be valid in the diagnosis of facet joint pain of local anesthetic, 1 mL of 2% lidocaine, was the have not been studied for transforaminal usage. The main determinant. Numerous authors (710-714,721- only study that compared a short-acting local anes- 732) described results of diagnostic transforaminal thetic (lidocaine) with a long-acting local anesthetic epidural injections or selective nerve root blocks. (bupivacaine) in selective nerve root blocks used 2 The pattern of provoked symptoms from mechani- test blocks in a random order to test the validity of cal stimulation of nerve roots during selective nerve the block response (725). However, no differences in root blocks was described (713,722,724). The litera- effect were found between lidocaine and bupiva- ture on diagnostic selective nerve root blocks in the caine. Significant false-positive rates have been de- evaluation of low back pain was analyzed with the scribed with multiple other diagnostic interventional conclusion that selective nerve root blocks provide techniques involving facet joints, intervertebral discs, important prognostic information about surgical and sacroiliac joints. However, at present, there are outcomes (726). no false-positive with selective nerve root blocks 5.3.1 Rationale if properly performed; the only outcome is either Diagnostic selective nerve block is typically per- negative or positive. Further, multiple confounding formed in a patient with persistent pain when history, factors of psychological issues and sedation have not examination, imaging, and other precision diagnostic been studied for selective nerve root blocks. injections and electrophysiologic testing do not iden- Thus, properly performed, controlled diagnostic tify the pain generator. selective nerve root blocks can be an effective tech- 5.3.2 Validity nique in evaluating patients with multilevel pathol- The reported sensitivity of a diagnostic selective ogy to help identify the pain generator. Similarly, they nerve root block ranges from 45% to 100% (554,71 are useful when the location of symptoms seems to 0,711,714,718,725,727). The face validity of selective conflict with abnormalities identified with imaging nerve root blocks may be accomplished by providing findings (719,732) or when no other cause was found the blockade under fluoroscopic visualization utiliz- based on evaluation and application of precision diag- ing contrast and small volume of local anesthetic with nostic techniques. provocative and analgesic response. However, thus 5.3.3 Cost Effectiveness far, there are no means to eliminate false-positives Cost effectiveness of diagnostic transforaminal and establish construct validity for selective nerve epidural injections or selective nerve root blocks has root blocks. North et al (554), examined the specificity not been evaluated. However, the feasibility and cost- and sensitivity of a battery of local anesthetic blocks. effectiveness of appropriately performed controlled They evaluated lumbosacral nerve root blocks, medial comparative local anesthetic blocks has been de- branch blocks, sciatic nerve blocks, and compared to scribed (229,587-589). lumbar subcutaneous injection of an identical volume 5.3.4 Evidence of 3 mL of 0.5% bupivacaine. They showed that false- The evidence is moderate for selective nerve root positive results were common and specificity was low. blocks in the preoperative evaluation of patients with They concluded that there was only a limited role for negative or inconclusive imaging studies and clinical uncontrolled local anesthetic blocks in the diagnostic findings of nerve root irritation. evaluation of sciatica and referred pain syndromes in 5.3.5 Safety and Complications general. Complications are infrequent. However, the most The construct validity of selective nerve root common and worrisome complications of transforam- blocks has not been established. As for facet joint inal epidural injections are related to dural puncture, block or sacroiliac joint blocks, and provocative dis- infection, intravascular injection, air embolism, vascu- cography, no standards have been established to lar trauma, particulate embolism, cerebral thrombo- eliminate false-positive responses with transforami- sis, epidural hematoma, neural or spinal cord dam- nal epidural injections. However, true-positive re- age, and complications related to administration of sponses may be secured by performing controlled steroids (733-760). Recent reports of paraplegia, ver- blocks with placebo injections of normal saline. tebral artery dissection, neurological disorders, and death are concerning.

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5.4 Sacroiliac Joint Blocks 5.4.2 Validity The sacroiliac joint is accepted as a potential The face validity of sacroiliac joint block has been source of low back and/or buttock pain with or with- established by injecting small volumes of local anes- out lower extremity pain (436-456). Diagnostic blocks thetic with contrast into the joint and determining of a sacroiliac joint can be performed to determine contrast spread in posterior, anterior and lateral ra- whether the sacroiliac joint is the source of the pa- diographs. Construct validity of sacroiliac joint blocks tient’s pain (229,230,460-465). The sacroiliac joint can has been established by determining the false-positive be anesthetized with intraarticular injection of local rate of single, uncontrolled, sacroiliac joint injections anesthetic. of 20% and 22% (230,461). False-positive responses 5.4.1 Rationale may occur with extravasation of anesthetic agent out The rationale for sacroiliac joint blocks for di- of the joint due to defects in the joint capsule (785). agnosis is based upon the fact that sacroiliac joints False-negative results may occur from faulty needle are innervated and have been shown capable of placement, intravascular injection or inability of the being a source of low back pain and referred pain local anesthetic to reach the painful portion of the in the lower extremity (436-456). There are no defi- joint due to loculations (23,48,436-440,788-791). nite historical, physical, or radiological features to 5.4.3 Prevalence provide accurate diagnosis of sacroiliac joint pain Several authors have shown the sacroiliac joint to (229,230,436-440,460,461,465,562,761-786). Never- be a source of pain in 10% to 30% of cases by a single theless, many authors (563,763-765,777-786) have block (229,460) and 10% to 26.6% by a double block advocated provocative maneuvers, which may enter paradigm (230,461,462). In post fusion patients the into the differential diagnosis of sacroiliac joint pain. prevalence was demonstrated to be 35% with single Multiple publications by Laslett et al (562,777,778) local anesthetic blocks (465). Table 5 shows descrip- extensively evaluated the value of provocations tests, tion of prevalence studies of sacroiliac joint pain with and they believed that multiple tests can provide ap- a controlled design. propriate diagnosis of sacroiliac joint pain or more 5.4.4 Cost Effectiveness importantly can rule it out. Various tests described There are no studies evaluating the cost effective- by others and a systematic methodological review ness of diagnostic sacroiliac joint blocks. has been skeptical (786,787). In a study utilizing com- 5.4.5 Evidence parative, local anesthetic diagnostic intraarticular The evidence for the accuracy of sacroiliac joint sacroiliac joint blocks to identify positive respond- diagnostic injections is moderate for the diagnosis of ers with chronic low back pain due to SI joint pain sacroiliac joint pain. from non-responders, it was shown that there were 5.4.6 Safety and Complications no significant differences between responders and Complications of sacroiliac joint injection include non-responders with regard to pain referral areas, infection, trauma to the sciatic nerve, embolic phe- while major differences between two groups were nomena, and complications related to drug adminis- found using intensity maps; however, this study also tration. showed correlation between the positive outcome of 6.0 Therapeutic Interventional three or more provocational tests and the positive Techniques outcomes to the comparative local anesthetic blocks (781,783). In contrast, a review by Berthelot et al (785) Therapeutic interventional techniques in the man- assessed the literature on both provocative SI joint agement of chronic spinal pain include various types maneuvers as well as comparative local anesthetic of neural blockade and minimally invasive surgical intraarticular SI joint blocks, and concluded that both procedures. These include epidural injections, facet are unreliable for diagnosing pain originating from joint injections, neuroablation techniques, intradiscal the SI joint. Many studies have evaluated the accura- therapies, percutaneous disc decompression, vertebral cy of plain films (766), computed tomography (767), augmentation and implantables. single photon emission computed tomography (768), 6.0.1 Rationale bone scans (769,770), nuclear imaging (771-774), and The rationale for therapeutic interventional tech- magnetic resonance imaging (775,776) with variable niques in the spine is based upon the following con- results. siderations:

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Table 5. Characteristics of reported prospective diagnostic studies evaluating prevalence of sacroiliac joint pain.

Study Participants Objective(s) Interventions(s) Result(s)

Maigne et al (461) 54 patients aged To determine Successful blockade of the sacroiliac Prevalence = 18.5% 18-75 with chronic the prevalence of joint in 54 patients. A screening block AHRQ Score unilateral LBP with sacroiliac joint pain in was done with 2% lidocaine and a False-positive rate 3/5 or without radiation a selected population confirmatory block was performed = 20% to the posterior thigh of patients with with bupivacaine 0.5%. Greater than QUADAS Score for > 50 days (median low back pain and 75% relief was considered a positive 10/14 4.2 months). Patients assess certain pain block. had failed epidural provocation tests. or lumbar facet injections.

Manchikanti et 120 patients (age To determine the All patients had facet blocks. The incidence of al (230) 18-90) presenting to frequency of various Nonresponders who fit criteria had SIJ pain was 2% of the clinic with > 6 structures responsible double injection SIJ blocks. The the overall sample AHRQ Score months of low back for low back pain. screening block was done with 2% and 10% of those 4/5 pain and no structural lidocaine and the confirmatory suspected to have basis for the pain by block was performed using 0.5% SIJ pain. The false- QUADAS Score radiographic imaging. bupivacaine. positive rate was 11/14 20 patients were 22%. evaluated for SI joint pain.

Irwin et al (462) 158 patients To evaluate prevalence The fluoroscopically guided 26.6% were found underwent sacroiliac and correlation contrast-enhanced sacroiliac joint to have sacroiliac AHRQ Score joint injections with between age, gender, injections were performed initially joint pain by dual 3/5 average symptoms and body mass index with 2 mL of 2% lidocaine for the injections. duration of 34 by dual comparative first injection, followed by 2 mL of QUADAS Score months. Patients local anesthetic 0.25% bupivacaine, a local anesthetic, 7/14 failed conservative blocks. for the confirmatory injection. A modalities prior to patient was required to have at least injection therapy. 70% reduction of familiar painful symptoms after the initial injection for 3 or 4 hours for positive response.

◆ Chronic spinal pain is a complex problem (1-4,9- has not been demonstrated conclusively (1-4,10- 21,52-56,209-227). 12,14,16,17,26,29,41-44,57-97,200-208,227,463- ◆ Cardinal source(s) of chronic spinal pain, par- 489,791-795). ticularly discs and joints, are accessible to neural ◆ There is increasing evidence supporting use of in- blockade (1-4,11-42,46-51). terventional techniques in managing spinal pain ◆ Removal or correction of structural abnormalities (1-4,13,22-25,29-31,41,42,47,48,51,56). of the spine may fail to cure and may worsen pain- 6.0.2 Environment ful spinal conditions (1-4,41-44,64,227,463-489). The requirements for safe use of therapeutic in- ◆ Degenerative processes of the spine and the origin terventions include a sterile operating room or a proof spinal pain are complex without correlation of cedure room, appropriate monitoring equipment, radiographic changes to clinical picture and prog- radiological equipment, special instruments based on nosis (1-4,41-44,300-311,362-365,370,375,377,463- technique, sterile preparation with all the resuscita- 489,521,544,545,560-577,791-808). tive equipment, needles, gowns, injectable drugs, in- ◆ The effectiveness of a large variety of therapeutic travenous fluids, anxiolytic medications, and trained interventions used to manage chronic spinal pain personnel for preparation and monitoring of the

30 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

patients. Minimum requirements include history and injections were no better than placebo for chronic physical examination, informed consent, and appro- lumbar spine pain. priate documentation of the procedure. Six randomized clinical trials offer data on the 6.0.3 Contraindications use of intraarticular injections in the spine (826-831). Contraindications include ongoing bacterial in- Open, controlled and uncontrolled clinical studies that fection, possible pregnancy, bleeding diathesis, and evaluated the long-term relief from intraarticular fac- anticoagulant therapy. Precautions are warranted in et joint injections are abundant (803,831-840). Table 6 patients with anticoagulant or antiplatelet therapy, illustrates published results. diabetes mellitus and artificial heart valves (557-559). The effectiveness of intraarticular corticosteroid lumbar facet joint injections (824,826,828-831) and 6.1 Facet Joint Interventions cervical facet joint injections (827) was studied com- A preponderance of the evidence supports the paring the results to those of a similar group not re- existence of facet joint pain (15,30,34-36,50,51,128, ceiving intraarticular steroids. Of these, 3 randomized 129,232-313,808-820), although there are a few de- trials, 1 by Carette et al (826) involving lumbar facet tractors (221-226,821,822). Based on a detailed review joint injections, a second study by Fuchs et al (831) and of the literature, the general consensus appears to be the third one by Barnsley et al (827) involving cervical that facet joint pain can be diagnosed with reasonable facet joint injections were included. Even then, Carette certainty only on the basis of controlled diagnostic loet al (826) failed to exclude placebo responders, which cal anesthetic blocks (21,34-36,823-825). Therefore, may account for the relatively high incidence of pa- assessment of the efficacy of interventional proce- tients in their study with presumed facet joint pain dures for the treatment of facet joint pain requires (58%), diluting the findings of true responses, making that studies only employ controlled diagnostic medial detection of differences between the study and con- branch blocks or intraarticular injections as selection trol groups more difficult. criteria for such studies. Fuchs et al (831) investigated the efficacy and safe- Facet joint pain may be managed by intraarticular ty of intraarticular sodium hyaluronate (SH) compared injections, medial branch blocks, or neurolysis of me- with intraarticular glucocorticoids (triamcinolone ace- dial branches (12-15,30,51). tonide; TA) in the treatment of chronic nonradicular Relief with intraarticular injections or medial lumbar pain. They included 60 patients in this ran- branch blocks was considered as short-term if docu- domized, controlled, blind-observer clinical study and mented for less than 6 weeks, and long-term, if doc- randomly assigned to 2 groups to receive 10 mg of SH umented for 6 weeks or longer. Relief with medial or 10 mg TA per facet joint. The facet joints on both branch neurotomy was considered short-term if it was sides at level L3-4, L4-5, and L5-S1 were treated once less than 3 months, and long-term if it was 3 months per week under computed tomographic guidance. or longer. They used outcome parameters with visual analog 6.1.1 Intraarticular Blocks scale, Roland Morris Questionnaire, Oswestry Disabil- Therapeutic benefit has been reported with the in- ity Questionnaire, the Low Back Outcome Score, and jection of corticosteroids, local anesthetics, or normal the Short Form 36 questionnaire. The results showed saline into the facet joints. The literature describing significant pain relief, improved function and quality the effectiveness of these interventions is abundant. of life with both treatments; however, this study also European guidelines for the management of chronic showed intraarticular hyaluronic acid was not inferior non-specific low back pain (56) described intraarticular to intraarticular glucocorticoid injections. The follow-up facet joint injections as ineffective, reviewing the lit- was carried out at 3 and 6 months after completion of erature from January 1995 to November 2002. Boswell treatment; thus, this was considered as a positive study et al (30) concluded that intraarticular injections were for both hyaluronic acid and glucocorticoid injections. ineffective on a long-term basis. Slipman et al (15) in The drawbacks of this study include lack of diagnosis a critical review determined that the evidence for the of facet joint pain by controlled local anesthetic blocks treatment of lumbar zygapophysial joint syndrome which may have increased the probability of inclusion with intraarticular injections should be rated as level of patients without facet joint pain. III (moderate) to IV (limited). Bogduk (823) in a nar- Barnsley et al (827) included a small number of rative review suggested that intraarticular facet joint patients, a total of 41, whose origin of neck pain

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Table 6. Results of published reports of effectiveness of intraarticular injections of cervical and lumbar facet joints

Methodological Initial Long-term Relief Results Quality Score(s) Relief

Study Study No. of Characteristics AHRQ Cochrane Patients Short- Long- < 6 6 term term Score(s) Score(s) 3 months weeks months < 6 relief > weeks 6 weeks

Lumbar Spine 33% vs 15% vs Carette et al (826) PC, RA, DB 10/10 10/10 C=50 NA N N 42% 42% T=51

Fuchs et al (831) RA, DB 9/10 9/10 60 SI SI SI P P

Schulte et al (834) p 6/8 --- 39 62% 41% 36% 9 N

Lynch and Taylor 53% vs p 6/8 --- Extraarti.=15 62% 56% P P (838) 89% Intraarti. =35

Murtagh (803) p 6/8 --- 100 NA 54% 54% P P

Desoutet et al (837) p 6/8 --- 54 54% 38% 38% P N

Lippitt (839) R 5/8 --- 99 42% 51% 14% N N

Lau et al (840) R 6/8 --- 34 56% 44% 35% P N

Cervical Spine Barnsley et al (827) RA, DB 10/10 9/10 41 50% NA NA N N

Kim et al (835) p 4/8 --- 60 SI SI SI P P

Folman et al (836) p 4/8 --- 30 SI SI NA P P

R = Retrospective; P = prospective; RA = randomized; PC = placebo controlled; DB = double blind; C = control; T = treatment; NA = not available; SI = significant improvement; P = positive; N = negative

was posttraumatic following whiplash. Consequent- Both well-controlled trials of Carette et al (826) ly, these results, although from randomized trials, and Fuchs et al (831) were included in the lumbar eval- may not be applied across a heterogenous popula- uation. Carette et al (826) showed that 42% of the tion. methylprednisolone group (20 patients), versus 33% Among the other 3 randomized trials, Marks of the saline group (16 patients) achieved significant et al (828) and Nash (829) compared the effects of relief at the 1-month follow-up. However, at 6-month intraarticular injections with medial branch blocks follow-up, 46% of the patients in the methylpredniso- with a single injection, with only short-term evalua- lone group compared to 15% of the patients in the sa- tion. Lilius et al (830) used overly broad criteria for line group continued to experience marked pain relief, inclusion without confirming the diagnosis by con- with a statistically significant difference. Fuchs et al trolled diagnostic blocks, and used excessive injectate (831) showed positive results both with intraarticular volumes (3 mL to 8 mL) of active agents. hyaluronic acid and glucocorticoid injections with in-

32 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

jections performed under fluoroscopy with excellent ations, Lippitt (839) reported greater than 50% relief outcome parameters. The only drawback was the lack initially in 42% of patients, which declined to 14% at of diagnostic blocks and exclusion of patients with 6 months and 8% at 12 months in 99 patients. Lau et false-positive pain. al (840) also reported initial relief in 56% of the pa- Barnsley et al (827) showed that the time to re- tients, which declined to 44% at 3 months, and 35% turn to 50% of baseline pain was 3 days in the ste- at 6 to 12 months. Thus, all the observational studies roid group and 3.5 days in the local anesthetic group. showed positive results. Less than half of the patients reported relief of pain Kim et al (835) classified patients with zygapoph- for more than 1 week, and fewer than 1 in 5 patients ysial joint pain of C5/6 and C6/7 treated with thera- reported relief for more than 1 month, regardless of peutic cervical zygapophysial joint injections with a whether the injection was with steroids or local anes- mixture of 0.5 mL of 1% lidocaine with 5 mg of triam- thetic. cinolone under fluoroscopy. The therapeutic effects Among the non-randomized trials, multiple ob- were compared with reduction of numeric rating scale servational studies were evaluated for inclusion. (NRS) of pain before and immediately after blockade Among these, 6 prospective studies (803,834-838) and and symptom-free periods after 12 months. The NRS 2 retrospective evaluations (839,840) were included in scores decreased immediately after blockade and the evidence synthesis. Schulte et al (834) evaluated 39 pa- symptom-free duration after blockade lasted longer tients with lumbar facet syndrome using a standarized in the herniated nucleus pulposus group with 11.3 + protocol with injection of steroid, lidocaine and 5% 1.7 months than the other two groups; the myofascial phenol under fluoroscopic control, and evaluated on pain syndrome group had relief for 3.2 + 0.9 months, follow-up based on a specially designed question- while the whiplash-associated disorders group had re- naire, which included McNab criteria, visual analogue lief lasting for 3.0 + 0.8 months. While it is difficult scale, and pain disability index. They reported pain re- to understand the philosophy behind the longer and lief up to 6 months after treatment. The outcome was better response in the herniated nucleus pulposus assessed excellent or good by 62% (24 patients) of the group overall results showed that it was effective in patients after one month, by 41% (16 patients) after all groups longer than 6 weeks. 3 months, and by 36% (14 patients) after 6 months. Folman et al (836) prospectively evaluated the ef- They concluded that facet joint injection therapy us- fectiveness of facet joint injections on chronic cervical ing a standardized protocol is safe, effective, and easy pain. Their follow-up was limited to only 3 months. to perform. Multiple disadvantages of this study in- They reported relief of approximately 12 to 13 weeks clude lack of appropriate diagnosis of facet joint pain in patients with chronic pain which was superior to by controlled local anesthetic blocks, including many the relief of 3 days as reported in patients similarly false-positive patients and the injection of phenol treated following whiplash neck injury. The study was along with steroid. Combinations of phenol and ste- excluded from the analysis as it failed to include false- roid have not been recommended since phenol is in- positive patients and failed to exclude outcome pa- jected to induce inflammation whereas prednisolone rameters and had only limited follow-up periods. suppresses the inflammation. However, the results Among the observational studies Gorbach et al were positive with 62% of the patients reporting ex- (833) and Shih et al (832) were excluded. Gorbach et cellent or good pain relief after 1 month with a single al (833) performed the injections under fluoroscopy block which extended to 36% of the patients after 6 and reported good pain relief with a single injection months. Lynch and Taylor (838) reported initial pain however, they failed to exclude false-positive pa- relief in 31 of 35 patients receiving intraarticular ste- tients and failed to include outcome parameters with roids, whereas 8 of 15 patients receiving extraarticu- a short-term follow-up. Basically they demonstrated lar steroids reported initial pain relief. Long-term pain that there was a positive immediate effect in 74% relief was reported in 62% at 3 months, and 56% at 6 and a positive medium-term effect in 33% of the pa- months. Destouet et al (837) reported significant pain tients. They also postulated that outcome depended relief for 1 to 3 months in 54% of the patients and 3 on clinical, not on morphologic or imaging findings. to 6 months in 38% of the 54 patients. Murtagh (803) Shih et al (832) evaluated a large number of patients reported long-term relief of up to 6 months in 54% (277 patients) and included bilateral injections in 117 of the 100 patients. Among the retrospective evalu- patients. They performed procedures under fluoros-

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copy with arthrography and provided follow-up at 1, medial branch blocks. Thus, 3 (828,829,842) of 6 stud- 3, 6 and 12 weeks. They reported excellent or good ies were excluded. The three remaining studies met response in 73.6% of the patients in the treatment inclusion criteria (841,843,844). group, while the control group showed improvement Manchikanti et al (841) evaluated 73 patients for in only 26.4% of the patients. However the relief de- lumbar facet joint pain by means of controlled, com- clined from 72.1% after 3 weeks in the study group to parative local anesthetic blocks. They randomly allo- 40.7% after 6 weeks, and 31.4% after 12 weeks. They cated patients into 2 groups, either receiving thera- also showed synovial cysts in 9% of the patients of peutic medial branch blocks with a local anesthetic and whom 92% responded well. Three of the patients had Sarapin or with a mixture of local anesthetic, Sarapin contrast medium extravasating into the epidural space and methylprednisolone. Significant improvement during injection. The study was excluded due to short- was documented in both groups in various param- term follow-up and lack of exclusion of false-positives eters of pain relief, functional status, opioid intake, and lack of functional assessment parameters. return to work, and psychological status. Significant 6.1.1.1 Cost Effectiveness pain relief was seen with 1 to 3 injections in 100% of No studies were performed evaluating cost ef- the patients up to 1 to 3 months, 82% of the patients fectiveness of therapeutic intraarticular facet joint for 4 to 6 months, and 21% for 7 to 12 months. The injections. mean relief was 6.5 + 0.76 months. 6.1.1.2 Evidence Manchikanti et al (843) evaluated effectiveness of For intraarticular injections of local anesthetics therapeutic medial branch blocks in managing chronic and steroids, there is moderate evidence for short and neck pain in a preliminary report of a double-blind, long-term improvement in managing low back pain randomized controlled trial. They reported data from and the evidence is limited for short and long-term a total of 60 patients, with 15 patients in each of the relief in the management of neck pain. 4 groups. Thirty patients were in a non-steroid group 6.1.2 Medial Branch Blocks and an additional 30 patients were in a steroid group. Therapeutic benefit has been reported with me- All of the patients met the diagnostic criteria of cervical dial branch blocks with local anesthetic and local an- facet joint pain by means of comparative, controlled di- esthetic and steroids. The literature describing the agnostic blocks. Four types of interventions were includ- effectiveness of medial branch blocks as a therapeu- ed. Group I served as control, receiving medial branch tic intervention is scarce. A single systematic review blocks using bupivacaine. Group II consisted of cervical (30) and evidence-based guidelines (1,2) evaluated medial branch blocks with bupivacaine and Sarapin. the effectiveness of medial branch blocks in the man- Group III consisted of cervical medial branch blocks with agement of chronic spinal pain as a therapeutic en- bupivacaine and betamethasone. Group IV consisted of tity. The European guidelines for the management of cervical medial branch blocks with bupivacaine, Sarapin chronic non-specific low back pain by Airaksinen et and betamethasone. Significant pain relief was defined al (56) showed no significant effectiveness of medial as 50% or greater improvement in pain, and functional branch blocks; however, the literature search was lim- status improvement was evaluated by Neck Pain Dis- ited from January 1995 through November 2002, even ability Index, which improved significantly at 3 months, though guidelines were published in 2006. 6 months and 12 months in 80%–87%, 80%–93%, and The therapeutic role of medial branch blocks was 87%–93% of patients respectively. The average number evaluated in 6 randomized clinical trials (828,829,841- of treatments for one year was 3.8 + 0.7 in the non-ste- 844) and 2 prospective controlled trials (845,846). Ta- roid group and 3.4 + 1.0 in the steroid group. Duration ble 7 shows details of the included studies. of average pain relief with each procedure was 13.4 + Among the randomized trials, Marks et al 3.5 weeks in the non-steroid group, and it was 15.9 + (828) and Nash (829) compared the effectiveness of 8.0 weeks in the steroid group with no significant differ- intraarticular injections and medial branch blocks ence among the groups. Clinically significant return-to- with one injection, without any long-term follow-up. work was seen, which was statistically insignificant. This Manchikanti et al (842) compared the effect of Sarapin study showed that therapeutic cervical medial branch on various types of nerve blocks including epidurals nerve blocks, with or without Sarapin or steroids, may and medial branch blocks in a random manner. How- provide effective management for chronic neck pain of ever, this was not a specific study of effectiveness of facet joint origin.

34 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Manchikanti et al (844) evaluated effectiveness ments for one year was 3.7 with no significant differ- of therapeutic lumbar facet joint nerve blocks in ences among the groups. Duration of average pain managing chronic low back pain in a preliminary re- relief with each procedure was 14.8 + 7.9 weeks in port of a prospective, randomized, double-blind trial. the non-steroid group, and it was 12.5 + 3.3 weeks They reported data from a total of 60 patients, with in the steroid group with no significant difference 15 patients in each of the 4 groups. Thirty patients among the groups. Clinically significant return-to- were in a non-steroid group and additional 30 pa- work was seen, which was statistically insignificant. tients were in a steroid group. All of the patients met This study showed that therapeutic lumbar medial the diagnostic criteria of lumbar facet joint pain by branch nerve blocks, with or without Sarapin or ste- means of comparative, controlled diagnostic blocks. roids, may provide effective management for chronic Four types of interventions were included. Group I low back pain of facet joint origin. served as control, receiving lumbar facet joint nerve Manchikanti et al (845) evaluated the therapeu- blocks using bupivacaine. Group II consisted of lum- tic effectiveness of cervical facet joint nerve blocks bar facet joint nerve blocks with bupivacaine and in chronic neck pain in a prospective outcome study. Sarapin. Group III consisted of lumbar facet joint They evaluated 100 consecutive patients meeting the nerve blocks with bupivacaine and betamethasone. diagnostic criteria of facet joint pain by means of com- Group IV consisted of lumbar facet joint nerve blocks parative, controlled diagnostic blocks. There were sig- with bupivacaine, Sarapin and betamethasone. Sig- nificant differences in numeric pain scores and pain nificant pain relief was defined as 50% or greater relief (> 50%) at 3 months (92%), 6 months (82%), decrease in pain and functional status improvement and 12 months (56%) compared to baseline measure- was evaluated by Oswestry Disability Index, which ments. There was significant improvement in func- improved significantly at 3 months, 6 months and 12 tional status, psychological status and employment months in 73%–87%, 87%–93%, and 73%–93% of among patients eligible for employment (employed patients respectively. The average number of treat- and unemployed) from baseline to 12 months.

Table 7. Results of published reports of effectiveness of cervical, thoracic and lumbar medial branch blocks

Methodological Initial Long-term Relief Results Quality Score(s) Relief

Study No. of Study Short- Long- Characteristics Patients < 6 3 6 term term weeks months months relief relief AHRQ Cochrane < 6 > 6 Score(s) Score(s) weeks weeks CERVICAL

80%- 80%- 80%- Manchikanti et al (843) RA, DB 7/10 10/10 60 P P 87% 87% 93%

Manchikanti et al (845) P 8/8 --- 100 92% 92% 82% P P

THORACIC

Manchikanti et al (846) P 8/10 --- 55 71% 71% 71% P P

LUMBAR 73%- 73%- 87%- Manchikanti et al (844) RA, DB 8/10 8/10 60 P P 87% 87% 93%

Manchikanti et al (841) RA 8/10 6/10 73 100% 100 82% P P

P = prospective; RA = randomized; DB = Double-blind; P = positive

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Manchikanti et al (846) in a prospective outcome istent for effectiveness of radiofrequency neurotomy study with minimum of one-year follow-up, evaluated for chronic cervical zygapophysial joint pain after flex- therapeutic role of thoracic medial branch blocks in ion/extension injury. Manchikanti et al (13) concluded managing chronic thoracic pain. Fifty-five consecutive that there was strong evidence for short-term relief patients meeting the diagnostic criteria of thoracic and moderate evidence for long-term relief of facet facet joint pain by means of comparative, controlled joint pain. Niemesto et al (14), within the framework diagnostic blocks were included. Medial branch blocks of the Cochrane Collaboration Back Review Group, were performed with local anesthetic with or without concluded that there was limited evidence that radio- steroids. The results showed significant differences in frequency denervation had a positive short-term ef- numeric pain scores and significant pain relief (>50%) fect on chronic cervical zygapophysial joint pain, and in 71% of the patient at 3 months and 6 months, a conflicting short-term effect on chronic low back 76% at 12 months, 71% at 24 months and 69% at 36 pain. In the European Guidelines for the management months, compared to baseline measurements. Func- of chronic non-specific low back pain (56), utilizing tional improvement was demonstrated at 1 year, 2 the literature through 2002, published in 2006, they years and 3 years from baseline. There was significant concluded that there is conflicting evidence that ra- improvement with increase in employment among diofrequency denervation of the facet joints is more the patients eligible for employment from baseline to successful than placebo for eliciting short-term or 1 year, 2 years, and 3 years in conjunction with im- long-term improvements in pain or functional dis- proved psychological function. ability in mechanical chronic low back pain (Level C 6.1.2.1 Cost Effectiveness evidence). However they also concluded that there is The cost effectiveness of lumbar facet joint nerve limited evidence that intraarticular denervation of the blocks was evaluated by Manchikanti et al (841) with facet joints is more effective than extra-articular de- 1-year improvement of quality of life at $3,461. The nervation. Further, they concluded that proper selec- cost of one-year improvement was similar to various tion of patients with successful diagnostic blocks and investigations with neural blockade, but also was sig- an optimal technique may be important to achieve nificantly better than the cost effectiveness with in- better results; however, they also denied the recom- trathecal morphine delivery or lumbar laminectomy, mendation of radiofrequency facet denervation for with or without instrumented fusion. patients with non-specific chronic low back pain. In 6.1.2.2 Evidence a health technology assessment by Canadian Agency The evidence for lumbar, cervical, and thoracic for Drugs and Technologies in Health by Murtagh medial branch blocks in managing chronic low back, and Foerster (62) in an evaluation of radiofrequency neck, mid back and upper back pain is moderate for neurotomy for lumbar pain, utilizing the modern short-term and long-term pain relief. evidence, concluded that the procedure continues to 6.1.3 Medial Branch Neurotomy be an emerging technology, with some studies sug- Percutaneous neurotomy of medial branches is a gesting it is efficacious, but procedural and other procedure that offers pain relief by denervation of the methodological shortcomings rendering much of this nerves that innervate a painful joint. The denervation research inconclusive. They also added that the most may be performed by radiofrequency thermoneuroly- rigorous assessment to date suggests that meticulous sis utilizing a thermal or pulsed mode, cryoneurolysis, attention to diagnosis and treatment may generate or laser denervation. positive results. Slipman et al (15) concluded that cur- There have been 5 systematic reviews of medial rent studies failed to give more than sparse evidence branch radiofrequency neurotomy (12-15,30) and to support the use of interventional techniques in the there also have been multiple guidelines (3,4,56). treatment of lumbar zygapophysial joint pain and the However, there have not been any significant publica- evidence for radiofrequency denervation was at Level tions or systematic reviews with pulsed radiofrequen- 3 or moderate. cy, cryoneurolysis, and laser neurotomy. The systematic reviews by Manchikanti et al (13) Geurts et al (12) concluded that there was moder- and Boswell et al (30) evaluated the effectiveness ate evidence that radiofrequency lumbar facet dener- of facet joint neurotomy utilizing the criteria estab- vation was more effective for chronic low back pain lished by Agency for Health Care Research and Qual- than placebo, and there was only limited evidence ex- ity (AHRQ) for evaluation of randomized and non-ran-

36 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

domized trials and Cochrane Musculoskeletal Review lesions when necessary, and other 15 patients under- Group for randomized trials. They concluded that the going local injections with steroid and anesthetic at evidence for pain relief with radiofrequency neuroto- the greater occipital nerve, followed by transcutane- my of medial branch nerves was moderate to strong ous electrical nerve stimulation when necessary. There in cervical and lumbar spine. Slipman et al (15) utilized were no statistically significant differences between the criteria by AHRQ. Thus, the systematic reviews by the two treatment groups at any time point in the tri- Manchikanti et al (13), Slipman et al (15), and Boswell al. They concluded that they did not find evidence that et al (30) met inclusion criteria. radiofrequency treatment of cervical facet joints and Due to several deficiencies, 2 systematic reviews upper dorsal root ganglions is a better treatment than (12,14) were excluded from evidence synthesis. infiltration of the greater occipital nerve, followed The therapeutic role of medial branch neurotomy by TENS for patients fulfilling the clinical criteria of was evaluated in 8 randomized trials (847-854), and in cervicogenic headache. This study was totally flawed 18 observational studies (855-872). Two randomized not only in the diagnosis but also in the application trials (847,848) and 15 observational studies (855-869) of technique. Authors claim that they developed a were included in evidence synthesis. Six of 8 random- sequence of various cervical radiofrequency neuroto- ized trials were excluded because of inappropriate in- mies that proved successful in a prospective pilot trial clusion criteria, inappropriate diagnostic evaluation, with 15 chronic headache patients. Their diagnosis inappropriate interventions, or inadequate follow-up. was not established by controlled diagnostic blocks; Fifteen of 18 observational studies were included in in addition, the treatments were targeting 2 differ- evidence synthesis. Results of various studies included ent structures, namely cervical facet joints and dorsal in evidence synthesis are illustrated in Table 8 show- root ganglion compared to occipital nerves. Thus, this ing the results of cervical medial branch neurotomy, in study was excluded from evidence synthesis. Table 9 showing the results of lumbar medial branch Van Wijk et al (854) in a study which sounds el- neurotomy and Table 10 showing thoracic medial egant and technically competent, described radio- branch neurotomy. frequency denervation of lumbar facet joints in the Lord et al (847) evaluated percutaneous radiofre- treatment of chronic low back pain: a randomized, quency neurotomy in patients with cervical facet joint double-blind, sham lesion-controlled trial evaluated pain with controlled local anesthetic blocks, in a dou- a total of 81 out of 462 patients randomly assigned ble-blind, placebo-controlled trial. The results showed to radiofrequency denervation or sham treatment. that the median time that elapsed before the pain re- Multiple outcome measures were used. They con- turned to at least 50% of the preoperative level was cluded that the combined outcome measure and 263 days in the active treatment group and 8 days in VAS showed no difference between radiofrequency the control group. The authors concluded that in pa- and sham, though in both groups, significant VAS tients with chronic cervical facet joint pain, percutane- improvements occurred. However, the global per- ous radiofrequency neurotomy with multiple lesions ceived effect was in favor of radiofrequency. They of target nerves can provide long-lasting relief. In the also concluded that in selected patients, radiofre- second study, Van Kleef et al (848) showed that after quency facet denervation appears to be more ef- 3, 6, and 12 months, the number of successes in the fective than sham treatment. This study has numer- lesion and sham groups was 9 and 4, 7 and 3, and 7 ous deficiencies, such as criteria for inclusion which and 2, respectively. These results demonstrated that consisted of a single diagnostic block and only 50% radiofrequency denervation of the lumbar facet joints relief on visual analog scale reduction from the can be effective for pain reduction in patients with diagnostic block, which will not eliminate false- lumbar facet joint pain. positives. There also has been criticism regarding Haspeslagh et al (853) in a randomized controlled technical aspects of this procedure (873,874). It has trial of cervical radiofrequency lesions as a treatment been compared with a study by Dreyfuss et al (865) for cervicogenic headache evaluated 30 patients with which was meticulously performed. Other random- cervicogenic headache according to Sjaastad diagnos- ized trials were also excluded as they failed to meet tic criteria, with 15 patients receiving a sequence of inclusion or methodological criteria. The study by radiofrequency treatments with cervical facet joint Leclaire et al (851), on the surface appeared to be denervation followed by cervical dorsal root ganglion an elegant, well-performed, double-blind, placebo-

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controlled trial, similar to the one by Van Wijk et al ical relevance, while another study (852) compared (854). However this study had numerous deficien- reproducibility of lesion size of 2 current radiofre- cies, as it failed to define the study population using quency techniques. appropriate diagnostic criteria which was a fatal er- Multiple non-randomized evaluations were in- ror. Patients were evaluated with a single diagnostic cluded in the evidence synthesis. Staender et al (858) block. These authors considered any pain relief of 1 performed a computerized tomography-guided cryo- day duration during a 7-day period following a sin- neurolysis in 76 patients with lumbar facet joint syn- gle diagnostic block. This type of pain relief may be drome. In this prospective evaluation a diagnosis was as a result of many, many factors including natural established after 3 positive CT-guided medial branch sequence; consequently, any results or conclusions nerve blocks. Outcome measurements which includ- based on this study would be erroneous (875,876). ed visual analog score, use of medication, ability to Thus, it was excluded from the analysis. A study by work and physical conditions was evaluated at 3 days, Gallagher et al (849) was not included because it 3 months and every 3 months thereafter, with a me- used the invalidated Shealy technique, and failed dian follow-up period of 22.5 months ranging from 6 to describe appropriate diagnostic techniques and to 43 months. They reported significant reductions in outcome analysis. It is also unclear whether these the VAS at 3 months and 6 months postoperatively. interventions were performed with or without flu- In 40% of patients pain was reduced for 12 months oroscopy. Two other studies were excluded from or longer, 18 patients underwent a second, 7 a third, inclusion and evidence synthesis: one study used and 1 a fourth kryorhizotomy. Birkenmaier et al (857) intraarticular facet joint denervation (850), which is evaluated cryoneurolysis for lumbar facet pain diag- not medial branch neurotomy and is of unclear clin- nosed with positive medial branch local anesthetic

Table 8. Characteristics of results of studies of cervical medial branch neurotomy Methodological Quality Score(s) Long-term Relief Results Initial Study No. of Study Relief< 3 Characteristics Patients Short- Long- AHRQ Cochrane months term term Score(s) Score(s) 6 mos. 12 mos relief<3 relief≥3 months months

LA=12 50% vs 8% vs 8% vs 9/10 Lord et al (847) PC, RA, DB 9/10 RFTN=12 67% 58% 58% P P

Barnsley (855) P 7/8 --- 35 74% 74% 74% P P

McDonald et al P 7/8 --- 28 71% 71% 71% P P (862)

Sapir and Gorup P 7/8 --- 46 NA NA NA P P (861)

Shin et al (856) P 7/8 --- 28 68% 68% 68% P P

Schaerer (864) R 5/8 --- 117 NA NA 68% N N

Tzaan and Tasker R 5/8 --- 90 NA 41% NA N N (863) R = Retrospective; P = prospective; RA = randomized; PC = placebo controlled; DB = double blind; LA = local anesthetic; RFTN = radiofrequency thermoneurolysis; NA = not available; P = positive; N = negative

38 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Table 9. Characteristics of results of studies of lumbar medial branch neurotomy

Methodological Quality Score(s) Long-term Relief Results

Short- Long- Initial term term Study AHRQ Cochrane No. of Relief< 12 relief<3 relief≥3 Study Characteristics Score(s) Score(s) Patients 3 mos. 6 mos. mos. mos. months

38% vs 19% vs 13% vs Van Kleef et al (848) PC, RA, DB 9/10 7/10 C=16T=15 P P 67% 47% 47%

Dreyfuss et al (865) P 8/8 --- 15 93% 87% 87% P P

Mogalles et al (859) P 6/8 --- 15 93% 93% 93% P P

Vad et al (867) P 8/8 --- 12 83% 83% 83% P P Schofferman and Kine R 5/8 --- 20 85% 85% 85% P P (866) Schaerer (864) R 5/8 --- 117 NA NA 68% N N Tzaan and Tasker (863) R 5/8 --- 90 NA 41% NA N N North et al (868) R 6/8 --- 42 45% 45% 45% N N Birkenmaier et al (857) P 5/8 --- 46 72% 57% 57% P P Staender et al (858) P 5/8 --- 76 40% 40% 40% P P Martinez-Suarez et al R 4/8 --- 252 75% 75% 75% P P (860) R = Retrospective; P = prospective; RA = randomized; PC = placebo controlled; DB = double blind; NA = not available; P = positive; N = negative

Table 10. Characteristics of results of studies of thoracic medial branch neurotomy

Long-term Relief Results

AHRQ Initial Study No. of Short- Long- Study Methodological Relief Characteristics Patients term term Quality Score(s) < 3 month 6 12 relief relief months months <3 ≥3 months months

Stolker et al (869) P 5/8 40 83% 83% 83% P P

Tzaan and Tasker R 5/8 90 NA 41% NA N N (863)

R = Retrospective; P = prospective; NA = not available; P = positive; N = negative

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blocks. In this prospective evaluation, the outcome lash symptoms and visual analog pain scores in a signif- parameters were low back pain improvement, im- icant proportion of patients at 1 year in both litigant proved activity and overall satisfaction, with determi- and non-litigant patients. Vad et al (867) described nation of outcomes at 6 weeks, 3, 6, and 12 months. the role of lumbar radiofrequency denervation in They reported significant improvement in low back baseball pitchers. They reported a median pain relief pain (>50%) achieved in 72% of patients at 6 weeks; of 1.3 years (range: 1 to 2.1 years) and improved func- 70% at 3 months, and 57% at 12 months. Thus, only tion in 83%, or 10 of 12 patients. Stolker et al (869) one study (857) evaluating cryoneurolysis has shown studied thoracic facet joint neurolysis in 40 patients positive results. This was only a prospective study and and reported positive results, with 47.5% of the pa- there have not been any randomized studies evaluat- tients being pain-free and an additional 35% having ing cryoneurolysis thus far. Further, this was evaluated relief greater than 50% at 2-months follow-up. After only in the lumbar spine. a follow-up of 18 to 54 months, they reported 83% of Mogalles et al (859) evaluated percutaneous la- the patients with greater than 50% pain relief. ser denervation of the zygapophysial joints in the A prospective study by Shin et al (856) evaluated facet pain syndrome. This prospective evaluation in- the role of radiofrequency neurotomy of cervical me- cluded percutaneous laser denervation in 15 patients dial branches for chronic cervicobrachialgia, radiating in whom the facet joint pain was confirmed by 2 di- in typical facet joint patterns to the neck and shoul- agnostic blocks. Of the 15 patients undergoing laser der. Twenty-eight patients with facet joint pain were denervation, 8 experienced complete relief and 6 ex- identified with comparative local anesthetic blocks perienced more than 50% pain relief. They concluded and subsequently underwent radiofrequency neuroly- laser denervation is an effective treatment; however sis. The primary outcome was pain relief at 1, 2, 3, 6, 9, this appears to be the first published study on laser and 12 months. Sixty-eight percent of patients had a denervation in a prospective study. Though selection successful outcome (> 50% pain relief) after 6 months criteria was appropriate, there were no appropriate of follow-up; 29% reported complete pain relief. outcome parameters and the results have not been Among the retrospective evaluations, Martinez- substantiated in a randomized double-blind trial. Suarez et al (860) evaluated 252 patients with diagno- Barnsley (855) evaluated the results of radiofre- sis of lumbar facet joint pain. They reported effective- quency for cervical facet joint pain as applied in usual ness in 74.7% of cases. Schofferman and Kine (866), in clinical practice. He included the diagnosis of cervical a chart review of 20 patients, reported 10.5 months of facet joint pain made with comparative local anes- mean relief (range: 4–9 months) following lumbar ra- thetic blocks. The primary outcome was duration of diofrequency neurotomy. Tzaan and Tasker (863) eval- complete pain relief for all consecutive procedures uated 118 consecutive percutaneous radiofrequency performed over a 2-year period. Of the 35 patients facet rhizotomies performed on 90 patients. They re- included in the study, 60% of patients obtained com- ported that with the first procedure, 41% of patients plete pain relief for a duration in excess of 35 weeks. had greater than 50% subjective reduction of pain. McDonald et al (862) determined the long-term effi- The study included cervical, thoracic and lumbosacral cacy of percutaneous radiofrequency medial branch facets. North et al (868) evaluated radiofrequency neurotomy in the treatment of chronic neck pain in lumbar facet denervation with long-term outcome as- 28 patients diagnosed as having cervical zygapophy- sessment by a disinterested third party interview. For- sial joint pain, on the basis of controlled diagnostic ty-five percent of patients undergoing denervation blocks. They reported complete relief of pain in 71% reported at least 50% relief of pain at long-term fol- of patients after an initial procedure. The median du- low-up. Schaerer (864) evaluated radiofrequency fac- ration of relief after a first procedure was 219 days et rhizotomy in 117 consecutive patients with chronic when failures were included, but 422 days when only neck and low back pain and reported that overall re- the successes were considered. Dreyfuss et al (865) de- sults were fair to excellent in 68% of patients, with an scribed lumbar facet joint radiofrequency neurotomy average follow-up of 13.7 months. in 15 patients utilizing strict criteria and procedural The effectiveness of pulsed radiofrequency was considerations, and noted 60% of the patients were evaluated in 2 studies (870,871). Mikeladze et al (870) improved at 1 year. Sapir and Gorup (861) studied 46 retrospectively evaluated 114 patients with clinical patients reporting overall reduction in cervical whip- signs of facet joint involvement and a favorable re-

40 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

sponse to a diagnostic medial branch block utilizing Utilizing traditional radiofrequency neurotomy local anesthetic. With application of pulsed radio- techniques as practiced in the United States in the frequency they reported that of 114 patients with cervical and lumbar region, the evidence for radio- positive response to diagnostic block, 46 patients did frequency neurotomy of medial branches is strong not response favorably to pulsed radiofrequency ap- for short-term and moderate for long-term relief. Evi- plication. They reported success in 68 patients, with dence for cryo denervation and pulsed radiofrequency average relief lasting 3.93 + 1.86 months. Eighteen pa- is indeterminate. tients also had the procedure repeated with the same 6.1.4 Safety and Complications duration of pain relief that was achieved initially. Complications are rare. Among them, the most Previous surgery, duration of pain, sex, spinal levels common and worrisome complications of facet joint (either cervical or lumbar), and stimulation levels did interventions are related to needle placement, drug not influence outcomes. This study is not only prelimi- administration, and neurolysis (1-4,30,34-36,50,51,590- nary but also had many flaws. They applied a single 610,699,878-885). Complications include dural punc- diagnostic block, which is subject to multiple false- ture, spinal cord trauma, infection, intraarterial or positives. In a sense, 46 patients who did not respond intravenous injection, spinal anesthesia, chemical may represent the false-positives themselves. Further, meningitis, neural trauma, pneumothorax, radiation appropriate outcome parameters were not applied. exposure, facet capsule rupture, hematoma forma- Lindner et al (871) also evaluated pulsed radiofre- tion, and steroid side effects. In addition, potential quency treatment of the lumbar medial branch for side effects with radiofrequency denervation include facet pain, the results of which were reported in 48 painful cutaneous dysesthesias, increased pain due to patients. Authors offered the pulsed radiofrequency neuritis or neurogenic inflammation, anesthesia do- treatment to patients who did not respond with con- lorosa, cutaneous hyperesthesia, pneumothorax and ventional radiofrequency heat lesioning. They defined deafferentation pain. a successful outcome as a greater than 60% improvement on the numeric rating scale at 4-month follow- 6.2 Epidural Injections up. The successful outcome was established in 21 of 29 Several approaches are available to access the non-operative patients and 5 of 19 operative patients. lumbar epidural space: caudal, interlaminar, and In the unsuccessful patients who were subsequently transforaminal (1-4,24,25,45,886). There are sub- treated with heat lesions, the success rate was 1 of stantial differences between the 3 approaches. The 6. While this study did not compared heat lesioning interlaminar entry is directed more closely to the as- directly to pulsed radiofrequency, it appears that pa- sumed site of pathology, requiring less volume than tients failed to response to heat lesioning when they the caudal route. The caudal entry is relatively eas- failed to respond to pulsed radiofrequency. This may ily achieved, with minimal risk of inadvertent dural confirm a proposed neuropathic component in facet puncture. The transforaminal approach is target spe- joint pain, with patients responding better to medial cific with smallest volume, fulfilling the aim of reach- branch nerve blocks (albeit for a shorter period) than ing the primary site of pathology; the ventrolateral radiofrequency. Overall the evidence for pulsed radio- epidural space. frequency is very preliminary and indeterminate. Due to the inherent variations, differences, ad- 6.1.3.1 Cost Effectiveness vantages, and disadvantages applicable to each tech- No cost effectiveness evaluations were performed nique (including the effectiveness and outcomes), with medial branch neurotomy. caudal epidural injections; interlaminar epidural in- 6.1.3.2 Evidence jections (cervical, thoracic, and lumbar epidural injec- Evidence for radiofrequency neurotomy of me- tions); and transforaminal epidural injections (cervical, dial branch of cervical spine utilizing the techniques thoracic, and lumbosacral) are considered as separate described by Lord et al (847), McDonald et al (862), entities within epidural injections and are discussed as and Barnsley (855) with multiple lesioning and strict such below. criteria of 100% pain relief with diagnostic blocks, a In this evaluation, we considered all relevant tedious and time-consuming procedure as described quality systematic reviews (11,24-26,28,886-888) along by Bogduk (877), is strong for short- and long-term with randomized, and non-randomized trials for each relief of cervical facet joint pain. category, including caudal, interlaminar, and transfo-

www.painphysicianjournal.com 41 Pain Physician: January 2007:10:7-111

raminal epidural injections. Short-term effect was de- Koes et al (26), Van Tulder et al (28), and guidelines fined as a significant relief of less than 6 weeks and by Airaksinen et al (56). All these studies included es- long-term effect was defined as 6 weeks or longer sentially the same criteria as well as the same studies, relief. uniformly arriving at inaccurate conclusions. In con- Of particular importance are the European trast, Abdi et al (24) and Boswell et al (25) in a system- guidelines for the management of chronic non-spe- atic review and Bogduk et al (886) in a comprehensive cific low back pain (56). They included 4 high qual- review, evaluated caudal epidural steroid injections as ity systematic reviews (11,26,887,888); however, they a separate procedure, reaching opposite conclusions. included studies only through 2002 even though the They concluded that the effectiveness of caudal epi- guidelines were published in 2006. They did, how- dural injections in managing lumbar radiculopathy ever, include a 2004 systematic review. Based on the was moderate. available literature at the time and also not separat- Among the multitude of trials, there were 11 ing the types of epidurals (caudal, interlaminar and randomized trials (889-899), 5 prospective evalua- transforaminal), they summarized the evidence as no tions (900-904), and many retrospective evaluations evidence for the effectiveness of epidural corticoste- (886,905-907). The results of published reports of the roids in patients with non-radicular, non-specific low randomized trials and prospective trials of caudal back pain. However, they also concluded the epidural epidurals utilized in evidence synthesis and guideline corticosteroid injections should only be considered preparation are shown in Table 11. for radicular pain, if a contained disc prolapse is the Of the 11 randomized trials, 3 studies were ex- cause of the pain and if the corticosteroid is injected cluded (897,898,890) from evidence synthesis, due to close to the target. Further, they added that the in- non-availability of analyzable information (898), due jection should be fluoroscopically guided and should to lack of data at 3 months (897), and due to lack of aim at the ventral part of the epidural space, mean- appropriate data and nonuse of fluoroscopy in 2005 ing a transforaminal approach. They also concluded (890). Of the 8 randomized trials, 6 trials evaluated pre- that there was conflicting evidence that convention- dominantly patients with disc herniation or radiculitis al epidural steroids without fluoroscopic guidance (889,891,894-896,899), 2 trials evaluated post surgery are effective in radicular pain. The general consensus syndrome (892,893), 1 study (899) evaluated a mixed from the systematic reviews (11,26,28,887,888) is that population with 50% with post surgery syndrome and there is conflicting evidence for the effectiveness of the other 50% with sciatica, and 1 study (891) evalu- epidural and perineural corticosteroid injections for ated similarities between interlaminar and caudal. radicular pain (Level C) (56). However, Abdi et al (24), Four of the 6 trials of disc herniation or radicular pain Boswell et al (25) and Bogduk et al (886), utilizing were positive for long-term relief (889,894,896,899), separate though more stringent criteria, separating whereas, only one of the 2 trials (892) for post surgery interlaminar, caudal and transforaminal injections, syndrome was positive for short-term relief. The study have arrived at different conclusions. These review- of a mixed population (899) was positive for long- ers demonstrated the effectiveness of transforaminal term relief. Thus, overall 4 of 6 studies were positive and caudal epidural injections and ineffectiveness of for pain of disc herniation and radiculopathy, and 1 of interlaminar epidural injections in managing lum- 2 were positive for post surgery syndrome pain. bar pain. Boswell et al (25) and Abdi et al (24) have Among the 5 prospective evaluations (900-904), shown moderate effectiveness of cervical interlami- the role of caudal epidural steroids was evaluated nar epidural injections. in 2 studies in patients with radiculopathy or sciatica 6.2.1 Caudal Epidural Injections (902,903), in 2 studies in patients with chronic low Several systematic reviews have evaluated the back pain (900,901), and in 1 study (904) with spinal effectiveness of epidural steroids in general and in- stenosis. All showed positive results for short-term terlaminar epidural steroids in particular (11,24- and long-term pain relief. 26,28,886-888). While all the reviews included caudal Only 1 study was performed with fluoroscopic epidural steroid injections, some failed to separate visualization (889). In this study, caudal steroid epi- caudal and interlaminar techniques, arriving at erro- dural was compared with targeted steroid place- neous conclusions (11,28,887,888). Of importance are ment during spinal endoscopy for chronic sciatica in systematic reviews performed by Nelemans et al (11), a prospective, randomized, double-blind trial. In this

42 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Table 11. Results of published reports on caudal epidural steroid injections

Methodological Initial Long-term Quality Score(s) Results Relief Relief Study Study No. of Patients Short- Long- Characteristics AHRQ Cochrane term term < 6 Score(s) Score(s) 3 mos 6 mos relief relief weeks <6 ≥6 weeks weeks

Dashfield et al Caudal=30 RA, DB 9/10 8/10 SI SI SI P P (889) Endoscopy=30

25% 20% vs 20% vs. Breivik et al (894) RA, DB 8/10 7/10 C=19T=16 P P vs. 63% 50% 50% Bush and Hillier 64% vs RA, DB 8/10 8/10 C=11T=12 100% NA P N (895) 83%

Matthews et al 56% RA, DB 8/10 7/10 C=34T=23 SI NA N P (896) vs 67% Helsa and Breivik 59% vs RA, DB 7/10 7/10 69crossover NA NA P P (899) 25%

Forceful injection=29 49% vs Revel et al (892) RA 7/10 6/10 NA NA P N Regular=31 19%

D= 16 Meadeb et al RA 6/10 6/10 D+G = 15 NA NA NA N N (893) G = 16

McGregor et al Caudal=14 RA 6/10 5/10 NA NA NA N N (891) Interlaminar =16

Manchikanti et al ND=45 71% 67% vs 47% vs P 5/8 --- P P (901) PD=17 vs 65% 65% 41%

Yates (902) P 5/8 --- 20 NA NA NA P P

Waldman (903) P 5/8 --- 53 63% 67% 71% P P

Ciocon et al (904) P 5/8 --- 30 SI SI SI P P

G1=15 0% 0% 0% Manchikanti et al P 5/8 --- G2=22 100% 59% 19% P P (900) G3=33 97% 55% 15%

P = prospective; RA = randomized; DB = double blind; C = control; T = treatment; NA = not available; SI = significant improvement; vs = versus; P = positive; N = negative; ND = negative discography; PD = positive discography; D = disruption, G = Glucocorticoid

study, for the caudal group significant improvements months and depression at 6 months only. The authors were found for descriptive pain at 6 months, as well concluded that the targeted placement of epidural as visual analog scale at 6 weeks, 3 months, and 6 steroid onto the affected nerve root causing sciatica months. This study also showed present pain intensity does not significantly reduce pain intensity and anxi- improvements at 3 months and 6 months along with ety and depression compared with untargeted caudal improvements in anxiety at 6 weeks, 3 months and 6 epidural steroid injection. However, both techniques

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benefited the patients. were utilized for evidence synthesis with exclusion of 6.2.1.1 Cost Effectiveness 10 studies (908,912,917-919,923-925,927,928). Since 11 The cost effectiveness of fluoroscopically directed randomized trials (over 10) were available in evidence caudal epidural steroids was $3,635 and that of trans- synthesis for interlaminar epidural steroid injections foraminal steroids was $2,927 per year (905). In a pro- in the lumbar spine, no prospective or other observa- spective evaluation, the cost for 1-year improvement tional evaluations were utilized in the evidence syn- for quality of life was $2,550 in patients treated with thesis. caudal epidurals using local anesthetic and Sarapin or Of the 13 randomized trials included in the evi- steroids under fluoroscopy (900). dence synthesis, 11 of them evaluated the effective- 6.2.1.2 Evidence ness of interlaminar epidural steroid injections, ei- The evidence for caudal epidural steroid injec- ther on disc herniation, sciatica, or radiculopathy in tions is strong for short-term relief and moderate for the lumbar spine (891,909,910,912-916,920,921,929), long-term relief, in managing chronic low back and whereas, 2 randomized evaluations included cervical radicular pain. The evidence in post-lumbar laminec- disc herniation with radiculitis or brachialgia (922,926). tomy syndrome and spinal stenosis is limited. One study resulted in 2 publications (910,911). None 6.2.2 Interlaminar Epidural Injections of the randomized evaluations were performed to Multiple systematic reviews provided conflicting manage axial low back pain. Results of the included opinions (11,24-26,28,886-888). Further, most of the studies are illustrated in Table 12. Of the 11 random- systematic reviews (11,26,28) utilized combined cau- ized trials evaluating lumbar radiculitis, 6 were posi- dal and interlaminar epidural steroid injections. Con- tive for short-term relief (909,910,912,913,920,921, sequently, no reasonable definitive conclusions may 929), whereas only one study was positive for long- be drawn from these systematic reviews, and their term relief (916). Among the negative studies, Cuckler conclusions may not be applied in clinical practice set- et al (915) included patients suffering with post sur- tings. Thus far, all the systematic reviews concluded gery syndrome. that interlaminar epidural steroid injections lacked For evaluation of cervical pain and radiculopathy, long-term effectiveness. Multiple guidelines (1-4,56) 2 randomized trials (922,926), 1 prospective trial (930), also showed no significant evidence for long-term and multiple retrospective evaluations (938-949) were relief. Two systematic reviews (24,25) separately ana- available. In the evaluation of cervical interlaminar epi- lyzed caudal and interlaminar epidurals. However, dural steroids in managing cervical radiculopathy, both they also concluded that there was strong evidence randomized trials were positive (922,926). None of the for short-term relief with only limited evidence for randomized evaluations were performed to evaluate long-term relief of greater than 6 weeks. European the management of axial neck pain. guidelines for the management of chronic non-spe- Results of included studies are illustrated in Ta- cific low back pain (56) evaluated the literature from ble 13. Among the retrospective evaluations (938- January 1995 through November 2002. In addition, 947,949), the majority demonstrated favorable re- they also used evidence from 4 high quality systematic sults. In the one prospective study of the cervical spine reviews (11,26,887,888). But, they combined transfo- (930), patients received cervical interlaminar epidural raminal, caudal and interlaminar epidural injections in steroid injections for cervical radiculopathy and cervi- the management of chronic low back pain. They con- cal transforaminal epidural steroid injections if they cluded that epidural corticosteroid injections could failed to respond to the interlaminar epidural steroid only be considered for radicular pain and the evidence injections. was conflicting with regards to conventional epidural 6.2.2.1 Cost Effectiveness steroids without fluoroscopy even in radicular pain. In the evaluation of cost effectiveness, Manchikanti They also concluded that there is no evidence for the et al (905) and Price et al (911) concluded that interlam- effectiveness of epidural corticosteroids in patients inar epidural steroid injections were not cost effective. with non-radicular, non-specific low back pain. 6.2.2.2 Evidence Twenty-three randomized trials (891,908-929), 9 The evidence of interlaminar epidural steroid in- prospective evaluations (930-938), and numerous ret- jections in managing lumbar radiculopathy is strong rospective studies (939-949) were identified. Among for short-term relief and limited for long-term relief. the 23 randomized trials, 13 met inclusion criteria and In managing cervical radiculopathy, the evidence is

44 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Table 12. Results of published reports of lumbar interlaminar epidural steroid injections

Methodological Initial Long-term Quality Score(s) Results Relief Relief Study No. of Study Short- Long- Characteristics AHRQ Cochrane Patients term term < 6 3 Score(s) Score(s) 6 mos relief relief weeks mos <6 >6 weeks weeks

Arden et al RA, DB, PC 10/10 9/10 228 75% NSD NSD P N (910)

RA, DB, PC C=80 Carette et al 10/10 10/10 SIT NSD NSD P N (913) T=78 C=31 Cuckler et al RA, DB 9/10 9/10 NSD NSD NSD N N (915) T=42 C=15 Rogers et al RA, SB 6/10 5/10 SI NSD NSD P N (921) T=15 Wilson- McDonald et al RA 10/10 7/10 93 SI NSD NSD P N (909) C=24 Snoek et al RA 7/10 6/10 NSD NSD NSD N N (914) T=27 C=48 31% vs RA 7/10 7/10 SI NA P P Dilke et al (916) T=51 60%

19% C=16 19% vs Ridley et al RA 9/10 8/10 vs NA P N T=19 90% (920) 90% C=46 Kraemer et al RA 6/10 5/10 SI NA NA P N (929) T=40 steroid = 46 steroid + SI SI SI Pirbudak et al RA 6/10 6/10 P P (912) amitriptyline (AM) (AM) (AM) = 40

14=caudal McGregor et al RA 6/10 5/10 NSD NSD NA N N (891) 16=interlaminar

RA = randomized; SB = single blind; DB = double blind; PC = placebo controlled; NA = not available; SI = significant improvement; SIT = significant improvement in treatment group; AM = amitriptyline; NSD = no significant difference; vs = versus, C = control, T = treatment; P = positive; N = negative

moderate for short-term and long-term relief. The jections for lumbar nerve root pain was strong for evidence is indeterminate in the management of neck short-term and moderate for long-term improve- pain, low back pain, and lumbar spinal stenosis. ment. The evidence for cervical transforaminal epi- 6.2.3 Transforaminal Epidural Injections dural steroid injections for cervical nerve root pain Transforaminal epidural injections have emerged was moderate. The evidence was limited for lumbar as a target-specific modality for the treatment for radicular pain in post surgery syndrome. DePalma et management of spinal pain. Review of the literature al (18) performed a critical appraisal of the evidence showed 4 systematic reviews (18,24,25,56). for selective nerve root injection in the treatment Two systematic reviews (24,25) showed the evi- of lumbosacral radiculopathy and showed there dence of lumbar transforaminal epidural steroid in- was moderate evidence in support of these mini-

www.painphysicianjournal.com 45 Pain Physician: January 2007:10:7-111

Table 13. Results of published reports of cervical interlaminar epidural steroid injections

Methodological Initial Long-term Quality Score(s) Results Relief Relief Study No. of Study Characteristics AHRQ Cochrane Patients Short- Long- < 6 3 term term Score(s) Score(s) 6 mos weeks mos. relief <6 relief ≥6 weeks weeks Local anesthetic + steroids =14 Castagnera et al 75% vs RA 7/10 6/10 Local 79% 79% P P (922) 96% anesthetic + steroids + Morphine =10 C=17 36% vs 12% vs 12% vs Stav et al (926) RA 6/10 5/10 P P T=25 76% 68% 68%

RA = randomized; vs = versus, C = control, T = treatment; P = positive mally invasive and safe procedures in treating pain- Among the 7 prospective evaluations included ful radicular symptoms. European guidelines for the for evaluation, 2 studies evaluated the effectiveness management of chronic non-specific low back pain of cervical transforaminal epidurals (930,975), show- (56) also provided a favorable level of evidence for ing positive results. The remaining 5 studies (965,973- transforaminal epidural steroid injections. Follow- 975,977) evaluated lumbar transforaminal epidural ing the review of the literature from January 1995 to steroid injections. One study (975) compared effec- November 2002, they concluded that epidural corti- tiveness of transforaminal epidural steroid injections costeroid injections should only be considered for ra- in lumbar spine with discectomy. One evaluation re- dicular pain if a contained disc prolapse is the cause ported the effect on spinal stenosis (977). Multiple ret- of the pain and if the corticosteroid is injected close rospective evaluations also showed positive results. to the target through a transforaminal approach un- The results of the included studies are described der fluoroscopic guidance (56). Favorable evidence in Tables 14 and 15. Riew et al (961) performed a was also provided in other guidelines (1-4). study with a minimum 5-year follow-up to evaluate The evaluation for evidence synthesis led to nerve root blocks in the treatment of lumbar radicular identification of 12 randomized controlled trials pain. This was a continuation of a previous random- (950-961), 15 observational reports (930,962-976), ized double-blind controlled study evaluating the ef- and multiple retrospective evaluations (905,977- fect of nerve root blocks on the need for operative 998). Of the 12 randomized controlled trials (950- treatment of lumbar radicular pain (950). All of the 961), 7 trials were included in evidence synthesis patients in both studies (950,961) were considered (950,952,953,955,956,958-961), whereas of 15 pro- to be operative candidates by the treating surgeon spective evaluations (930,962-976), 7 were included and all had initially requested operative intervention. (930,965,968,973-975,977). A summary of reported They had been then randomized to be treated with studies is listed in Tables 14 and 15. a selective nerve-root block with either bupivacaine Among the 7 randomized trials included in the ev- or bupivacaine and betamethasone. Both the treat- idence synthesis meeting inclusion criteria, 6 of them ing physician and the patient were blinded to the evaluated effectiveness in lumbar disc herniation and type of medication. Of the 55 randomized patients, radiculopathy (950,952,955,956,958,961), showing 29 avoided an operation in the original study; 21 of positive results in 4 of the 6, both in short-term and those 29 patients were reevaluated with a follow-up long-term with 2 negative studies (951,958). The sev- questionnaire at a minimum of 5 years after the initial enth trial (953) studied effectiveness in post surgery block, and 17 of 21 patients still had not had operative syndrome and yielded negative results. intervention. There was no difference between the

46 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

group treated with bupivacaine alone and the group for symptomatic disc herniation in 70 patients; 63% or treated with bupivacaine and betamethasone with re- 44 had significant relief of their symptoms and did not gard to the avoidance of surgery for 5 years. At the wish to proceed with surgical treatment with an aver- 5-year follow-up evaluation, all of the patients who age of 13-month follow-up. In addition, 75% would had avoided operative treatment had significant de- attempt cervical epidural steroid injections again in crease in neurological symptoms and back pain com- the future. They concluded that cervical epidural in- pared with baseline values. Authors concluded that jections are a reasonable part of the non-operative the majority of patients with lumbar radicular pain treatment of patients with symptomatic cervical disc who avoid an operation for at least one year after re- herniations. They also concluded that a large percent- ceiving a nerve root injection with bupivacaine alone age of the patients may obtain relief from radicular or in combination with betamethasone will continue symptoms and avoid surgery for the follow-up period to avoid operative intervention for a minimum of 5 up to one year. In addition, patients older than 50 years. Ng et al (958) studied periradicular infiltration years and those who received the injection earlier, less of nerve roots (synonymous with transforaminal or than 100 days from diagnosis, seemed to have a more selective nerve root injections) with local anesthetic favorable outcome. and steroid versus local anesthetic alone. They evalu- 6.2.3.1 Cost Effectiveness ated 86 patients with unilateral leg pain and an MRI In the management of chronic low back pain, showing a lumbar herniated disc or foraminal stenosis cost per 1 year improvement of quality of life was at a level compatible with the symptoms. All the pa- $2,927 per year with transforaminal epidural steroid tients received a single level injection under fluoros- injections (905). Furthermore, in patients treated with copy with 2 mL of 0.25% bupivacaine with 40 mg of transforaminal steroids, operations were avoided for methylprednisolone in one group, while the second contained herniations, costing $12,666 less per re- group received bupivacaine alone. The results showed sponder in the steroid group (952). Cost effectiveness no significant difference between the groups. In both was also demonstrated by others by avoiding surgical the groups there was only a modest decrease in VAS at intervention (949,950,959,961). 3 months. Criticism of this study is that only one injec- 6.2.3.2 Evidence tion was offered. Yang et al (960) evaluated the effect The evidence for lumbar transforaminal epidural of transforaminal epidural steroids on candidates for steroid injections in managing lumbar nerve root pain discectomy in 21 patients. They reported that 63% of is strong for short-term and moderate for long-term the patients had significant pain relief lasting through improvement. The evidence for cervical transforaminal 24-month follow-up, avoiding surgery, with the trans- epidural steroid injections in managing cervical nerve foraminal epidural resulting in significant relief of root pain is moderate for short-term and long-term im- leg pain and improvement in activities of daily living. provement. The evidence is limited in managing lumbar However, there was no improvement in the low back radicular pain in postlumbar laminectomy syndrome. pain. Kolstad et al (959) studied cervical transforami- The evidence is indeterminate in managing axial low nal epidural steroids on 21 patients awaiting cervical back pain, axial neck pain, and lumbar disc extrusions. disc surgery. Patients were given 2 epidural injections 6.2.4 Safety and Complications 2 weeks apart and followed for 4 months. They used 2 Complications of caudal, interlaminar, and trans- outcome assessment measures including visual analog foraminal epidural injections are predominantly of scale for neck and radicular pain and Odom’s criteria. two types: those related to needle placement and Outcomes were measured at baseline, 6 weeks and 4 those related to drug administration (556-558,601- months. Five of the 21 patients canceled their surgery 603,735-760,877,878,882,886,996-1035). Reported due to improvement in pain, and overall there was a complications include dural puncture, spinal cord significant decrease in radicular pain at 6 weeks and trauma, infection, hematoma formation, abscess 4 months. Neck pain was also improved, and patients formation, subdural injection, intracranial air injec- with spondylosis responded as well as patients with tion, epidural lipomatosis, pneumothorax, nerve disc herniations. damage, headache, death, brain damage, increased There was one new retrospective evaluation for intracranial pressure, intravascular injection, vascu- cervical disc herniation and radiculopathy (949). Lin et lar injury, cerebral vascular or pulmonary embolus al (949) evaluated cervical epidural steroid injections and effects of steroids. Spinal cord trauma and spi-

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Table 14. Results of published reports on lumbar transforaminal epidural injections Methodological Initial Quality Score(s) Long-term Relief Results Relief Study No. of Study Long- Characteristics AHRQ Cochrane Patients Short- < 6 3 6 term Score(s) Score(s) term <6 weeks months months ≥6 weeks weeks Karppinen et al (951, RA, DB, PC 9/10 8/10 C=80 NA NA NA N N 952) T=80 33% vs 33% vs 33% vs Riew et al (961) P, RA, DB 8/10 7/10 55 P P 77% 77% 77%

Riew et al (950) RA, DB LA = 27 33% vs 33% vs 33% vs P P 8/10 7/10 LA+S =28 77% 77% 77% LA=43 42% vs 42% vs Ng et al (958) RA, DB 8/10 8/10 NSI N N LA+S=43 48% 48%

Devulder et al (953) RA 6/10 5/10 60 NSI NSI NSI N N

Vad et al (955) RA 7/10 7/10 48 48% vs 8% vs 8% vs P P 84% 84% 84% Thomas et al (956) RA 6/10 5/10 C=15 SI SI SI P P T=16

Yang et al (960) P 4/8 --- 21 63% 63% 63% P P

Lutz et al (965) P 4/8 --- 69 75% 75% 75% P P

Butterman (973) P 4/8 --- 232 SI SI SI P N 42%- P P Buttermann (974) P 4/8 --- 169 NA NA 56%

Botwin et al (977) P 4/8 --- 34 75% 75% 75% P P

P = prospective; RA = randomized; DB = double blind; PC = placebo controlled; LA = local anesthetic; LA+S = Local anesthetic + steroid; NA = not available; SI = significant improvement; SIT = significant improvement in treatment group; AM = amitriptyline; NSI = no significant improvement; vs = versus, C = control, T = treatment; P = positive; N = negative

nal cord or epidural hematoma formation are cata- epidural scarring, which can physically prevent direct strophic complications, but rarely seen following application of drugs to nerves and other spinal tis- epidural injections. sues and to treat chronic back pain. Epidural lysis of adhesions and direct deposition of corticosteroids 6.3 Epidural Adhesiolysis in the spinal canal can also be achieved with a 3-di- Percutaneous epidural adhesiolysis or lysis of epi- mensional view provided by epiduroscopy or spinal dural adhesions or epidural adhesiolysis with a spinal endoscopy. endoscope (myeloscope or epiduroscope) are inter- Duration of relief of less than 3 months was conventional pain management techniques that play an sidered as short-term and longer than 3 months was active role in managing chronic intractable low back considered as long-term. pain (1-4,31,65,499,500,1036). 6.3.1 Percutaneous Adhesiolysis The purpose of percutaneous epidural lysis of Clinical effectiveness of percutaneous adhe- adhesions is to minimize the deleterious effects of siolysis was evaluated in 1 systematic review (31),

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Table 15. Results of published reports on cervical transforaminal epidural injections

Initial Long-term Relief Results Relief AHRQ Study No. of Study Methodological Short- Long- Characteristics Patients term term Quality Score(s) < 6 3 6 <6 ≥6 weeks months months weeks weeks

Bush and Hillier P 4/8 68 93% 93% 93% P P (930)

Kolstad et al (959) P 4/8 21 SI SI SI P P

Cyteval et al (975) P 4/8 30 60% 60% 60% P P

Lin et al (949) R 4/8 70 63% 63% 63% P P

P = prospective; R = retrospective; SI = significant improvement; P = positive

and 1 health technology assessment (65). Chopra et tive studies on epidural adhesiolysis was small and al (31) concluded that there was strong evidence to adhesiolysis may provide benefit by eliminating indicate effectiveness of percutaneous epidural ad- scar tissue, thereby allowing application of drugs hesiolysis with administration of epidural steroids to the nerves for the treatment of low back pain. for short-term and long-term in chronic, refractory Of the 14 relevant articles identified, 5 random- low back pain and radicular pain. There was mod- ized trials (1037-1041), 2 prospective evaluations erate evidence of effectiveness of the addition of (1042,1043), and 3 retrospective evaluations (1044- hypertonic saline. The evidence of effectiveness of 1046) were included in the analysis. The remaining hyaluronidase was negative. In preparation of Eu- studies failed to meet inclusion criteria and were ex- ropean guidelines for the management of chronic cluded from the evidence synthesis (1047-1050). non-specific low back pain, Airaksinen et al (56) Three randomized trials (1037,1039,1040) and one of evaluated percutaneous adhesiolysis as part of the 2 retrospective studies (1044) included patients with epidural corticosteroid injections. They concluded and without previous surgery. One study (1045) included that epidural corticosteroid injections should only only post surgical patients. All the studies included pa- be considered for radicular pain if a contained tients with chronic, refractory low back pain and lower disc prolapse is the cause of the pain and if the extremity pain. Among the 3 recent studies, one was corticosteroid is injected close to the target. Fur- randomized (1041) and 2 were prospective (1042,1043), ther, they also concluded that the injection should and included patients with radiculitis secondary to disc be fluoroscopically guided and should aim at the herniation and also post surgery syndrome. ventral part of the epidural space, near the spinal Of the 4 randomized trials included in evidence nerve root, indirectly improving targeted delivery synthesis (1037,1039-1041), all were positive for short- after adhesiolysis of epidural steroid injections. In term and long-term pain relief. Of the 2 prospective the technology assessment of epidural adhesioly- evaluations (1042,1043) both were positive for short- sis for the treatment of back pain (65) from the term relief, whereas only one study (1043) was positive Office of the Medical Director, Washington State for long-term relief of 6 months. Among the two ret- Department of Labor and Industries, randomized, rospective evaluations (1044,1045), both were positive prospective, and retrospective studies were evalu- for short-term relief. However, only one study (1045) ated. They concluded that the number of prospec- was positive for long-term relief. The summary of the

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Table 16. Results of published reports of percutaneous lysis of lumbar epidural adhesions and hypertonic saline neurolysis

Methodological Initial Quality Score(s) Long-term Relief Results Relief Study No. of Study Characteristics AHRQ Cochrane Patients Short- Long- < 3 3 6 12 Score(s) Score(s) term term mos. mos. mos. mos. <3 mos >3 mos Manchikanti et al G1=25 33% 0% 0% 0% RA, DB 10/10 10/10 P P (1036) G2=25 64% 64% 6o% 6o% G3=25 72% 72% 72% 72% Heavner et al (1037) RA, DB 7/10 7/10 59 83% 49% 43% 49% P P Manchikanti et al RA 5/10 6/10 C=15 NSI NSI NSI NSI P P (1040) Tx=30 97% 97% 93% 47%

Veihelmann et al RA 6/10 5/10 99 SI SI SI SI P P (1041) Gerdesmeyer et al P 5/8 --- 25 SI SI SI SI P P (1042) Gerdesmeyer et al P 5/8 --- 61 SI SI SI SI P P (1043) Manchikanti et al R 4/8 --- 129 79% 68% 36% 13% P N (1044) Manchikanti et al R 4/8 --- 60 100% 90% 72% 52% P P (1045) RA=randomized; DB=double blind; R=retrospective; C=control; T=treatment; NA=not available; SI=significant improvement; NSI= no significant improvement; P= positive; N =negative

studies included in the evidence synthesis is described and moderate evidence for long-term improvement in in Table 16. managing chronic, refractory low back and lower ex- 6.3.1.1 Cost Effectiveness tremity pain. The technology assessment (65) conclud- Cost effectiveness for 1-year of improvement ed that the number of studies was too small. in the quality of life varied from $2,028 to $5,564 There were 3 reports, one prelimary report (1052), (1040,1044,1045). and 2 randomized double-blind trials (889,1053); 6.3.1.2 Evidence however, only one study met inclusion criteria (1053). The evidence is strong in managing chronic low The study by Dashfield et al (889) studied endoscopic back and lower extremity pain in post surgery syn- delivery of steroids or caudal epidural steroid injec- drome. The evidence is moderate in managing low tion in patients without adhesions. The primary pur- back and lower extremity pain secondary to disc her- pose of spinal endoscopy is adhesiolysis; thus, since niation producing radiculopathy. The evidence is lim- there was no adhesiolysis, the study failed to meet ited in managing back and/or lower extremity pain inclusion criteria. In addition, 3 prospective evalu- secondary to spinal stenosis. ations (1054-1056), and 2 (1056,1057) of the 3 ret- 6.3.2 Endoscopic Adhesiolysis rospective evaluations were included (1056-1058). Spinal endoscopic adhesiolysis and target delivery One randomized trial (1053) included in the analy- of steroids (1051) were evaluated in 1 systematic re- sis showed significant short-term and long-term im- view (31), and 1 health technology assessment (65). provement. Among the 3 prospective, observational The systematic review by Chopra et al (31) con- studies, one study (1058) evaluated the effectiveness cluded that there was strong evidence to indicate ef- of spinal endoscopic adhesiolysis in lumbar spinal fectiveness of spinal endoscopic adhesiolysis and epidu- stenosis, showing good short-term and long-term im- ral steroid administration for short-term improvement, provement in patients with low back pain; however,

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long-term improvement of leg pain was seen only spinal and intracranial pressures, epidural hematoma, in the mono-segmental group. The other 2 prospec- bleeding, infection, elevated intraocular pressures with tive evaluations (1054,1056) also showed positive re- resultant visual deficiencies, and even blindness. Ste- sults. Both the retrospective evaluations (1045,1046) roids, hypertonic saline, hyaluronidase, instrumention showed positive short-term and long-term relief. with endoscope, and administration of high volumes of Table 17 illustrates the results of various studies of fluids may cause elevated epidural hydrostatic pressures spinal endoscopy. The majority of the studies includ- (556,557,878,1009-1011,1014,1015,1018,1024-1036), ed a heterogenous group of patients, most with post and consequently, spinal cord compression. Unin- surgery syndrome or epidural fibrosis. tended access of the subarachnoid or subdural space 6.3.2.1 Cost Effectiveness is possible. If recognized early, injection of local anes- The cost effectiveness of spinal endoscopy in pathetic or hypertonic saline may be avoided; hypertonic tients failing to respond to all conservative modalities saline injected into the subarachnoid space has been of treatments, including percutaneous adhesiolysis reported to cause cardiac arrhythmias, myelopathy, with a spring-guided catheter, was shown to be $7,020 paralysis, and loss of sphincter control. to $8,127 (1045,1057). 6.3.2.2 Evidence 6.4 Sacroiliac Joint Interventions Evidence for spinal endoscopy is strong for short- The sacroiliac joint is a diarthrodial synovial joint term relief and moderate for long-term relief, in man- with abundant innervation and capability of being a aging chronic refractory low back and lower extremity source of low back pain and referred pain in the low- pain secondary to post-lumbar surgery syndrome. er extremity (435-465). The sacroiliac joint has been 6.3.3 Complications shown to be a source of pain in 10% to 26.6% of the Complications were typically minor: mild back pain suspected cases (230,461,462). and recognized dural puncture. However, severe com- Sacroiliac joint pain may be managed by plications, following adhesiolysis and spinal endoscopy, intraarticular injections or neurolysis of the sacroiliac have been reported (1059-1073). These include spinal joint. Relief with intraarticular injections was consid- cord compression, catheter shearing, excessive intra- ered short-term if less than 6 weeks and long-term if

Table 17. Results of published reports of spinal endoscopy

Methodological Initial Results Quality Score(s) Long-term Relief Relief Study No. of Study Characteristics AHRQ Cochrane Patients Short- Long- 12 Score(s) Score(s) < 3 mos 3 mos 6 mos term term ≥3 mos <3 mos mos Manchikanti et al C = 33 33% vs 0% vs 0% vs 0% vs RA, DB 10/10 10/10 P P (1053) Tx=50 90% 80% 56% 48%

Igarashi et al Mono=34 SI SI in SI in P 5/8 SI P P (1055) Multi=24 mono mono Geurts et al P 6/8 20 55% 55% 40% 35% P P (1054) Richardson et al P 4/8 34 SI SI SI SI P P (1056) Manchikanti et al R 4/8 60 100% 75% 40% 22% P P (1045) Manchikanti et al R 4/8 85 100% 77% 52% 21% P P (1057) P = prospective; R = retrospective; RA = randomized; DB = double blind; vs=versus; SI =s ignificant improvement; Mono = monosegmental; Multi = multisegmental; P = positive www.painphysicianjournal.com 51 Pain Physician: January 2007:10:7-111

Table 18. Results of published reports on therapeutic intraarticular sacroiliac joint injections.

Methodological Initial Long-term Quality Score(s) Results Relief Relief Study No. of Study Characteristics AHRQ Cochrane Patients Long- 3 6 Short-term Score(s) Score(s) < 6 wks term ≥6 mos mos. <6 wks wks 10 6 joints Maugars et al (1075) RA 6/10 6/10 – steroids 70% 62% 58% P P 7 joints - placebo

Pereira et al (1085) P 5/8 --- 10 80% 80% 80% P P

Chakravarty and R 4/8 --- 33 50% NSI NSI N N Dias (1089)

Slipman et al (1088) R 6/8 --- 31 SI SI SI P P

P = prospective; R = retrospective; RA = randomized; SI = significant improvement; NSI = no significant improvement; N = negative; P = positive

6 weeks or longer. Relief with radiofrequency neurot- none of the 7 of the placebo joint injections reporting omy was considered short-term if less than 3 months, any significant relief. There was significant improve- and long-term 3 months or longer. ment in 62% of the patients at 3 months and 58% 6.4.1 Intraarticular Injections of the patients at 6 months. Slipman et al (1088) in a The effectiveness of intraarticular sacroiliac joint retrospective study with independent clinical review injections was evaluated in a systematic review (23) of 31 patients receiving an average of 2.1 therapeu- and was also mentioned in European Guidelines for tic injections concluded that fluoroscopically guided the management of chronic non-specific low back therapeutic sacroiliac joint injections are a clinically pain (56). McKenzie-Brown et al (23) in the systematic effective intervention in the treatment of patients review concluded that the evidence for the therapeu- with sacroiliac joint syndrome. tic intraarticular sacroiliac joint injections was limited Pereira et al (1085) in a prospective observational to moderate. Airaksinen et al (56) showed that there study evaluated 10 patients with sacroiliitis of which was limited evidence for injection of the sacroiliac 9 of them had bilateral sacroiliitis. They treated 21 joint with corticosteroids to relieve sacroiliac pain of joints with corticosteroid without local anesthetic. unknown origin for a short time, thus Level C evidence. The results showed good to excellent pain relief in However, they added that a sacroiliac joint injection is 8 of 10 patients lasting a mean of 13.5 months. The not recommended for the treatment of non-specific 2 non-responders suffered from fibromyalgia and chronic low back pain. reactive depression. They used MRI to guide the in- Four randomized trials (1074-1077), 9 prospective jections. They also showed that subchondral marrow evaluations (1078-1086), and 4 retrospective evalua- edema resolved on follow-up MRI, minimally in 3 tions (463,1087-1089) were identified. However, only patients, partially in 3 patients, and completely in 3 1 randomized trial (1075), 1 prospective evaluation patients. (1085), and 2 retrospective evaluation (1088,1089) Chakravarty and Dias (1089) in an audit of con- met the inclusion criteria (Table 18). servative management of chronic low back pain in Maugars et al (1075), in a double-blind study of a secondary care setting, evaluated the results of 10 patients suffering with painful sacroiliitis, reported intraarticular sacroiliac joint injections with cortico- improvement in 5 of the 6 sacroiliac joints injected steroid in 33 patients, averaging 40 years of age with with corticosteroid with 70% relief at 1-month, with a range of 70 to 74 years. They reported 50% pain

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relief for the duration of local anesthetic only. There injections, and analgesics. The pulsed radiofrequency was a 50% global subject to improvement 1 day to 4 denervation of the medial branch of the L4, posterior weeks after the injection, 9% improvement 4 weeks primary rami of L5, and lateral branches S1 and S2 to 3 months later, and only 1% at 3 to 6 months. were carried out. Outcome measures included visual Slipman et al (1088) in a retrospective evaluation analogue score and quality of life assessments. Sixteen with independent clinical review, reported a signifi- patients or 73% experienced excellent or good pain cant reduction in Oswestry Disability scores, visual an- relief following pulsed radiofrequency denervation. alogue pain scores, and work status. All 3 retrospective evaluations were included in 6.4.1.1 Cost Effectiveness the evidence synthesis (Table 19). Among the retro- No studies were performed evaluating the cost spective reports, Ferrante et al (1090) evaluated the effectiveness of therapeutic sacroiliac joint injections. effectiveness of sacroiliac joint radiofrequency dener- 6.4.1.2 Evidence vations in 33 patients. They reported that only 36% The evidence for intraarticular sacroiliac joint in- of the patients met the criteria for successful dener- jections is limited for short- and long-term relief. vation at 6 months. Yin et al (453) in a retrospective 6.4.2 Radiofrequency Neurotomy evaluation of 14 patients reported that 64% of the Percutaneous radiofrequency neurotomy of sac- patients experienced a successful outcome. Finally, roiliac joints has been reported to provide long-term Cohen and Abdi (1092) evaluated radiofrequency le- relief (453,454,1090-1094). sioning on 9 patients and reported that 89% obtained Of all the evaluations performed on radiofre- >50% pain relief from this procedure that persisted quency neurotomy in managing sacroiliac joint pain, 4 at the 9-month follow-up. In addition to the thermal reports were prospective (454,1091,1093,1094) and 3 radiofrequency Vallejo et al (454) evaluated the effec- were retrospective (453,1090,1092,1093). However, 2 tiveness of pulsed radiofrequency however, there has prospective evaluations (1091,1093) only had 3-months not been any significant literature on utilization of follow-up and consequently failed to meet inclusion pulsed radiofrequency; not only in the sacroiliac joints criteria. Two prospective evaluations (454,1094) were but other areas also. Thus, it was not included in evi- included. dence synthesis. Burnham and Yasui (1094) published the results of 6.4.2.1 Cost Effectiveness an alternate method of radiofrequency neurotomy of No cost effectiveness evaluations were performed the sacroiliac joint in a pilot study. They evaluated 9 with radiofrequency neurotomy of sacroiliac joint in- subjects with sacroiliac joint pain confirmed by a local nervation. anesthetic joint block. They were treated with a series 6.4.2.2 Evidence of radiofrequency strip lesions performed adjacent to The evidence for thermal and pulsed radiofrequency the lateral dorsal foraminal aperture plus conventional neurotomy in managing sacroiliac joint pain is limited. monopolar lesions at the L5 dorsal ramus. The follow- 6.4.3 Safety and Complications up was at 1, 3, 6, 9, and 12 months after the procedure. No complications have been reported in any of After the procedure, significant reductions of back and the studies included in this review. However, expected leg pain frequency and severity, analgesic intake, and complications include infection, hematoma formation, dissatisfaction with their current level of pain occurred. neural damage, trauma to the sciatic nerve, potential Complications were minimal. Overall, 8 of the 9 sub- gas and vascular particulate embolism, leakage of the jects were satisfied with the procedure. The median im- drug from the joint, and other complications related provement in pain intensity was 4.1 NRS and reduction to drug administration. of disability was 17.8 (Oswestry Disability Scale). Overall satisfaction was 67% at 12-month follow-up. 6.5 Intradiscal Therapies Vallejo et al (454) from a total of 126 patients The pathologic basis for some forms of low back with presumptive sacroiliac joint dysfunction based pain may lie in internally disrupted intervertebral on history and physical examination, performed ar- discs and in particular, sensitized annular tears (229, thrographically confirmed steroid/local anesthetic 230,367,375-377,407,1095). Multiple treatments de- sacroiliac joint injections, and selected 22 patients to scribed to manage internal disc disruption and dis- undergo pulsed radiofrequency when they failed to cogenic pain include surgical intervention with total respond to physical therapy, repeated sacroiliac joint disc excision and arthrodesis or conservative measures

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Table 19. Results of published reports of sacroiliac joint radiofrequency thermoneurolysis

Initial Long-term Relief Results Methodological Relief Study Quality No. of Short- Study Long-term Characteristics CriteriaAHRQ Patients 1 term <3 mos 3 mos 6 mos relief ≥3 Score year relief <3 mos mos

Burnham and P 6/8 9 89% 89% 89% 89% P P Yasui (1094)

Vallejo et al P 6/8 22 56% 41% 32% NA P N (454)

Yin et al (453) R 4/8 14 64% 64% 64% 64% P P

Ferrante et al R 4/8 33 35% 35% 35% NA N N (1090)

Cohen and R 4/8 9 89% 89% 89% NA P P Abdi (1092)

R = retrospective; P = prospective; NA = not available; P = positive; N = negative such as intradiscal steroid, chemonucleolysis, intradis- IDET was also reviewed in multiple guideline prepara- cal glycerol, and the use of intradiscal laser devices. tions (1,2,56). Two minimally invasive procedures have been Appleby et al (42) in a systematic review reviewed promoted as alternatives to major surgical interven- the literature from all the available studies and con- tion. Both involve the introduction of a flexible elec- cluded that there was compelling evidence for the rel- trode into the painful disc, with the aim of coagulat- ative efficacy and safety of intradiscal electrothermal ing the posterior annulus (1096). The first technique therapy. From 1998 to March 2005, authors selected is described as intradiscal electrothermal therapy or a total of 17 published reports and included them in IDET and the second technique was named radiofre- the review. This metaanalysis showed an overall mean quency posterior annuloplasty or RFA. improvement in pain intensity of 2.9 points, physi- For this evaluation, relief of less than 6 months cal function of 21.1 points as measured by SF-36 and was considered as short-term and relief of 6 months disability of 7.0 points as measured by the Oswestry or longer was considered as long-term. Disability Index. Andersson et al (41) performed a sys- 6.5.1 Intradiscal Electrothermal Therapy. tematic review of spinal fusion and intradiscal elec- Intradiscal electrothermal therapy (IDET), as origi- trothermal therapy in the treatment of intractable nally described, did not require placement of the discogenic low back pain. They concluded that the electrode explicitly in the annulus fibrosus (1097). The majority of patients reported improvement in symp- electrode is a flexible, thermal resistive coil which co- toms following both spinal fusion and IDET procedure. agulates the adjacent tissue with radiant heat. How- However, the IDET procedure appeared to offer suffi- ever, the mechanism of action of IDET has not been ciently similar symptom amelioration to spinal fusion established. It has been proposed that heating the an- without attendant complications. Gibson and Waddell nulus may serve to strengthen the collagen fibers, seal (43) concluded that the preliminary results of 3 similar fissures, denature inflammatory exudates, or coagu- trials of intradiscal electrotherapy suggests it is inef- late nociceptors (1098). fective, except possibly in highly selected patients. The evidence for intradiscal electrothermal ther- Freeman (57) performed a critical appraisal of the apy includes 3 systematic reviews (41-43), a technol- evidence of IDET and concluded that the evidence for ogy assessment update (64), critical appraisal of the the efficacy of IDET remains weak and has not passed evidence (57) and other multiple reviews. Evidence for the standard of scientific proof. European Guidelines

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for the Treatment of Chronic Non-specific Low Back in carefully selected cases, IDET can eliminate or dra- Pain (56) concluded that there is conflicting evidence matically reduce the pain of internal disc disruption that IDET, in patients with discogenic low back pain, is in a substantial proportion of patients and appears not more effective than sham treatment (Level C). Inter- to be superior to conventional conservative care for ventional Pain Management Guidelines by Boswell et internal disc disruption. At 24 months, 54% of the al (1) and Manchikanti et al (2) concluded that the evi- patients had achieved at least 50% relief with func- dence for intradiscal electrothermal therapy was strong tional improvement. for short-term relief and moderate for long-term relief Saal and Saal (1097,1104,1108) reported results in managing chronic discogenic low back pain. of their experience over a period of 6 months, 1 year, A technology assessment update (64) evaluating and 2 years, with overall improvement in 71% of the all the available studies concluded that initial results patients. They reported a VAS change for the entire from the studies are promising. However, the majority group of 3.2 with a mean change on the SF-36 physical of data comes from small case series studies. This as- function subscale of 20, and the mean change on the sessment considered IDET as a controversial and inves- SF-36 bodily pain subscale of 17.8. tigational therapy until more randomized controlled Derby et al (1103) reported that 63% of the 32 trials with long-term follow-up were conducted and patients had a favorable outcome, with no change in showed the effectiveness of IDET. outcome measures at the 6-month and 12-month fol- The relevant studies identified included 2 ran- low-ups. Bryce et al (1113) evaluated 51 patients, at domized controlled trials (1099,1100), 2 non-ran- 6 months follow-up, they demonstrated statistically domized controlled trials (1101,1102), 12 prospective significant improvement was measured by a mean evaluations (1097,1103-1113), and multiple case series change of over 20 points from the pretreatment score (1114-1120). Of the 12 prospective evaluations, 2 non- on the Roland Morris Disability Questionnaire. At one randomized controlled trials reported outcomes on year, data remained with significant improvement in the same patient population with different lengths of the 33 patients who had achieved this time point. follow-up (1101,1102). Of the remaining 10 prospec- Kapural et al (1096) evaluated 21 patients with tive trials, 5 reported outcomes on the same patient electrothermal therapy and an additional 21 patients population with different lengths of follow-up (109 with radiofrequency annuloplasty. From the third to 7,1104,1105,1107,1108). Table 20 summarizes demo- twelth month after the procedure, the intradiscal graphic and study characteristics of studies included electrothermal therapy group had significantly low- in the evidence synthesis. er mean pain scores with an average VAS pain score Two randomized controlled trials (1099,1100) of decrease of 7.4 + 1.9. There was also improvement in percutaneous intradiscal electrothermal therapy for pain disability index. chronic discogenic low back pain were double-blind The present evidence summarizes 1 positive ran- and placebo-controlled. Pauza et al (1099) in evalua- domized trial, 1 negative randomized trial, 7 positive tion of the effectiveness of intradiscal electrothermal prospective evaluations (1096,1101,1103,1107,1108, therapy for the treatment of discogenic low back pain 1110,1112), with 2 negative reports (1109,1116). in a randomized, placebo-controlled trial reported sig- 6.5.1.1 Cost Effectiveness nificant improvements in pain, disability and depres- Cost effectiveness of intradiscal electrothermal sion in the group treated with IDET. However, only 40% annuloplasty has not been evaluated. Andersson et al of patients treated with IDET achieved greater than (41) in their systematic review of intractable low back 50% relief of pain at 6 months. Freeman et al (1100), pain treatment with IDET versus spinal fusion surgery in a prospective randomized, double-blind, placebo- concluded that more than half of patients treated controlled trial with crossover offered to the placebo with IDET can avoid surgery and therefore spare the subjects when unblinding occurred at 6 months, with cost of surgery and its complications. a total of 57 subjects, randomized 38 patients to IDET 6.5.1.2 Evidence and 19 patients to placebo (sham) treatment. The re- The evidence for intradiscal electrothermal thera- sults showed no benefit from IDET over placebo. py (IDET) is moderate in managing chronic discogenic Karasek and Bogduk (1101) and Bogduk and low back pain. Karasek (1102) studied 53 patients with back pain 6.5.1.3 Complications and followed them for 2 years. They concluded that Complications include catheter breakage, nerve

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Table 20. Results of published reports of IDET

Methodological Initial Long-term Quality Score(s) Results Relief Relief Study No. of Study Short- Characteristics AHRQ Cochrane Patients Long-term < 6 6 1 term Score(s) Score(s) relief ≥6 mos mos year relief <6 mos mos 50% Pauza et al (1099) C = 27 Equal NA P N RA, DB, PC 10/10 10/10 Treat T = 37

Freeman et al C = 19 RA, DB, PC 10/10 10/10 0% 0% 0% N N (1100) T = 38

Kapural et al (1096) P 5/8 --- 21 SI SI SI P P

Karasek & Bogduk P --- C = 17 6% vs 53% 53% P P 5/8 (1101, 1102) T = 35 70% Saal and Saal (1097, P --- 58 SI SI SI P P 5/8 1104, 1108) Gerszten et al P --- 27 75% 75% 75% P P 5/8 (1107) Mekhail and P --- 32 SI SI SI P P 5/8 Kapural (1112)

Lutz et al (1110) P 5/8 --- 33 SI SI SI P P

Freedman et al P --- 36 NA 47% 16% N N 5/8 (1116) Spruit and Jacobs P 4/8 --- 20 NSI NSI NSI N N (1109) Derby et al (1103) R 4/8 --- 99 64% 64% 64% P P Bryce et al (1113) P 4/8 --- 51 SI SI 64% P P P = prospective; PC = placebo controlled; RA = randomized; R = retrospective; C= control; T = treatment; SI = significant improvement; NSI = No significant improvement; NA = not available; P = positive; N = negative

root injuries, post-IDET disc herniation, cauda equina a semirigid, radiofrequency probe, which does not, by syndrome, infection, epidural abscess, and spinal cord itself, generate heat. However, the electrode focuses damage (1121-1130). Appleby et al (42) tabulated an alternating, radiofrequency current onto surround- all the complications included in their meta-analysis. ing tissues, whose component molecules are isolated Complications included burning sensation, paresthe- and thereby heated. The electrode also serves to mon- sias and numbness, foot drop, increasing low back itor the temperature generated in those tissues. There pain, increase in radicular pain, headache, increase in is far less literature on this procedure than there is for the size of the herniation, cerebral spinal fluid leak, IDET (1096). inability to thread the catheters through scar tissue, There are no systematic reviews performed on nerve root injury and decreased sphincter control, dis- radiofrequency posterior annuloplasty. The relevant citis, and anterolisthesis. studies identified on intradiscal radiofrequency abla- 6.5.2 Radiofrequency Posterior Annuloplasty tion included 2 prospective evaluations (1096,1131). Radiofrequency posterior annuloplasty (RFA) Finch et al (1131) studied 31 patients by heating is also commonly known by the name of the device of their annular tears with a flexible radiofrequency used to place the lesion (discTRODE). The electrode is electrode placed across the posterior annulus and

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compared 15 patients with conservative manage- automated percutaneous discectomy, laser discecto- ment. The visual analog scale decreased significantly my, radiofrequency Coblation or plasma discectomy after the radiofrequency treatment and this decrease known as nucleoplasty, mechanical disc decompres- persisted at 12 months follow-up. The VAS did not sion with a high rotation per minute device for nuclear change over 12 months in untreated controlled sub- extraction also known as DeKompressor, and manual jects. The Oswestry Disability Index also decreased in percutaneous lumbar discectomy. Claims have been treated patients but not in controlled subjects. made from the literature that all of these alternative Kapural et al (1096) performed a prospective procedures can produce satisfactory results with small matched controlled trial of intradiscal thermal an- wounds and fewer serious complications; however, nuloplasty versus intradiscal radiofrequency ablation these claims remain controversial. for treatment of discogenic pain. They matched 42 The subject of the guidelines in this section is of patients with 21 having IDET and 21 having radiofre- percutaneous discectomy, which is a class of minimally quency annuloplasty. They reported the IDET group invasive surgical procedures that specifically treat con- had significantly lower mean pain scores than the ra- tained, herniated discs. Manual percutaneous lumbar diofrequency annuloplasty group; however, there was discectomy, microdiscectomy, and chemonucleolysis improvement noted in both groups. VAS pain scores are not included in this review. decreased from 6.6 + 2.0 before to 4.4 + 2.4 at one 6.6.1 Automated Percutaneous Lumbar Discectomy year after radiofrequency annuloplasty, whereas in Automated percutaneous lumbar discectomy or IDET group the average VAS pain score decreased from APLD is performed with a pneumatically driven, suc- 7.4 + 1.9 before IDET to 1.4 + 1.9 at 1-year follow-up. tion-cutting probe in a cannula with a 2.8 mm outer Similarly, pain disability index scores in the IDET group diameter. Most of the disc removal occurs 1 cm ante- had a significantly larger improvement than those for rior to the herniation removing approximately 1 to 3 patients who received radiofrequency annuloplasty. grams of disc material to reduce intradiscal pressure 6.5.2.1 Cost Effectiveness and decompress the nerve roots (1132-1134). Cost effectiveness of radiofrequency annuloplasty Waddell et al (1135), in a systematic review based has not been performed. on Cochrane Collaboration Review and meta-analy- 6.5.2.2 Evidence sis of surgical interventions in the lumbar spine (44), The evidence for radiofrequency posterior annu- identified 3 trials comparing automated percutaneous loplasty was limited for short-term improvement, and discectomy with other surgical techniques and con- indeterminate for long-term improvement in manag- cluded there was limited and contradictory evidence ing chronic discogenic low back pain. (Strength of Evidence C) that automated percutane- 6.5.2.3 Complications ous discectomy gives poorer clinical results than al- Complications are similar to IDET with catheter ternative surgical techniques with which it has been breakage, nerve root injuries, discitis, disc herniation, compared. cauda equina syndrome, infection, epidural abscess, The technology assessment performed for the De- and spinal cord damage (42,1121-1130). partment of Labor and Industries, Washington State on Percutaneous Discectomy (63) evaluated the litera- 6.6 Percutaneous Disc Decompression ture until 2004. Published studies included 5 random- A herniated intervertebral lumbar disc results ized trials (1133,1136-1139) of which Haines et al had from a protrusion of the nucleus pulposus. A ruptured 2 publications from one study (1138,1139). Revel et al annulus fibrosus causes an extruded disc while an in- (1133) and Krugluger and Knahr(1136) performed ran- tact but stretched annulus fibrosus results in a con- domized trials of APLD and chemonucleolysis, whereas tained disc prolapse which may compress one or more Chatterjee et al (1137) and Haines et al (1138,1139) per- nerve roots (63). formed trials comparing APLD with microdiscectomy. The primary goal of surgical treatment of a disc Multiple prospective and case series studies were also prolapse, protrusion or extrusion is the relief of nerve reported (1140-1147). Other studies included predic- root compression by removing the herniated nuclear tive factors, side effects and complications (1148-1151). material. The primary modality of treatment has been Evidence from 4 of the 4 randomized published stud- open discectomy. However, several alternative tech- ies were shown to be negative, while all observational niques include microdiscectomy, chemonucleolysis, studies were positive.

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Among the published randomized trials, 2 trials space narrowing, and 21% of patients had severe (1133,1136) compared APLD and chemonucleolysis. back pain, but no correlation to leg pain was made. Revel et al (1133) randomized patients with sciatica Krugluger and Knahr (1136) also conducted a caused by a disc herniation to undergo as an APLD or study comparing APLD with chemonucleolysis. The chemonucleolysis. The study measured outcomes with study initially selected 29 patients with symptomatic visual analog scale to measure sciatica and low back disc lesion confirmed by discography, however, due to pain, a straight leg test, the Schoebert Test, neurolog- epidural leakage of contrast material, 7 patients were ic status, self-assessment, disc height and herniation excluded with 22 patient randomized to either che- size. Patients were followed at 1 month, 3 months, monucleolysis or APLD. The results showed that at 6 and 6 months. The trial included 72 chemonucleolysis weeks, both groups showed significant improvement and 69 APLD patients of which 43% of chemonucle- in neurological deficits and Oswestry score. However, olysis patients and 26% of APLD patients were con- the differences between groups were not statistically sidered sedentary subjects, and the disc appeared de- significant at the 12-month follow-up. generated more often in the chemonucleolysis group Randomized trials of APLD and microdiscecto- (92%) than in the APLD group (76%). The study had my included Chatterjee et al (1137) and Haines et al 32 patients withdrawing during trial as therapeutic (1138,1139). Chatterjee et al (1137) compared APLD to failures. They described that there were no signifi- microdiscectomy in the treatment of contained lumbar cant differences between the two groups in most of disc herniation in a randomized study with blind as- the demographic data, clinical and radiographic vari- sessment. The study included 71 patients with radicular ables between the two groups. They concluded that pain as their dominant symptom after failure of conser- the results of both chemonucleolysis and APLD were vative therapy for at least 6 weeks and with MRI dem- generally disappointing, because 48% of the overall onstration of contained disc herniation at a single level population entering the study considered treatment with a disc bulge of less than 30% of the canal size. The a failure and 20% submitted to open laminectomy study excluded patients with dominant symptoms of within 6 months. They further described that while low back pain, disc extrusion, sequestration, subarticu- the failure rate of chemonucleolysis was similar to lar or foraminal stenosis, or multiple levels of hernia- that observed in various controlled studies, the results tion. The results showed satisfactory outcomes in 29% observed in the APLD group were strikingly different of the patients in APLD group and 80% of the microd- from most reported previous uncontrolled series. They iscectomy group. They concluded that APLD was inef- also postulated that APLD success rate in this study ap- fective as a method of treatment for small, contained proached that observed in the placebo groups in the lumbar disc herniations. Authors were criticized in that chemonucleolysis trials. At one-year follow-up, overall they failed to utilize CT discography. success rates were 66% in the chemonucleolysis group Haines et al (1138) conducted a randomized and 37% in the APLD group. study comparing APLD to conventional discectomy as Many aspects of the Revel et al’s study (1133), a first line treatment for herniated lumbar discs. The such as patient selection criteria, which led to poor study measured outcomes with physical signs related results have been criticized. The size of the disc her- to the severity of low back pain and sciatica, but used niation was an issue because for APLD it should not a modified Roland Scale for disability assessment, and occupy more than 30% of the spinal canal, where- the SF-36 for general health status. The primary end- as in Revel et al’s study (1133) in 59% of APLD and point was the patients’ outcome ratings 12 months 64% of chemonucleolysis patients the disc herniation after surgery. The study included patients with uni- covered between 25% and 50% of the spinal canal. lateral leg pain or paresthesia with no history of Further, in 71% of the APLD patients and 79% of che- lumbar spinal surgery, whereas exclusions included monucleolysis patients, the disc herniation had mi- moderate or advanced lumbar spondylosis, spondy- grated up to 5 mm cranially or caudally to the end- lolisthesis, lateral restenosis, herniated disc fragment plate levels, considered a contraindication of APLD. occupying more than 30% of the AP diameter of the Other factors included that at discography, 39% of spinal canal, herniated disc fragment migrating more the tested discs showed epidural leakage, 76% of the than 1 mm above or below the disc space, calcified discs were severely degenerated (APLD is not effec- disc herniation, lateral disc herniation, or posterior tive in diffuse annular bulging), 9% had marked disc disc space height less than 3 mm. Success rate of the

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2 procedures was identified as APLD 41% compared native to the standard open discectomy treatment. to conventional discectomy 40%. However they con- Laser energy is used to reduce pressure by vaporizing cluded that the study did not have power to identify a small volume of the nucleus pulposus. It is hypothe- clinically important differences because of insuffi- sized that the change in pressure between the nucleus cient patient enrollment. pulposus and the peridiscal tissue causes retraction of Among the prospective evaluations and case se- the herniation away from the nerve root (1153-1168). ries studies (1142,1147), all of them reported posi- Laser discectomy may be performed with or without tive results in greater than 50% of patients in a large endoscopy. The majority of the studies were without population. endoscopy. Delamarter et al (1132) described the predictive Based on the systematic review by Waddell et factors and concluded that it is difficult to predict the al (1135) there is no acceptable evidence (Strength clinical outcome in percutaneous discectomy. Duller- of Evidence D) for laser discectomy. Relevant stud- ud et al (1149) in a prospective study concluded that ies evaluating the effectiveness of laser disc decom- patients with normal or slightly narrow disc space expression included 14 studies (1154-1158,1160-1168) perienced better results compared to patients with a meeting inclusion criteria. There were no random- larger degree of disc space narrowing. ized trials. 6.6.1.1 Complications Table 21 illustrates results of percutaneous disc A retrospective review of 243 patients with treat- decompression with laser-assisted disc removal. All ment at 271 disc levels showed a technical failure rate the studies showed positive results (1154-1158,1160- of 2.6%, clinical and radiological changes consistent 1168). Results varied from satisfactory improvement with discitis in 2 patients, mild spasm in the extensor in 57% of the patients to 93% of the patients. In the muscles in 9% of the patients, 25% of the patient 14 reports included in the evidence synthesis, 2,181 with mild to moderate sensation on instability and 1 patients were studied with positive outcome in 1,600 patient developing functional paresis of lower limbs patients. one month after treatment (1149). In another case 6.6.2.1 Complications report of a 24-year-old who underwent APLD at L5/S1 Complications of percutaneous discectomy laser for relief of low back pain, it was reported that the can be divided into intraoperative and postoperative patient developed acute right lumbar radicular syn- categories (1169-1171). The general complications are drome, with MRI showing far lateral extraforaminal often due to patient positioning, anesthesia or aller- disc herniation at L5/S1 with compression of the right gic reaction. The intraoperative complications may be nerve root, which corresponded to the nucleotomy correlated to the surgical technique or instrumenta- site of the probe (1150). In a multicenter analysis of tion. Postoperative complications refer to bleeding percutaneous discectomy, two psoas muscle hemato- or infection and general postoperative complications mas and one transient radicular deficit was reported associated with the procedure itself such as cardiovas- (1151). cular problems. 6.6.1.2 Cost Effectiveness Ohnmeiss et al (1157) in a series of 164 laser dis- No cost effectiveness studies were conducted in cectomies, reported the tip of the instrument bent the United States. However, Stevenson et al (1152) in one case, 12 patients complained of postoperative conducted a prospective cost evaluation including dermatomal dysesthesia, which resolved in 5 cases, socioeconomic data comparing APLD to microdiscec- and 2 patients had signs of reflex sympathetic dys- tomy. Average cost of treatment and follow-up sur- trophy. gery was $2,317 per APLD patient compared to $1,567 Mayer et al (1169) in a retrospective analysis of per microdiscectomy patient. Further, the average cost 658 cases treated at 9 different centers observed 1.1% per APLD successful outcome was $3,264 compared to intraoperative complications and 1.5% postoperative $1,958 for microdiscectomy successful outcome. complications. They reported for radicular deficits in 6.6.1.3 Evidence 4 patients (0.5%), L5 nerve root injury in 3 cases, vas- The evidence is moderate for short-term and lim- cular injuries in 2 cases, sigmoid artery injury in 1 pa- ited for long-term relief. tient, anomalous iliolumbar artery injury in 1 patient, 6.6.2 Percutaneous Laser Discectomy and transverse process injury in 1 patient. Percutaneous laser discectomy or PLD is an alter- In a report of 10 cases, complications were present

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Table 21. Results of percutaneous disc decompression with laser assisted disc removal RF energy to dissolve nuclear material through molecular dissociation. Bipolar RF coagulation denatures 1 year relief proteoglycans, changing the internal environment of No. of the affected nucleus pulposus with reduction in intra- Study Results patients Number discal pressure (1172-1174). The proposed advantage Percent of of the coblation technology is that the procedure pro- Patients vides for a controlled and highly localized ablation, Siebert et al 180 73% 131 Positive resulting in minimal thermal damage to surrounding (1156) tissues. The bi-products of this non-heat driven process Ohnmeiss et al 164 71% 116 Positive are elementary molecules and low-molecular weight (1157) inert gases, which escape from the disc via the needle Leibler (1158) 117 70% 82 Positive (1172,1175,1176). There were no systematic reviews evaluating the Bosacco et al 61 72% 44 Positive effectiveness of nucleoplasty thus far in the literature. (1154) However, the literature was synthesized in prepara- Choy (1155) 518 75% 389 Positive tion of the guidelines and limited evidence was provided (1,2). The effectiveness of nucleoplasty has been Senel et al (1160) 102 57% 58 Positive reported in 6 prospective (1174,1175,1177-1180) eval- Knight and 388 73% 283 Positive uations. Goswami (1161) Sharps and Isaac (1175) evaluated 49 patients with Groemeyer et al 200 73% 126 Positive low back pain with or without radicular pain. The study (1162) excluded patients due to sequestered herniation, con- Tassi (1163) 92 83% 76 Positive tained herniation larger than one-third of the sagittal Zhao et al (1164) 173 82% 142 Positive diameter of the spinal canal or stenosis. The study evaluated pain on visual analog scale at 1 month, 3 months, Lee et al (1165) 60 93% 56 Positive 6 months and 1 year. Success was defined as a 2-point Tonami et al 26 65% 17 Positive reduction on the VAS, patient satisfaction, no use of (1166) narcotics, and return to work. Results showed signifi- Nerubay et al 50 74% 37 Positive cant improvement in visual analog scale at 1-month, 3 (1167) months, 6 months and 12 months; however, follow-up Simons et al 50 86% 43 Positive of the reported patients declined to 41 at 3 months, 24 (1168) at 6 months, and 13 at 12 months. Total 2181 73% 1600 Positive Among 3 studies published by Singh et al (1174,1177,1178), initially they (1174) published a prospective study of 67 patients with back and leg in 1.5% of the total number of cases, which reported pain, with 80% of the patients reporting statistically to have spondylodiscitis (1170). In another report, af- significant improvement in numeric pain scores at ter PLAD a patient developed a subacute cauda equi- 1-year. Singh et al (1178) also published results of 80 na syndrome (1171). patients with back and leg pain followed for 1-year 6.6.2.2 Cost Effectiveness with similar findings as in first study (1174). Singh In 1996 the average hospital cost for percutane- et al (1177) evaluated 47 patients presenting with ous laser discectomy was $3,720 (1153). This was 35% predominantly back pain and undergoing treat- of the average hospital cost for the open discectomy ment with nucleoplasty procedure using coblation of $10,600. technology. The proportion of patients who report- 6.6.2.3 Evidence ed >50% pain relief was 80%, 74%, 63%, and 53% The evidence is moderate for short-term and lim- at the 1-month, 3-month, 6-month, and 12-month ited to long-term relief. follow-up time periods, respectively. Functional im- 6.6.3 Nucleoplasty provements were also reported by 46% of patients Percutaneous disc decompression (PDD) with nu- for sitting ability, 41% for standing ability, and 49% cleoplasty (coblation technology) is performed with for walking ability at 12 months.

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Marin (1179) published results of 64 patients with of preprocedure back pain (15%) and new areas of contained disc herniation undergoing radiofrequency back pain (15%). However, all the other complications coblation to treat low back pain and/or leg pain. The reported with electrothermal therapy are also poten- average duration of pain before treatment with co- tial complications with nucleoplasty. blation was 18 months. The results demonstrated im- Table 22 illustrates the results of published evalu- provement in pain scores in 75% as very good and in ations of nucleoplasty. All of them were prospective 5% as good at the 6- to 12-month follow-up. Fifteen evaluations with no randomized trials. Further, all of percent of the patients showed some improvement them had less than 100 patients in the study. However, however it was not good, and 5% of the patients 5 of 6 showed positive results. showed no improvement at all. 6.6.3.2 Cost Effectiveness Gerszten et al (1180) in a prospective, non-ran- Cost effectiveness of percutaneous disc decom- domized, longitudinal cohort study evaluated 67 pa- pression with coblation nucleoplasty has not been tients with primarily radicular pain due to contained evaluated. disc herniation. They measured quality of life out- 6.6.3.3 Evidence comes at 3 months and 6 months of the 34 patients in The evidence of nucleoplasty is limited for short- whom a 3-month follow-up was available, VAS scores and long-term relief. were significantly improved. However, at 6 months 6.6.4 Mechanical High RPM Device following nucleoplasty, there was no longer a differ- The DeKompressor probe is a mechanical high ence in VAS pain score in 23 patients compared with rotation per minute device designed to extract the preoperative pain levels. Table 22 illustrates results of nuclear material through an introducer cannula using published trials meeting inclusion criteria. an auger-like device that rotates at high speeds. 6.6.3.1 Complications The DeKompressor is one of the new methods The side effects and complications after percuta- that extract the nuclear material of the disc using a neous disc decompression using coblation technology high RPM spiral tip instrument. have been reported (1181). From a total of 53 patients, There have been no systematic evaluations of per- the most common side effects at 24 hours post proce- cutaneous disc decompression utilizing the DeKom- dure was soreness at the needle insertion site (76%), pressor. There also have not been any guidelines de- new numbness and tingling (26%), increased intensity scribing this technology.

Table 22. Results of published evaluations of nucleoplasty

Initial Long-term Results Methodological relief relief Study Quality Score No. of Study Characteristics patients Short- Long- <6 term term AHRQ Score 6 mos 1 year mos relief <6 relief mos ≥6 mos Sharps and Isaac P 5/8 49 SI SI SI P P (1175) Singh et al (1174) P 5/8 67 79% 59% 56% P P Singh et al (1177) P 5/8 80 73% 60% 54% P P

Singh et al (1178) P 5/8 80 79% 76% 77% P P

Marin (1179) P 5/8 64 80% 80% 80% P P

Gerszten et al (1180) P 5/8 67 50% NSD NSD N N

P = prospective; SI = significant improvement; NSD = No significant difference; P = positive; N = negative

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Relevant literature included 2 publications from 1 on MRI. They excluded patients with extruded her- prospective clinical trial (1182,1183) and 1 case series niations and inconsistency between MRI and clinical report (1184). Both reports showed positive results. findings as well as other common exclusions like in- Alo et al (1182,1183) published the findings on fection and coagulopathy. Patients were also being the outcome of disc herniations treated with the medically treated with morphine and anti-inflam- DeKompressor in 2 publications from 1 study. Clini- matory drugs pre-operatively. Using a DeKompressor cal response in an initial cohort of 50 consecutive instrument under CT or fluoroscopic guidance, they patients with chronic radicular pain was evaluated in performed disc decompression on mainly L4-5 and a randomized prospective clinical trial. Data was col- L5-S1 discs with some L3-4 discs. They found that 11 lected on the 6-month outcomes. Their inclusion cri- patients did not respond satisfactorily to the treat- teria were radicular pain with contained herniation ment, but 39 patient were either able to suspend <= 6 mm., correlating history and physical findings, their medications (31 patients) or definitely reduce pain for >6 months, failure of conservative therapies, their medications (8 patients). The reduction in pain good to excellent short-term relief (<2 weeks) after was found to be stabilized after about 7 days in most a fluoroscopically guided transforaminal injection, patients. Of the ones who responded favorably, 25- confirmatory selective segmental spinal nerve block 36 out of 50 showed >70% relief. More importantly with 0.5-1.5 mL of anesthetic providing >80% relief they noted >70% improvement in 79% patients with lasting at least the duration of the local anesthetic postero-lateral hernias versus 50% of patients with and preservation of disc height (less than 50% loss). postero-medial hernias. They excluded patients with progressive neurologi- 6.6.4.1 Complications cal deficits, more than 2 symptomatic levels, previous A critical failure of the DeKompressor probe was open surgery at the proposed treatment level, spine reported. The complication (1185) happened while instability, fracture or tumor; pain drawing inconsis- performing a discectomy at L4/5 level using a percuta- tent with clinical diagnosis and significant coexisting neous DeKompressor probe on a 54-year-old patient. medical or psychological condition. They assessed the After operating the instrument for 1 to 2 minutes, the outcome using VAS score, analgesic usage; self report- probe was removed and it was found to be broken. ed functional improvement and overall satisfaction. It The remaining 4-inch tip was removed surgically, and may have been more objective had they utilized some patient recovered without any major complication. form of functional improvement measure. After 6 Similar instances have been reported by 2 other au- months, 74% patients reported reducing their analge- thors in the past. One of the instances was thought to sic intake, 90% reported improvement in functional have happened because of a bent cannula which may status and overall satisfaction with the therapy was have contributed to the break of the device. 80%. After 1-year follow-up, the data was published 6.6.4.2 Cost Effectiveness on 42 patients (54 levels). They noted an average re- There were no cost effectiveness studies of per- duction in pre-operative pain score (VAS) of 65%. Also cutaneous disc decompression utilizing DeKompressor noted was a reduction in the analgesic intake in 79% available in the literature. and functional improvement in 91% of patients. 6.6.4.3 Evidence Amoretti et al (1184) published results of a clini- The evidence for percutaneous disc decompres- cal follow-up of 50 patients treated by percutane- sion utilizing DeKompressor is limited for short- and ous lumbar discectomy using the DeKompressor. long-term relief. Although it is not a blinded and randomized study, the data collection was thought to be good. The in- 6.7 Vertebral Augmentation Procedures clusion and exclusion criteria were clearly defined. Vertebral compression fractures (VCFs) constitute They included patients with “lumbar sciatica of dis- a major healthcare problem in the United States, not co-lumbar origin” secondary to a herniated disc doc- only because of high incidence of these lesions, but umented by an MRI. Patients had undergone medi- also due to their direct and indirect negative conse- cal therapies such as “CT-guided infiltration” which quences for patient health-related quality of life and one assumes to be a corticosteroid injection. There the costs to the healthcare system (75,76,1186-1188). was no change in disc height and the discs possessed Vertebral fractures may result in pain about the frac- satisfactory hydration as documented by a T2 signal ture site, loss of height caused by vertebral collapse,

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spinal instability, and in many cases kyphotic defor- porotic vertebral compression fractures refractory to mity (76,1189). Regardless of their etiology, the main- conventional medical therapy (75). However, it was stay of management for symptomatic vertebral com- also concluded that there was no definite evidence pression fractures has been medical therapy that may to state that vertebroplasty is a safe and effective include analgesics, bedrest, external fixation, and re- procedure due to lack of comparative, blinded, ran- habilitation (75,1190,1191). However, such treatments domized clinical trials. are only partially effective in addressing symptoms Relevant studies evaluating vertebroplasty in- and about one-third of patients have been reported cluded multiple systematic reviews, prospective and to suffer from persistent pain and progressive func- comparative studies, as well as case series. Taylor et al tional limitation and loss of mobility (1192). The surgi- (75) identified 2 non-randomized, comparative studies cal treatment for vertebral compression fractures, re- (1211,1212) and 57 case series meeting the inclusion fractory to medical therapy, that addressed deformity criteria. Hulme et al (76) identified 65 non-controlled, has been decompression and stabilization of the frac- single-group cohort studies for vertebroplasty and ky- tured vertebra with different kinds of metal implants phoplasty combined. (1193). However, surgical fixation often fails because The evidence was considered short-term for less of poor quality of osteoporotic bone (1194). Further, than 6 months and long-term for 6 months or longer. the procedures have generally been limited to cases Taylor et al (75) showed that 1 prospective study where there is concurrent spinal instability or neuro- (1211) compared vertebroplasty with conventional logical deficit, due to the risks of open surgery in of- medical care and another prospective study com- ten elderly, frail patients (75,1194,1195). pared vertebroplasty and kyphoplasty (1212). In- Vertebroplasty and balloon kyphoplasty are 2 cluded patients were predominantly women over 65 minimally invasive surgical approaches developed for years who had experienced symptomatic osteopo- the management of symptoms of vertebral compres- rotic VCF, the remainder had neoplastic lesions. Even sion fractures (76,1196-1204). Galibert et al (1196) first though, no difference in pain relief compared with reported vertebroplasty in 1987 for the minimally in- medical therapy was reported in the 1 vertebroplasty vasive of hemangiomas, which, since then has been study (1212) and improvement in the functional ca- adapted for use in the treatment of intractable, focal, pacity was observed. In the study comparing balloon intense pain localized to a vertebral fracture. Kypho- kyphoplasty and vertebroplasty (1211), both pro- plasty was introduced in 1998 to restore vertebral body cedures appeared to provide a similar level of pain height and help realign the spine, using an inflatable relief after surgery, although there was insufficient balloon to reduce the fracture before the injection patients with follow-up in order to comment on 1- of cement (1197,1198). Currently, vertebroplasty and year outcome. In case series, a total of 3,029 patients kyphoplasty have been gaining popularity to stabilize with 4,861 vertebral fractures were included in 57 vertebral fractures mainly caused by osteoporosis but case series of vertebroplasty. Sample size varied con- also including malignant involvement of the spinal siderably (75), across the studies as did study dura- column, hemangioma, and vertebral osteonecrosis tion with up to 55 months of follow-up available fol- (75,76,1199). lowing vertebroplasty. Most patients (greater than 6.7.1 Vertebroplasty 80%) had experienced painful VCF as the result of Vertebroplasty involves a percutaneous injection primary or secondary osteoporosis (75). Only a small of polymethylmethacrylate (PMMA) into the fractured proportion of studies were specifically conducted in vertebral body. patients with neoplastic lesions. Overall the quality A number of reviews of literature and commen- of case series studies was poor. taries have promoted the use of vertebroplasty in Hulme et al (76) demonstrated that method- patients with symptomatic vertebral compression ological quality of various studies was poor. None of fractures from osteoporotic or neoplastic etiology the studies were randomized and only a few studies (75, 76,1192,1198,1200-1210). Of these, 2 systematic had an aspect of the study that was blinded (1213- reviews (75,76) of effectiveness and safety published 1218). In addition, confounding factors, bias, and in 2006 concluded that there is level 3 evidence to limitations were not consistently reported. There support vertebroplasty as effective therapy in the were 12 prospective, 29 retrospective and 6 unre- management of patients with symptomatic osteo- ported vertebroplasty studies showing the results

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of 2,958 subjects (in 47 studies), including 1,959 fe- of a tamp (balloon) into the vertebral body in order to males, 676 males, and 323 unreported with a mean compress the cancellous bone creating a cavity, and if age of 72 years, who underwent 4,456 procedures. possible realignment of the endplate of the vertebral Fifty percent of the vertebroplasty procedures were body (75). After the removal of the bone tamp the performed within the thoracolumbar regions of the PMMA fixes and stabilizes the fracture. spine including T11 to L2. A number of reviews of literature and com- 6.7.1.1 Effectiveness mentaries have promoted the use of kyphoplasty Hulme et al (76) reported a 16% to 47% full-scale in patients with symptomatic vertebral compression improvement in physical function after vertebroplasty fractures from osteoporotic or neoplastic etiology in 7 studies using different variants of a 5-point mobil- (75,76,1195,1198,1200-1210). Of these, 2 systematic ity scale (1215,1219-1224). Hulme et al (76) reported reviews (75,76) of effectiveness and safety published that 49% to 90% of subjects reported ambulation in 2006 concluded that there is level 3 evidence to improvements in 4 studies assessed by qualitative pa- support balloon kyphoplasty as effective therapy in tient response (1199,1213,1214,1225). They also re- the management of patients with symptomatic os- ported results of 3 studies that showed improvements teoporotic vertebral compression fractures refrac- in physical function using a validated health-related tory to conventional medical therapy (75). However, outcomes instrument (1226-1228). Vertebral height it was also concluded that there was no definite evi- restoration data was not reported qualitatively, how- dence to state that kyphoplasty is a safe and effec- ever, 39% of the patients (512 patients in 8 studies) tive procedure due to lack of comparative, blinded, following vertebroplasty intervention did not result randomized clinical trials. in an appreciable restoration of height or kyphotic Relevant studies evaluating kyphoplasty have angle. been many. Taylor et al (75) identified 4 non-random- Taylor et al (75) reported that a total of 3,029 ized comparative studies (1211,1233-1235) and mul- with 4,861 vertebral fractures were included in 57 tiple case series (1197,1201,1236-1243) that met the case series of vertebroplasty. There was a signifi- inclusion criteria. Of these 1 prospective study and 2 cant reduction in the pooled level of pain follow- retrospective studies compared balloon kyphoplasty ing vertebroplasty. However, only one vertebro- and conventional medical care. One prospective study plasty study reported use of a validated outcome compared the 2 procedures. Included patients were tool, Oswestry Disability Index, but failed to report predominantly women over 65 years who had experi- numerical outcomes (1229). Five vertebroplasty enced a symptomatic osteoporotic VCF, the remainder studies reported quality of life, 4 using a variety having neoplastic lesions. In 1 study (1234) patients of validated health-related quality of life measures had experienced pain for at least 12 months, whereas, (1199,1229-1231). Of these, 3 reported significant in another study (1235) patients experienced pain for improvement in quality of life following vertebro- an average of only 34 days. In case series a total of 641 plasty while 1 study reported no change (1231). patients with 1,070 vertebral fractures in 13 case series Taylor et al (75) also reported that 4 vertebroplasty of balloon kyphoplasty were included. The duration studies (1216,1218,1232,1233) reported a signifi- of pain was infrequently reported, although rare de- cant increase in vertebral height and 3 of these tails were available. The mean duration across balloon studies (1218,1232,1233) reported on a reduction kyphoplasty was 7.4 months, indicating that patients in kyphotic angle. Visual analog pain scores re- were likely to be refractory to conventional medical duced from an average of 8.2 to 3.0. therapy. Several balloon kyphoplasty studies assessed 6.7.1.2 Cost Effectiveness health-related quality of life utilizing an instrument There were no cost effectiveness studies of verte- (1197,1237,1238) with substantial overall improve- broplasty available in the literature. ments. 6.7.1.3 Evidence Hulme et al (76) included 13 prospective, 8 retro- The level of evidence for vertebroplasty is mod- spective and 1 unreported study evaluating kyphoplas- erate. ty showing the results of 1,288 subjects in 22 studies 6.7.2 Kyphoplasty including 829 females, 403 males and 56 unreported Balloon kyphoplasty is performed by injection of with a mean age of 72 years who underwent 1,624 poly methyl methacrylate (PMMA) following insertion procedures. Sixty percent of kyphoplasty procedures

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were performed within the thoracolumbar region of ramifications, asymptomatic emboli were counted as the spine including T11 to L2. a clinical complication. Pulmonary emboli occurred in 6.7.2.1 Effectiveness 0.6% and 0.01% of augmented vertebra for vertebro- A large proportion of patients had some pain re- plasty and kyphoplasty, respectively, while neurologic lief with 92% of the population involving 447 patients complications occurred in 0.6% and 0.03% of vertebra in 7 studies. Visual analog pain scores reduced from an (76). average of 7.5 to 3.4. Two studies showed change in Taylor et al (75) reported that rates of adverse SF-36 scores for kyphoplasty (75,76). Two kyphoplasty events including pulmonary embolism, neurologic studies showed improvements in disability, mean Os- complications, and perioperative mortality were low westry Disability Index preoperative 60% and postop- for both procedures although poorly reported across erative 32% in 77 subjects (1228,1244). Hulme et al studies. A significantly higher rate of cement leak- (76) also showed mean kyphotic angle restoration was age was reported for vertebroplasty than balloon ky- 6.6 degrees in 9 studies; however, not all subjects had phoplasty. In addition, no leaks were reported to be a reduction in kyphotic angular restoration of height. symptomatic with balloon kyphoplasty, while some A mean of 34% of kyphoplasty interventions did not 3% of leaks with vertebroplasty were reported to result in an appreciable restoration of height or ky- be symptomatic. The study of Fourney et al (1211), photic angle. Taylor et al (75) showed that compared comparing balloon kyphoplasty and vertebroplasty with medical therapy alone, balloon kyphoplasty sig- reported no cement leakages in balloon kyphoplasty nificantly improved patients level of pain and func- patients while 6 of 65 (9.2%) of patients treated with tionality based on the studies evaluated. One study vertebroplasty reported asymptomatic extravasa- (1234) reported statistically significant improvements tions. in both vertebral height and kyphotic angle following The systematic review by Hulme et al (76) report- balloon kyphoplasty. ed 17 vertebroplasty and 12 kyphoplasty clinical trials 6.7.2.2 Cost Effectiveness that reported new fractures. Of new vertebral frac- No systematic evaluation of cost effectiveness was tures using vertebroplasty and kyphoplasty, 60% and performed for kyphoplasty. 66%, respectively, were adjacent to the augmented 6.7.2.3 Evidence vertebra. The level of evidence for kyphoplasty is moderate. Taylor et al (75) reported incidence of new verte- 6.7.3 Complications bral fractures, both total and adjacent, was somewhat Immediate complications associated with verte- higher for balloon kyphoplasty than vertebroplasty, broplasty and kyphoplasty can be separated into 2 although their 95% confidence intervals overlapped. categories, procedural and cement leakage (76). Re- ported procedural complications include infection 6.8 Implantable Therapies (1222,1245,1246), fractures of the transverse process, Spinal cord stimulation systems and implantable pedicle, sternum, and ribs (1199,1212,1216,1219, intrathecal devices are frequently used in managing 1222,1247), and respiratory distress caused by the an- chronic intractable pain (1,2,22,29,56,67,71,1249- esthetic (1213,1248). Cement leakage occurred in 41% 1253). Significant improvements of less than one year of vertebra during vertebroplasty and 9% of vertebra were considered as short-term, whereas, one year or during kyphoplasty (76). The distribution of leaks was longer were considered as long-term. 32% and 11% epidural, 32.5% and 48% paraspinal, 6.8.1 Spinal Cord Stimulation 30.5 and 38% intradiscal, 1.7% and 1.5% pulmonary, Spinal cord stimulation consists of implanting and 3.3% and 1.5% foraminal for vertebroplasty and epidural electrodes transcutaneously and connecting kyphoplasty respectively with 1,081 leakage loca- them to a generator which is internalizing during a tions reported in 30 studies and 65 leakage locations second procedure if the test stimulation is successful. reported in 10 studies for vertebroplasty and kypho- In the United States, the primary indications for plasty respectively. Most leaks were clinically asymp- spinal cord stimulation are failed back surgery syn- tomatic (76). Clinical complications occurred for 2.6% drome and complex regional pain syndromes type I and 1.3% of augmented vertebra and 3.9% and 2.2% and type II (22,29,56,67,1249-1253). of subjects for vertebroplasty and kyphoplasty respec- Multiple systematic reviews (22,29,56,67,1250- tively. Because pulmonary emboli can cause serious 1254), 5 randomized controlled trials (1255-1259), 6

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prospective trials (1260-1265), and multiple case series improvements in CRPS Type I pain, post-herpetic neu- (1266-1283) were identified. ralgia pain and acute herpes zoster pain. Another Three of the 5 randomized trials were includ- prospective trial (1265) demonstrated pain relief in ed (1256,1257,1259). Two reports by Kemlar et al patients with interstitial cystitis with average pain (1257,1258) and two studies by North et al (1255,1259) score. Change was from 5.8 out of 10 to 1.6 out of 10 were included as one each. Raphael et al (1256) re- at a 14-month average follow-up timeframe. Of the ported positive results of spinal cord stimulation in 19 case series included, all showed favorable findings failed back surgery syndrome. Kemler et al (1257,1258) for the use of SCS in neuropathic pain (1266-1276). evaluated the effectiveness in complex regional pain Three addressed the use of SCS in CRPS (1266-1268). syndrome. Taylor et al (22,1251,1252,1254) in multiple Two reported its use in FBSS (1269,1270), 2 in chronic systematic reviews included analysis of spinal cord back pain (1271,1272), and 1 with lumbar spinal steno- stimulation (SCS) cost and its use in the back and ex- sis (1273). One studied its utility in refractory leg pain, tremity pain, failed back surgery syndrome (FBSS), and one studied abdominal pain, one reported on SCS and complex regional pain syndrome (CRPS). Their reviews interstitial cystitis, and one evaluated unilateral limb revealed moderate evidence to support SCS in CRPS pain conditions. Three studies (1274-1276) revealed Type I, FBSS, and chronic low back and lower extremity the results of large numbers of patients treated with pain with strong evidence supporting its use in CRPS SCS in a variety of neuropathic pain conditions. Type I and moderate evidence to support in use in the 6.8.1.1 Cost Effectiveness other diagnoses listed. Furthermore, they reported Taylor et al (1254) performed a systematic re- evidence to support the long-term cost effectiveness view of the literature. They reviewed 99 abstracts and of spinal cord stimulation compared to other standard found 14 studies that met the criteria of the review. modalities used for treatment of FBSS with a cost of They found across a range of health care institutions $29,123 in the SCS group and $38,029 in the control that the initial healthcare acquisition costs were off- group (1266). With CRPS, there is an estimated savings set by a reduction in post-implant healthcare resource of $60,000 over lifetime use. demand and costs. Costs were $29,123 in intervention Turner et al (1250) have reported on SCS for low group, compared to $38,029 in the control group for back pain, FBSS, and CRPS in 2 large systematic re- failed back surgery syndrome. In contrast, for CRPS views also evaluated which revealed similar findings (1254) in the lifetime analysis, spinal cord stimulation in whole to Taylor’s conclusions (29,1250-1253). per patient was estimated to be $60,000 cheaper than Cameron’s 20-year literature review (1253) includ- control therapy. ed studies totaling 3,679 patients and showed that 6.8.1.2 Evidence SCS has a “positive, symptomatic, long-term effect in The evidence for spinal cord stimulation in failed cases of refractory angina pain…” as well as with PVD, back surgery syndrome and complex regional pain peripheral neuropathic pain, and chronic low back syndrome is strong for short-term relief and moderate pain. It also concluded that SCS is safe and effective for long-term relief. for treatment of chronic neuropathic pain. 6.8.1.3 Complications Of the 5 randomized controlled studies, 3 that Complications with spinal cord stimulation range met the criteria for this review, all reported positive from infection, hematoma, nerve damage, lack of ap- findings. Kemler et al (1257) reported on CRPS plus propriate paraesthesia coverage, paralysis, nerve in- physical therapy (PT) versus PT alone. North et al (1259) jury, and death (1271,1277). evaluated FBSS patients who either underwent repeat 6.8.2 Implantable Intrathecal Drug Administration spinal surgery or SCS placement and found favorable Systems results with SCS superior to reoperation through three Continuous infusion of intrathecal medication is years follow-up. Raphael et al (1256) also revealed used for control of chronic, refractory, malignant and positive results for the use of SCS in FBSS patients. non-malignant pain. In an exhaustive review of avail- Among the prospective evaluations, 3 stud- able literature, Bennett et al (1278) concluded that ies (1260-1262) evaluated the use of SCS in patients clinical efficacy in large-scale randomized controlled with low back pain. All revealed positive findings for trials utilizing intrathecal delivery of most compounds control of back pain and/or lower extremity radicu- has not been demonstrated and variations between lar pain. Two prospective trials (1263,1264) showed study designs make useful comparisons of existing

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studies difficult. In another review, Walker et al (1279) al (1291) reported favorable results in patients with concluded that the evidence for the safety and effec- long-standing non-malignant neuropathic pain in a tiveness of combination spinal analgesic therapies is study of 14 patients, 61% reported good or fair pain moderate in acute pain, whereas, they found limited control with a mean follow-up duration of 2.4 years. or no evidence to support the combination analge- Angel et al (1292) reported good to excellent analgesics in chronic pain. Turner et al (71) performed a sys- sic response in 73% of 11 patients. Deer et al (1285) tematic review of effectiveness and complications of reported the results of the National Outcomes Reg- programmable intrathecal opioid delivery systems for istry for low back pain collected at 6- and 12-month chronic non-malignant pain. They included six studies follow-ups. They reported that in the implant group, in the evidence synthesis and found improvement in numeric pain ratings dropped by more than 47% for pain on average among patients who received a per- back pain and more than 31% for leg pain at 12- manent intrathecal drug delivery systems (1280-1285). month follow-up. They also reported improvement in All of the articles also reported some improvement Oswestry scores in 65% of the patients. in physical function. Guidelines also have been pub- Anderson and Burchiel (1280) in 30 patients im- lished on the drugs used in intrathecal infusion sys- planted with diverse diagnosis including 14 patients tems (1286). with failed back surgery syndrome with a mean age The literature supporting the use of intrathe- of 58 years showed positive outcomes. Kumar et al cal infusion systems includes four randomized trials (1281,1283), Rainov et al (1282), and Anderson et al (1287-1290), multiple prospective trials (1280-1286), (1284) all showed positive outcomes. and multiple retrospective evaluations (1291-1298). Retrospective reports dominate the literature on Among the randomized trials (1287-1290), Sid- intrathecal pain management (1294-1298). Among dall et al (1287) compared the effectiveness of in- the retrospective evaluations, the reports provided trathecal morphine or clonidine, alone or in combi- significant improvement at short-term and long-term nation, in the treatment of neuropathic pain after follow-up. spinal cord injury. They concluded that the combi- 6.8.2.1 Cost Effectiveness nation of morphine and clonidine produced signifi- In post lumbar laminectomy syndrome, it was cantly more pain relief than placebo 4 hours after shown that intrathecal morphine delivery resulted in administration. van Hilten et al (1288) evaluated lower cumulative 60-month costs of $16,579 per year the use of intrathecal baclofen for the treatment of and $1,382 per month versus medical management at dystonia in patients with complex regional pain syn- $17,037 per year or $1,420 per month (1299). drome, in a double-blind, randomized, controlled, In another study (194), the expected total cost of crossover trial of bolus intrathecal injections of ba- intrathecal morphine over 60 months was $82,893 (an clofen in various doses. They concluded that in some average of $1382 per month). patients, the dystonia associated with reflex sympa- 6.8.2.2 Evidence thetic dystrophy responded markedly to intrathe- The evidence for implantable intrathecal infu- cal baclofen. Smith et al (1289) reported significant sion systems is strong for short-term improvement in improvement in patients treated with intrathecal in- pain of malignancy or neuropathic pain. The evidence fusion systems when compared to patients treated is moderate for long-term management of chronic with conventional aggressive medical management pain. in patients with malignant pain. Staats et al (1290) 6.8.2.3 Complications in a multicenter, double-blind trial, reported that a The complications include post-dural puncture neuron-specific calcium channel blocker delivered via headache, infection, nausea, urinary retention, pru- an implanted intrathecal pump in patients with can- ritus, catheter and pump failure, pedal edema, hor- cer and AIDS-related pain syndromes significantly de- monal changes, granuloma formation, and decreased creased pain scores in 51% of the patients compared libido. to 18% in the placebo group at the 7-day follow-up. Turner et al (71) described complications derived Thus, all the randomized trials were performed for from 10 published reports. Non-pharmacological bio- neuropathic pain utilizing various types of drugs and logical complications included wound infection 12% short-term follow-up. across in 3 studies, meningitis 2% in 3 studies, and Among the prospective studies, Hassenbusch et pump malposition in 17% in 2 studies. CSF leaks dur-

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ing catheter placement leading to postdural head- the American Medical Association’s Current Procedur- ache were not commonly reported. Among the 10 al Terminology (CPT) aid the physician in performing studies, 7 studies (1281-1284,1291,1300,1301) did not a comprehensive and complete evaluation, and assist mention this complication at all, 2 (1280,1285) men- in complying with regulations. The CMS guidelines tioned, it but did not provide both the number of define 5 levels of services. The 3 crucial components patients assessed for this complication and the num- of evaluation and management services are history, ber who had the complication, and 1 (1292) report- physical examination, and medical decision-making. ed that no patients had it. In 1 study, one of 30 pa- Other components include counseling, coordination tients showed drug-seeking behavior and 1 patient of care, nature of presenting problem, and time. received an overdose of morphine and bupivacaine Suggested algorithm for comprehensive evalua- due to a programming error (1285). The most com- tion and management of chronic spinal pain is illus- monly reported drug side effects were nausea/vom- trated in Figure 1. iting. Other side effects mentioned in some articles in the complications review were provocation of 7.2 Medical Necessity Management asthma, insomnia, dry mouth, nightmares, myoclonic The following criteria should be considered care- jerk/spasm, dizziness, loss of appetite, diarrhea, and fully in performing interventional techniques: headache (1281,1301). 1. Complete initial evaluation, including history and Hardware complications were reported common- physical examination. ly on average across studies, 12% of patients with per- 2. Physiological and functional assessment, as neces- manent systems had catheter migration or dislodge- sary and feasible. ment, 19% had a catheter obstruction or occlusion, 3. Determination of indications and medical neces- and 5% had mechanical failure of the pump or bat- sity: tery, not including normal battery replacement (71). ♦ Suspected organic problem. Equipment revision was reported in 27% of patients ♦ Nonresponsiveness to less invasive modalities and pump removal was reported in 5% of the patients of treatments except in acute situations such as (71). acute disc herniation, herpes zoster and posther- There were a number of intrathecal granulomas petic neuralgia, reflex sympathetic dystrophy, and at the tip of the intrathecal catheter some of which intractable pain secondary to carcinoma. were large enough to cause spinal cord compression ♦ Pain and disability of moderate-to-severe degree. and neurologic dysfunction such as urinary inconti- ♦ No evidence of contraindications such as severe nence and paraparesis or paraplegia (71). Traumatic spinal stenosis resulting in intraspinal obstruction, syrinx, local erythema and edema in the area of the infection, or predominantly psychogenic pain. abdominal wall pocket and lower extremity edema, ♦ Responsiveness to prior interventions with im- transverse myelitis due to catheter-tip infection, post- provement in physical and functional status to dural puncture headache, diplopia, cranial nerve pal- justify repeat blocks or other interventions. sy, and intracranial subdural hematoma, dissociative ♦ Repeating interventions only upon return of pain mental state, symptoms of withdrawal, and patient and deterioration in functional status. self-draining of morphine have been reported (71). 8.0 Delivery of Interventional 7.0 Evaluation and Management Technology There is no consensus among the interventional 7.1 Evaluation pain management specialists with regards to type, Appropriate history, physical examination, and dosage, frequency, total number of injections, or medical decision making are essential to provide ap- other interventions. Yet significant attention in the propriate documentation and patient care (1302- literature seems to be focused on the complications 1307). There are numerous acceptable medical meth- attributed to the use of epidural steroids in the en- ods to evaluate a chronic spinal pain patient. These tire arena of interventional pain management. Thus, methods vary from physician to physician and text- various limitations of interventional techniques, spe- book to textbook. The guidelines established by the cifically neural blockade, have arisen from basically Centers for Medicare and Medicaid Services (CMS) and false impressions. Based on the available literature

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and scientific application, the most commonly used pain ratings as well as disability scores after 4 weeks, formulations of long-acting steroids, which include while patients receiving betamethasone showed no methylprednisolone (Depo-Medrol), triamcinolone significant difference in pain or disability scores. diacetate (Aristocort), triamcinolone acetonide (Ken- They concluded that the anti-inflammatory effect alog), and betamethasone acetate and phosphate of a depo-steroid can be greater than a non-depo- mixture (Celestone Soluspan), appear to be safe and steroid even at equally potent doses. Stanczak et al effective (882,890,966,1308-1330). Based on the pres- (1329) reviewed the results of 597 patients who re- ent literature, it appears that if repeated within 2 ceived Kenalog or Celestone Soluspan as an epidural weeks, betamethasone may be the best choice in injection for treatment of low back pain from 1997 avoiding side effects; whereas, if treatment is carried to 2002. The procedures were performed under fluo- out at 6-week intervals or longer, any one of the 4 for- roscopy. They showed that on days 0 to 3, on day mulations will be safe and effective. In recent years, 17, and on day 14 response was better with Kena- there has been substantial attention focused on par- log than Celestone. On day 14, 54% of Celestone re- ticulate and non-particulate steroids. Complication cipients and 71% of Kenalog recipients showed im- rates with epidural steroid injections are typically low provement in low back pain and improvement in leg and include paresthesia, hematoma, epidural abscess, or buttock pain. Anwar et al (890) in a prospective, meningitis, arachnoiditis, and inadvertent subdural randomized, single-blind study of epidural steroid or subarachnoid injection. However, in recent years, injection comparing triamcinolone with methylpred- complications with persistent paraplegia, cerebral in- nisolone acetate used a non-fluoroscopic technique farct, and other multiple central nervous systems se- with a caudal approach. Comparing 20 subjects in quelae have been reported. Undetected intraarterial each group, they showed that there were marked im- injection or arterial trauma have been implicated as provements in symptoms with both agents but there possible causes (743,1025). Tiso et al (1025) reported were no differences in terms of superiority from one a case of massive cerebellar infarction after unevent- agent to another. ful selective cervical transforaminal block, which was The questions also have been raised with regards attributed to intraarterial injection of corticosteroid. to the effectiveness of intraarticular facet joint injec- Subsequently, they conducted studies with focus on tions with steroids and medial branch blocks with ste- particulate size of compound versus blood vessel roids (826,828,829,843,844). dimension. They proposed a potential role for cor- Frequency and total number of injections or in- ticosteroid particulate embolus during unintended terventions are key issues, although controversial intraarterial injection as a potential mechanism. Oth- and rarely addressed (1-4,1331-1334). Descriptions ers (900,901,950,961,966,1329,1330) have evaluated of the frequency of various types of interventional effectiveness of various types of steroids comparing techniques are included here. These are based on to other types, along with comparing to local anes- available evidence and consensus regarding the thetic. There were no significant differences in some safety, clinical effectiveness, and cost effectiveness. studies (900,901,950,961) in the duration of relief However, they are not based on evidence synthe- whether steroids were used or not. In 1 study (966), sis methodology. Descriptions are provided only compared dexamethasone and triamcinolone for cer- for commonly used procedures, which frequently vical transforaminal injection with results indicating require repeat interventions. Medicare, Medicaid the effectiveness of dexamethasone was slightly less and third party payers in each region and state may than that of triamcinolone but the difference was have rules and regulations different from these neither statistically nor clinically significant. Thus, guidelines. Interventions permitted per year and authors of this study felt that non-particulate agent, per region are also variable. namely dexamethasone, theoretically appears to be a valid alternative to particulate agents such as tri- 8.1 Facet Joint Injections and Medial Branch amcinolone. Noe and Haynsworth (1330) compared Blocks Depo-Medrol to a non-depo form of betamethasone ♦ In the diagnostic phase, a patient may receive 2 in patients with low back pain. The results showed procedures at intervals of no sooner than 1 week that patients who received epidural methylpredniso- or preferably 2 weeks. lone (Depo-medrol) reported significant reduction in ♦ In the therapeutic phase (after the diagnostic phase

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is completed), the suggested frequency would be ventional procedures should be repeated only as 2–3 months or longer between injections, provided necessary according to the medical necessity crite- that >50% relief is obtained for 6 weeks. ria, and it is suggested that these be limited to a ♦ If the interventional procedures are applied for maximum of 4 to 6 times for local anesthetic and different regions, they may be performed at in- steroid blocks over a period of 1 year, per region. tervals of no sooner than 1 week or preferably 2 ♦ Under unusual circumstances with a recurrent in- weeks for most types of procedures. It is suggest- jury or cervicogenic headache, procedures may be ed that therapeutic frequency remain at 2 months repeated at intervals of 6 weeks after stabiliza- for each region. It is further suggested that all re- tion in the treatment phase. gions be treated at the same time, provided all procedures can be performed safely. 8.2 Medial Branch Neurotomy ♦ In the treatment or therapeutic phase, the inter- ♦ The suggested frequency would be 3 months or

Evaluation and Management

History Assessment Pain history Physicial Medical history Functional Psychological history Psychological Diagnostic testing

Impression

Management plan

Therapetic Diagnostic Alternatives Interventional Interventions Management

Reevaluation

Persisent pain Adequate pain relief New pain and improvement in Worsening pain functional status

Repeat Continue Comprehensive Therapeutic Evaluation Managment

Fig 1. A comprehensive patient evaluation. Adapted from ref. (2)

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longer (maximum of 3 times per year) between 8.5 Spinal Endoscopic Adhesiolysis each procedure, provided that > 50% relief is ob- ♦ The procedures are preferably limited to a maxi- tained for 10 to 12 weeks. mum of 2 per year provided the relief was > 50% ♦ The therapeutic frequency for medial branch for > 4 months. neurotomy should remain at intervals of at least 3 months for each region. It is further suggested 8.6 Sacroiliac Joint Injections that all regions be treated at the same time, pro- ♦ In the diagnostic phase, a patient may receive two vided all procedures are performed safely. procedures at intervals of no sooner than 1 week or preferably 2 weeks. 8.3 Epidural Injections ♦ In the therapeutic phase (after the diagnostic ♦ Epidural injections include caudal, interlaminar, phase is completed), the suggested frequency and transforaminal. would be 2 months or longer between injec- ♦ In the diagnostic phase, a patient may receive 2 tions, provided that > 50% relief is obtained for 6 procedures at intervals of no sooner than 1 week weeks. or preferably 2 weeks except in cancer pain or ♦ If the procedures are done for different joints, when a continuous administration of local anes- they be performed at intervals of no sooner than thetic is employed for reflex sympathetic dystro- 1 week or preferably 2 weeks. It is suggested that phy. therapeutic frequency remain at 2 months for ♦ In the therapeutic phase (after the diagnostic each joint. It is further suggested that both joints phase is completed), the suggested frequency of be treated at the same time, provided the injec- interventional techniques should be 2 months tions can be performed safely. or longer between each injection, provided that ♦ In the treatment or therapeutic phase, the inter- >50% relief is obtained for 6 to 8 weeks. ventional procedures should be repeated only as ♦ If the neural blockade is applied for different necessary according to the medical necessity cri- regions, they may be performed at intervals of teria, and it is suggested that they be limited to no sooner than 1 week and preferably 2 weeks a maximum of 4–6 times for local anesthetic and for most types of procedures. The therapeutic steroid blocks over a period of 1 year, per region. frequency may remain at intervals of at least 2 ♦ Under unusual circumstances with a recurrent in- months for each region. It is further suggested jury, procedures may be repeated at intervals of 6 that all regions be treated at the same time, pro- weeks after stabilization in the treatment phase. vided all procedures can be performed safely. ♦ In the treatment or therapeutic phase, the inter- 8.7 Sacroiliac Joint Radiofrequency Neurotomy ventional procedures should be repeated only as ♦ The suggested frequency is 3 months or longer necessary according to medical necessity criteria, between each procedure (maximum of 3 times and it is suggested that these be limited to a max- per year), provided that >50% relief is obtained imum of 4–6 times per year. for 10 to 12 weeks. ♦ Under unusual circumstances with a recurrent in- ♦ The therapeutic frequency for neurotomy should jury, carcinoma, or reflex sympathetic dystrophy, remain at intervals of at least 3 months for each blocks may be repeated at intervals of 6 weeks region. It is further suggested that all regions be after diagnosis/stabilization in the treatment treated at the same time, provided all procedures phase. are performed safely.

9.0 An Algorithmic Approach 8.4 Percutaneous Adhesiolysis ♦ The number of procedures are preferably limited In the changing paradigm of modern medicine, to: with its major focus on evidence-based medicine, in- With a 3-day protocol, 2 interventions per terventional pain physicians may benefit from the year, practice of evidence-based interventional pain man- With a 1-day protocol, 4 interventions per agement. An algorithmic approach, if developed year. properly, may assist the physician in the clinical practice of interventional pain management.

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An algorithmic approach was developed, based the management of chronic spinal pain, as an ongo- on the structural basis of spinal pain, and incorporated ing process utilizing the best available clinical evidence acceptable evidence of diagnostic and therapeutic in- from systematic research. A policy committee with terventional techniques available in managing chronic broad representation, consisting of academic and clin- spinal pain. Consensus was utilized in the absence of ical practitioners recognized as experts in one or more specific evidence. Figure 2 describes a proposed algo- interventional techniques under consideration and rithmic approach for the diagnosis of chronic low back representing a variety of practices and geographic pain and Figure 3 describes an algorithmic approach areas, assisted in preparation of these guidelines. All to management of chronic low back pain. Figure 4 de- types of relevant and published evidence and consen- scribes a proposed algorithmic approach for diagnosis sus were utilized. These guidelines are a comprehen- and management of chronic neck pain. sive review of interventional techniques for managing chronic spinal pain. It is hoped that these guidelines 10.0 Conclusion will assist both physicians and patients in making ap- The American Society of Interventional Pain Phy- propriate health care decisions for the diagnosis and sicians has developed and updated evidence-based treatment of chronic spinal pain. practice guidelines for interventional techniques in

Chronic low back pain

Based on clinical evaluation

Facet Joint Blocks Epidural Injections Sacroiliac Joint Injections

Positive Negative Positive Negative Positive Negative

Provocative Discography Facet Joint Blocks Facet Joint Blocks

Positive Negative Positive Negative Positive Negative

Sacroiliac Joint Injections Provocative Discography Provocative Discography

Positive Negative Positive Negative Positive Negative

Epidural Injections Sacroiliac Joint Injections Epidural Injections

Positive Negative Positive Negative Positive Negative

Stop process Stop process Stop process

Fig 2. An algorithmic approach to diagnosis of chronic low back pain without disc herniation.

72 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Chronic Low Back Pain

Somatic Pain Radicular pain

i. Facet joint pain i. No Surgery / PostSurgery / Spinal Stenosis Intraarticular Step 1: Caudal / Interlaminar Facet joint blocks/ or Medial branch blocks or Transforaminal epidural Radiofrequency Step 2: Percutaneous Adhesiolysis Thermoneurolysis ii. no surgery ii. SI joint pain Step 3: Percutaneous disc decompression SI joint pain iii. post surgery iii. Discogenic pain Step 4: Spinal Endoscopic Adhesiolysis Intradiscal therapy Step 5: Implantable therapy

Fig 3. A suggested algorithm for therapeutic interventional techniques in management of chronic low back pain.

Chronic neck pain

Based on clinical evaluation

Facet Joint Blocks Epidural Injections#

Positive Negative Positive Negative

Epidural Injections# Facet Joint Blocks

Positive Negative Positive Negative

Stop process Stop process

OR OR

Provocative Discography* Provocative Discography*

Positive Negative Positive Negative

Fig 4. An algorithmic approach to diagnosis of chrnoic neck pain without disc herniation.

# Transforaminal epidural injections have been associated with reports of risk * Not based on evidence synthesis www.painphysicianjournal.com 73 Pain Physician: January 2007:10:7-111

Author Affiliation Ricardo M. Buenaventura, MD Timothy R. Deer, MD Dayton Pain Med Director, Salahadin Abdi, MD, PhD 3490 Far Hills Avenue, Suite 202 The Center for Pain Relief and Professor and Chief, Division of Kettering, OH 45429 Clinical Professor, Anesthesiology Pain Medicine e-mail: [email protected] West Virginia University Department of Anesthesiology, Chairman, Committee on Pain Perioperative Medicine, and Pain Allen W. Burton, MD Medicine Management Associate Professor The American Society of University of Miami, Miller School Section Chief of Cancer Pain Anesthesiology of Medicine Management 400 Court Street, Suite 304 1611 NW 12th Ave., SW 303 Department of Anesthesiology and Charleston WV 25301 Miami, FL 33136 Pain Medicine-Unit 409 e-mail: [email protected] e-mail: [email protected] 1400 Holcombe Blvd. University of Texas Elmer E. Dunbar, MD Sairam L. Atluri, MD MD Anderson Cancer Center Medical Director Tri State Pain Management Institute Houston, TX 77030-4009 Pain Control Network 7655 Five Mile Road, Suite 117 e-mail: [email protected] 6400 Dutchman Parkway, Suite 60 Loveland, OH 45242 Louisville KY 40205 e-mail: [email protected] James D. Colson, MD e-mail: [email protected] Assistant Professor of Anesthesiology Ramsin M. Benyamin, MD Pain Medicine Service Richard S. Epter, MD President Department of Anesthesiology Augusta Pain Center Millennium Pain Center West Virginia University Hospitals P.O. Box 211839 1015 S. Mercer 1 Medical Center Drive Augusta GA 30917-1839 Bloomington, IL 61701 Morgantown, WV26506 e-mail: [email protected] Clinical Instructor e-mail: [email protected] Department of Surgery James Giordano, PhD College of Medicine Harold J. Cordner, MD Scholar-in-Residence University of Illinois Florida Pain Management Associates Center for Clinical Bioethics Urbana-Champaign, IL 13825 US Highway 1 Georgetown University Medical e-mail: [email protected] Sebastian FL 32905 Center e-mail: [email protected] 4000 Reservoir Rd. Mark V. Boswell, MD, PhD Washington, DC 20057 Sukdeb Datta, MD Professor of Anesthesiology e-mail: [email protected] Director, Messer-Racz Pain Center Director Department of Anesthesiology Pain Management Services Hans C. Hansen, MD Texas Tech University Health VA Tennessee Valley Healthcare Medical Director Sciences Center System The Pain Relief Centers, PA 3601 4th Street MS 8182 1310 24th Avenue South 1224 Commerce Street SW Lubbock, TX 79424 Nashville, TN 37212 Conover, NC 28613 e-mail: [email protected] Assistant Professor e-mail: [email protected] Vanderbilt University School of Richard C. Bowman, MD, PhD Medicine Joseph F. Jasper, MD The Center for Pain Relief Department of Anesthesiology Medical Director 400 Court Street, Suite 304 Nashville TN 37212 Advanced Pain Medicine Physicians Charleston WV 25301 e-mail [email protected] 1628 South Mildred Street, Suite #105 [email protected] Tacoma, WA 98465-1613 e-mail: [email protected]

74 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

David S. Kloth, MD David M. Schultz, MD Howard S. Smith, MD, PhD Medical Director Medical Advanced Pain Specialists Academic Director of Pain Connecticut Pain Care, PC Assistant Professor Management 109 Newton Road Department of Anesthesiology Professor of Anesthesiology Danbury CT 06810 University of Minnesota Medical Albany Medical College e-mail: [email protected] School 47 New Scotland Avenue 2104 Northdale Blvd. NW, Suite 220 Albany, NY 12208 Laxmaiah Manchikanti, MD Minneapolis, MN 55433 e-mail: [email protected] CEO, American Society of e-mail: [email protected] Interventional Pain Physicians Peter S. Staats, MD Medical Director Nalini Sehgal, MD Interventional Pain Management Pain Management Center of Associate Professor of 160 Avenue at the Common Paducah Rehabilitation Medicine Shrewsbury, NJ 07702 2831 Lone Oak Road Medical Director of Interventional e-mail: [email protected] Paducah, KY 42003 Pain Program Associate Clinical Professor of University of Wisconsin School of John R. Swicegood, MD Anesthesiology and Perioperative Medicine and Public Health Medical Director Medicine Dept. of Orthopedics and Rehabilitation Advanced Interventional Pain and University of Louisville, KY 40292 Madison, WI Diagnostics of Western Arkansas e-mail: [email protected]. e-mail: [email protected] PO Box 10206 Fort Smith, AR 72917 Vikram B. Patel, MD Rinoo V. Shah, MD e-mail: aipd@sbcglobalnet Associate Professor of Anesthesiology Assistant Professor Director of Pain Fellowship Interventional Pain Management Andrea M. Trescot, MD Program Department of Anesthesiology Director, Pain Fellowship Program Dept. of Anesthesiology Guthrie Clinic University of Florida Loyola University Medical Center Sayre, PA Gainesville, FL 2160 S. First Avenue e-mail: [email protected] The Pain Center Maywood, IL 60153 1564 Kingsley Ave e-mail: [email protected] Vijay Singh, MD Orange Park, FL 32073 Medical Director e-mail: [email protected] Pain Diagnostics Associates 1601 Roosevelt Road Niagara, WI 54151 e-mail: [email protected]

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References Groen GJ. Efficacy of radiofrequency roiliac joint interventions. Pain Physi- 1. Boswell MV, Shah RV, Everett CR, Se- procedures for the treatment of spinal cian 2005; 8:115-125. hgal N, Mckenzie-Brown AM, Abdi S, pain: A systematic review of random- 24. Abdi S, Lucas LF, Datta S. Role of epidur- Bowman RC, Deer TR, Datta S, Col- ized clinical trials. Reg Anesth Pain Med al steroids in the management of chron- son JD, Spillane WF, Smith HS, Lucas- 2001; 26:394-400. ic spinal pain: A systematic review of Levin LF, Burton AW, Chopra P, Staats 13. Manchikanti L, Singh V, Vilims B, Han- effectiveness and complications Pain PS, Wasserman RA, Manchikanti L. In- sen HC, Schultz DM, Kloth DS. Medial Physician 2005; 8:127-143. terventional techniques in the manage- branch neurotomy in management of ment of chronic spinal pain: Evidence- 25. Boswell M, Hansen H, Trescot A, Hirsch chronic spinal pain: Systematic review J. Epidural steroids in the management based practice guidelines. Pain Physi- of the evidence. Pain Physician 2002; cian 2005; 8:1-47. of chronic spinal pain and radiculopathy. 5:405-418. Pain Physician 2003; 6:319-334. 2. Manchikanti L, Staats PS, Singh V, 14. Niemisto L, Kalso E, Malmivaara A, Seit- 26. Koes BW, Scholten RJ, Mens JMA, Bout- Schultz DM, Vilims BD, Jasper JF, Kloth salo S, Hurri H. Cochrane Collaboration DS, Trescot AM, Hansen HC, Falasca TD, er LM. Epidural steroid injections for Back Review Group. Radiofrequency de- low back pain and sciatica. An updated Racz GB, Deer T, Burton AW, Helm S, Lou nervation for neck and back pain: a sys- L, Bakhit CE, Dunbar EE, Atluri SL, Calo- systematic review of randomized clini- tematic review within the framework of cal trials. Pain Digest 1999; 9:241-247. dney AK, Hassenbusch S, Feler CA. Evi- the Cochrane collaboration back review 27. Bigos SJ, Boyer OR, Braen GR, Brown dence-based practice guidelines for in- group. Spine 2003, 28:1877-1888. terventional techniques in the manage- K, Deyo R. Acute Low Back Problems in 15. Slipman CW, Bhat AL, Gilchrist RV, Isaac ment of chronic spinal pain. Pain Physi- Adults. Clinical Practice Guideline Num- Z, Chou L, Lenrow DA. A critical review cian 2003; 6:3-80. ber 4. AHCPR Publication No. 95-0642. of the evidence for the use of zygapoph- Agency for Health Care Policy and Re- 3. Manchikanti L, Singh V, Kloth DS, Slip- ysial injections and radiofrequency de- man CW, Jasper JF, Trescot AM, Varley search, Public Health Service, US De- nervation in the treatment of low back partment of Health and Human Servic- KG, Atluri SL, Giron C, Curran MJ, Rive- pain. Spine J 2003; 3:310-316. ra JJ, Baha A, Bakhit CE, Reuter M. In- es, Rockville, December 1994. 16. Occupational Medicine Practice Guide- terventional techniques in the manage- 28. van Tulder MWV, Koes BW, Bouter LM. lines. Evaluation and Management of ment of chronic pain: Part 2.0. Pain Phy- Conservative treatment of acute and Common Health Problems and Func- sician 2001; 4:24-96. chronic nonspecific low back pain. A tional Recovery in Workers. American 4. Manchikanti L, Singh V, Bakhit CE, Fel- systematic review of randomized con- College of Occupational and Environ- trolled trials of the most common inter- lows B. Interventional techniques in the mental Medicine. 2nd edition, 2004. management of chronic pain. Part 1.0. ventions. Spine 1997; 22:2128-2156. 17. van Tulder MW, Koes B, Malmivaara A. Pain Physician 2000; 3:7-42. 29. Turner J, Loeser J, Deyo R, Sanders SB. Outcome of non-invasive treatment 5. Manchikanti L. Medicare in interven- Spinal cord stimulation for patients modalities on back pain: an evidence- with failed back surgery syndrome or tional pain management: A critical anal- based review. Eur Spine J 2006; 15 Sup- ysis. Pain Physician 2006; 9:171-198. complex regional pain syndrome: A sys- pl 1:S64-S81. temic review of effectiveness and com- 6. Specialty Utilization data files from CMS: 18. DePalma MJ, Bhargava A, Slipman CW. A plications. Pain 2004; 108:137-147. http://www.cms.hhs.gov/physicians/ critical appraisal of the evidence for se- pfs. 30. Boswell MV, Colson JD, Spillane WF. lective nerve root injection in the treat- Therapeutic facet joint interventions: A 7. The National Uniform Claims Commit- ment of lumbosacral radiculopathy. systematic review of their role in chron- tee. Specialty Designation for Interven- Arch Phys Med Rehabil 2005; 86:1477- ic spinal pain management and com- tional Pain Management- 09. 1483. plications. Pain Physician 2005; 8:101- 8. Medicare Payment Advisory Commis- 19. Bogduk N, Govind J. Medical Manage- 114. sion Report to the Congress. Paying for ment of Acute Lumbar Radicular Pain: 31. Chopra P, Smith HS, Deer TR, Bowman Interventional Pain Services in Ambula- An Evidence-Based Approach. Cam- RC. Systematic review of adhesiolysis tory Settings. December 2001. bridge Press, Newcastle 1999. in managing chronic low back pain. Pain 9. Practice guidelines for chronic pain 20. Bogduk N, McGuirk B. Medical Manage- Physician 2005; 8:87-100. management. A report by the American ment of Acute and Chronic Low Back 32. Shah RV, Everett CR, McKenzie-Brown Society of Anesthesiologists Task Force Pain. An Evidence-Based Approach: AM, Sehgal N. Discography as a diag- on Pain Management, Chronic Pain Sec- Pain Research and Clinical Manage- nostic test for spinal pain: A systemat- tion. Anesthesiology 1997; 86:995- ment. Amsterdam: Elsevier Science BV, ic and narrative review. Pain Physician 1004. 2002. 2005; 8:187-209. 10. Sanders SH, Harden RN, Benson SE, 21. Bogduk N, McGuirk B. Management of 33. Everett CR, Shah R, Sehgal N, McKen- Vicente PJ. Clinical practice guidelines Acute and Chronic Neck Pain. An Evi- zie-Brown AM. A systematic review of for chronic non-malignant pain syn- dence-Based Approach. Elsevier, 2006. diagnostic utility of selective nerve root drome patients II: An evidence-based 22. Taylor RS, Van Buyten JP, Buchser E. blocks. Pain Physician 2005; 8:251- approach. J Back Musc Rehabil 1999; Spinal cord stimulation for chronic back 255. 13:47-58. and leg pain and failed back surgery 34. Bogduk N. International Spinal Injec- 11. Nelemans PJ, Debie RA, DeVet HC, Stur- syndrome: A systematic review and tion Society guidelines for the perfor- mans F. Injection therapy for subacute analysis of prognostic factors. Spine mance of spinal injection procedures. and chronic benign low back pain. Spine 2005; 30:152-160. Part 1: Zygapophyseal joint blocks. Clin 2001; 26:501-515. 23. McKenzie-Brown A, Shah RV, Sehgal N, J Pain 1997; 13:285-302. 12. Geurts JW, van Wijk RM, Stolker RJ, Everett CR. A systematic review of sac-

76 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

35. Boswell MV, Singh V, Staats PS, Hirsch siolysis in the management of chronic trials on the efficacy and safety of drugs JA. Accuracy of precision diagnostic spinal pain: An update. Pain Physician for the treatment of low back pain. J blocks in the diagnosis of chronic spinal 2007; 10:129-146. Pain Symptom Manage 2004; 28:72- pain of facet or zygapophysial joint ori- 48. Hansen HC, McKenzie-Brown AM, Co- 95. gin. Pain Physician 2003; 6:449-456. hen SP, Swicegood JR, Colson JD, 60. Musculoskeletal Guidelines. Musculo- 36. Sehgal N, Shah RV, McKenzie-Brown Manchikanti L. Sacroiliac joint interven- skeletal Imaging Guidelines. MedSolu- AM, Everett CR. Diagnostic utility of tions: A systematic review. Pain Physi- tions, Inc. 2004; pp 3-17. facet (zygapophysial) joint injections cian 2007; 10:165-184. 61. Macario A, Pergolizzi JV. Systematic lit- in chronic spinal pain: A systematic re- 49. Buenaventura RM, Shah RV, Patel V, Be- erature review of spinal decompression view of evidence. Pain Physician 2005; nyamin R, Singh V. Systematic review via motorized traction for chronic disco- 8:211-224. of discography as a diagnostic test for genic low back pain. Spine 2006; 6:171- 37. American Geriatrics Society. The man- spinal pain: An update. Pain Physician 178. agement of chronic pain in older per- 2007; 10:147-164. 62. Murtagh J, Foerster V. Radiofrequen- sons: New guidelines from the Ameri- 50. Sehgal N, Dunbar EE, Shah RV, Colson cy neurotomy for lumbar pain [Issues can Geriatrics Society. J Am Geriatr Soc JD. Systematic review of diagnostic util- in emerging health technologies issue 1998; 46:128-150. ity of facet (zygapophysial) joint injec- 83]. Ottawa: Canadian Agency for Drugs 38. Saal JS. General principles of diagnos- tions in chronic spinal pain: An update. and Technologies in Health; 2006. tic testing as related to painful lumbar Pain Physician 2007; 10:213-228. 63. Percutaneous Discectomy. Washington spine disorders. Spine 2002; 27:2538- 51. Boswell MV, Colson JD, Sehgal N, Dun- State Department of Labor and Indus- 2545. bar E, Epter R. A systematic review of tries, Office of Medical Director; Febru- 39. Guyer R, Ohnmeiss D. Lumbar discogra- therapeutic facet joint interventions ary 24, 2004. phy. Spine J 2003; 3:11S-27S. in chronic spinal pain. Pain Physician 64. Intradiscal Electrothermal Therapy 40. Cohen SP, Larkin TM, Barna SA, Palmer 2007; 10:229-253. (IDET). Technology Assessment Update. WE, Hecht AC, Stojanovic MP. Lumbar 52. Morley S, Eccleston C, Williams A. Sys- Washington State Department of Labor discography: a comprehensive review tematic review and meta-analysis of and Industries, Office of the Medical Di- of outcome studies, diagnostic accura- randomized controlled trials of cogni- rector; September 30, 2003. cy, and principles. Reg Anesth Pain Med tive behaviour therapy and behaviour 65. Belozer M, Wang G. Epidural adhe- 2005; 2:163-183. therapy for chronic pain in adults, ex- siolysis for the treatment of back pain. 41. Andersson GB, Mekhail NA, Block JE. cluding headache. Pain 1999; 80:1-13. Health Technol Assess 2004; 5:1-19. Treatment of intractable discogenic low 53. van Tulder MW, Ostelo R, Vlaeyen JW, 66. Khadilkar A, Milne S, Brosseau L, Rob- back pain. A systematic review of spinal Linton SJ, Morley SJ, Assendelft WJ. Be- inson V, Saginur M, Shea B, Tugwell fusion and intradiscal electrothermal havioral treatment for chronic low back P, Wells G. Transcutaneous electrical therapy (IDET). Pain Physician 2006; pain: a systematic review within the nerve stimulation (TENS) for chronic 9:237-248. framework of the Cochrane Back Re- low-back pain. Cochrane Database Syst 42. Appleby D, Andersson G, Totta M. Meta- view Group. Spine 2001; 26:270-281. Rev 2005; 3:CD003008. analysis of the efficacy and safety of in- 54. Rossy LA, Buckelew SP, Dorr N, Hag- 67. Mailis-Gagnon A, Furlan AD, Sandoval tradiscal electrothermal therapy (IDET). glund KJ, Thayer JF, McIntosh MJ, Hewett JA, Taylor R. Spinal cord stimulation for Pain Med 2006; 4:308-316. JE, Johnson JC. A meta-analysis of fibro- chronic pain. Cochrane Database Syst 43. Gibson JN, Waddell G. Surgery for de- myalgia treatment interventions. Ann Rev 2004; 3:CD003783. generative lumbar spondylosis: Up- Behav Med 1999; 21:180-191. 68. French SD, Cameron M, Walker BF, Reg- dated Cochrane Review. Spine 2005; 55. Hayden JA, Van Tulder MW, Tomlinson G. gars JW, Esterman AJ. A Cochrane re- 30:2312-2320. Systematic review: Strategies for using view of superficial heat or cold for low 44. Gibson JN, Grant IC, Waddell G.The Co- exercise therapy to improve outcomes back pain. Spine 2006; 31:998-1006. chrane review of surgery for lumbar in chronic low back pain. Ann Intern 69. Clarke JA, van Tulder MW, Blomberg SE, disc prolapse and degenerative lum- Med 2005; 142:776-785. de Vet HC, van der Heijden GJ, Bron- bar spondylosis. Spine 1999; 24:1820- 56. Airaksinen O, Brox JI, Cedraschi C, Hil- fort G. Traction for low-back pain with 1832. debrandt J, Klaber-Moffett J, Kovacs F, or without sciatica. Cochrane Database 45. Abdi S, Datta S, Trescot AM, Schul- Mannion AF, Reis S, Staal JB, Ursin H , Syst Rev 2005; 4:CD003010. tz DM, Adlaka R, Atluri SL, Smith HS, Zanoli G. Chapter 4: European guide- 70. Kay TM, Gross A, Goldsmith C, Santagu- Manchikanti L. Epidural steroids in the lines for the management of chronic ida PL, Hoving J, Bronfort G, Cervical management of chronic spinal pain: A nonspecific low back pain. Eur Spine J Overview Group. Exercises for mechan- systematic review. Pain Physician 2007; 2006; 15:S192-S300. ical neck disorders. Cochrane Database 10:185-212. 57. Freeman BJC. IDET: A critical appraisal Syst Rev 2005; 3:CD004250. 46. Datta S, Everett CR, Trescot AM, Schul- of the evidence. Eur Spine J 2006; 15: 71. Turner JA, Sears JM, Loeser JD. Program- tz DM, Adlaka R, Abdi S, Atluri SL, Smith S448-457. mable intrathecal opioid delivery sys- HS, Shah RV. An updated systematic re- 58. Eriksen J, Sjogren P, Bruera E, Ekholm O, tems for chronic non-malignant pain: A view of diagnostic utility of selective Rasmussen NK. Critical issues on opi- systematic review of effectiveness and nerve root blocks. Pain Physician 2007; oids in chronic non-cancer pain: an epi- complications. www.lni.wa.gov/Claim- 10:113-128. demiological study. Pain 2006; 125:172- sIns/Files/OMD/pumpReview2006.pdf 47. Trescot AM, Chopra P, Abdi S, Datta S, 179. 72. Assendelft WJ, Morton SC, Yu EI, Suttorp Schultz DM. Systematic review of ef- 59. Schnitzer TJ, Ferraro A, Hunsche E, Kong MJ, Shekelle PG. Spinal manipulative fectiveness and complications of adhe- SX. A comprehensive review of clinical therapy for low back pain. Cochrane Da- www.painphysicianjournal.com 77 Pain Physician: January 2007:10:7-111

tabase Syst Rev 2004; 1:CD0004474. validation of an international appraisal cal and valid scientifically or simply ni- 73. Karjalainen K, Malmivaara A, van Tulder instrument for assessing the quality of hilistic? Spine J 2002; 2:315-319. M, Roine R, Jauhiainen M, Hurri H, Koes clinical practice guidelines: the AGREE 98. Interventional techniques in the man- B. Multidisciplinary biopsychosocial re- project. Qual Saf Health Care 2003; agement of chronic spinal pain: evi- habilitation for neck and shoulder pain 12:18-23. dence-based practice guidelines. Amer- among working age adults. Cochrane 85. Cates JR, Young DN, Bowerman DS, Por- ican Society of Interventional Pain Phy- Database Syst Rev 2003; 2:CD002194. ter RC. An independent AGREE evalua- sicians - Medical Specialty Society. 2003 74. Singh K, Ledet E, Carl A. Intradiscal ther- tion of the Occupational Medicine Prac- (revised 2005). 47 pages. NGC:004173. apy: a review of current treatment mo- tice Guidelines. Spine J 2006; 6:72-77. 99. Opioid guidelines in the management of dalities. Spine 2005; 30:S20-S26. 86. Manchikanti L, Abdi S, Lucas LF. Evi- chronic non-cancer pain. American So- 75. Taylor RS, Taylor RJ, Fritzell P. Balloon dence synthesis and development of ciety of Interventional Pain Physicians kyphoplasty and vertebroplasty for ver- guidelines in interventional pain man- — Medical Specialty Society. 2006. 40 tebral compression fractures: A com- agement. Pain Physician 2005; 8:73- pages. NGC:004853. parative systematic review of efficacy 86. 100. Wu JS, Wong RK, Lloyd NS, Johnston M, and safety. Spine 2006; 31:2747-2755. 87. Manchikanti L, Heavner J, Racz GB, Me- Bezjak A, Whelan T; Supportive Care 76. Hulme PA, Krebs J, Ferguson SJ, Ber- khail NA, Schultz DM, Hansen HC, Singh Guidelines Group of Cancer Care On- lemann U. Vertebroplasty and kypho- V. Methods for evidence synthesis in in- tario. Radiotherapy fractionation for plasty: A systematic review of 69 clini- terventional pain management. Pain the palliation of uncomplicated painful cal studies. Spine 2006; 31:1983-2001. Physician 2003; 6:89-111. bone metastases - An evidence-based 77. Bouza C, López T, Magro A, Navalpotro 88. Moore RA, Derry S, Phillips CJ, McQuay practice guideline. BMC Cancer 2004; L, Amate JM. Efficacy and safety of bal- HJ. Nonsteroidal anti-inflammatory 4:71. loon kyphoplasty in the treatment of drugs (NSAIDs), cyxlooxygenase-2 se- 101. Shekelle P, Woolf S, Grimshaw J. Clinical vertebral compression fractures: A lective inhibitors (coxibs) and gastro- guidelines: Developing guidelines. BMJ systematic review. Eur Spine J 2006; intestinal harm: review of clinical trials 1999; 318:593-596. 15:1050-1067. and clinical practice. BMC Musculoskel- 102. Connis R, Nickinovich D, Caplan R, Arens et Disord 2006; 7:79. 78. Hollingworth W, Jarvik JG. Evidence on J. The development of evidence-based the effectiveness and cost-effective- 89. Fuhrer MJ. Overview of clinical trials in clinical practice guidelines. Integrating ness of vertebroplasty: A review of pol- medical rehabilitation: impetuses, chal- medical science and practice. Int J Tech- icy makers’ responses. Acad Radiol lenges, and needed future directions. nol Assess Health Care 2000; 16:1003- 2006; 13:550-555. Am J Phys Med Rehabil 2003; 82:S8-15. 1012. 79. Ploeg WT, Veldhuizen AG, The B, Siets- 90. Liddle SD, Baxter GD, Gracey JH. Exer- 103. Sackett D, Richardson WS, Roseberg W, ma MS. Percutaneous vertebroplasty as cise and chronic low back pain: what Haynes RB. Evidence Based Medicine. a treatment for osteoporotic vertebral works? Pain 2004; 107:176-190. Churchill Livingstone, Philadelphia, compression fractures: a systematic re- 91. Murphy AY, van Teijlingen ER, Gobbi 1996. view. Eur Spine J 2006; 15:1749-1758. MO. Inconsistent grading of evidence 104. West S, King V, Carey T, Lohr K, McKoy 80. Leonardi M, Pfirrmann CW, Boos N. In- across countries: a review of low back N, Sutton S, Lux L. Systems to rate the jection studies in spinal disorders. Clin pain guidelines. J Manipulative Physiol strength of scientific evidence. Evidence Orthop Relat Res 2006; 443:168-182. Ther 2006; 29:576-581. Report/Technology Assessment No. 47 81. Waggershauser T, Schwarzkopf S, Rei- 92. Arnau JM, Vallano A, Lopez A, Pellise F, University of North Carolina: Agency for ser M. Facet blockade, peridural and Delgado MJ, Prat N. A critical review of Healthcare Research and Quality. AHRQ periradicular pain therapy. Radiologe guidelines for low back pain treatment. Publication No. 02-E016; April 2002. 2006; 46:520-526. Eur Spine J 2006; 15:543-553. 105. Tunis SR, Stryer DB, Clancy CM. Practi- cal clinical trials: Increasing the value of 82. Resnick DK, Choudhri TF, Dailey AT, 93. Shaneyfelt TM, Mayo-Smith MF, Roth- Groff MW, Khoo L, Matz PG, Mummane- wangl J. Are guidelines following guide- clinical research for decision making in ni P, Watters WC 3rd, Wang J, Walters lines? The methodological quality of clinical and health policy. JAMA 2003; BC, Hadley MN; American Association clinical practice guidelines in the peer 290:1624-1632. of Neurological Surgeons/Congress of reviewed medical literature. JAMA 1999; 106. Silagy C, Rubin G, Henderson-Smart D, Neurological Surgeons. Guidelines for 281:1900-1905. Gross P. A guide to the development, the performance of fusion procedures 94. Bogduk N. In defense of radiofrequency implementation and evaluation of clini- for degenerative disease of the lumbar neurotomy. Reg Anesth Pain Med 2002; cal practice guidelines. National Health spine. Part 13: injection therapies, low- 27:439-441. and Medical Research Council, Canber- back pain, and lumbar fusion. J Neuro- 95. Manchikanti L, Jasper J, Singh V. Co- ra, Commonwealth of Australia, 1998, surg Spine 2005; 2:707-715. chrane Review by Nelemans et al. Spine pp 1-79. 83. Helm SH 2nd. California Workers’ Com- 2001; 26:2641-2643. 107. O’Brien P, Silagy C, McCallum J, pensation System: Are Occupational 96. Errico TJ, Gatchel RJ, Schofferman J, O’Connell, D, Glasziou P, Hill A. How to Medicine Practice Guidelines sufficient Benzel EC, Faciszewski T, Eskay-Auer- use the evidence: Assessment and ap- for the treatment of chronic spinal pain bach M, Wang JC. A fair and balanced plication of scientific evidence. Nation- or do they require supplementation view of spine fusion surgery. Spine J al Health and Medical Research Council, by guidelines for interventional tech- 2004; 4:129S-142S. Canberra, Commonwealth of Australia, 2000, pp 1-84. niques? Pain Physician 2004; 7:229- 97. Gatchel RJ, McGeary D. Cochrane col- 238. laboration-based reviews of health- 108. van Tulder M, Assendelft W, Koes B, 84. AGREE Collaboration. Development and care interventions: Are they unequivo- Bouter LM. Method guidelines for sys-

78 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

tematic reviews in the Cochrane Collab- ic pain in Australia: A prevalence study. vey. The prevalence of neck pain and re- oration Back Review Group for Spinal Pain 2001; 89:127-134. lated disability in Saskatchewan adults. Disorders. Spine 1997; 22:2323-2330. 122. Elliott AM, Smith BH, Hannaford PC, Spine 1998; 23:1689-1698. 109. Eccles M, Mason J. How to develop cost- Smith WC, Chambers WA. The course of 134. Linton SJ, Hellsing AL, Hallden K. A popu- conscious guidelines. Health Technol chronic pain in the community: Results lation based study of spinal pain among Assess 2001; 5:1-69. of a 4-year follow-up study. Pain 2002; 35–45-year old individuals. Spine 1998, 110. Cook DJ, Greengold NL, Ellrodt AG, We- 99:299-307. 23:1457-1463. ingarten SR. The relation between sys- 123. Yeung SS, Genaidy A, Deddens J, Alhe- 135. Miemelainen R, Videman T, Battie MC. tematic reviews and practice guide- mood A, Leung PC. Prevalence of mus- Prevalence and characteristics of upper lines. Ann Intern Med 1997; 127:210- culoskeletal symptoms in single and or mid-back pain in Finnish men. Spine 216. multiple body regions and effects of 2006; 31:1846-1849. 111. Keffer JH. Guidelines and algorithms: perceived risk of injury among manual 136. Walker BF, Muller R, Grant WD. Low Perceptions of why and when they are handling workers. Spine 2002; 27:2166- back pain in Australian adults: preva- successful and how to improve them. 2172. lence and associated disability. J Manip- Clin Chem 2001; 47:1563-1572. 124. Bressler HB, Keyes WJ, Rochon PA, Bad- ulative Physiol Ther 2004; 27:238-244. 112. Hatala R, Guyatt G. Evaluating the ley E. The prevalence of low back pain in 137. Bot SD, van der Waal JM, Terwee CB, teaching of evidence-based medicine. the elderly. A systemic review of the lit- van der Windt DA, Schellevis FG, Bouter JAMA 2002; 288:1110-1112. erature. Spine 1999; 24:1813-1819. LM, Dekker J. Incidence and prevalence 113. A guide to the development, implemen- 125. Lawrence RC, Helmick CG, Arnett FC. Es- of complaints of the neck and upper ex- tation and evaluation of clinical practice timates of the prevalence of arthritis tremity in general practice. Ann Rheum guidelines. National Health and Medi- and selected musculoskeletal disorders Dis 2005; 64:118-123. cal Research Council, Canberra, Com- in the United States. Arthritis Rheum 138. Cecchi F, Debolini P, Lova RM, Macchi C, monwealth of Australia, 1998, pp 1-79. 1998; 41:778-799. Bandinelli S, Bartali B, Lauretani F, Ben- 114. Whiting P, Rutjes A, Reitsma J, Bossuyt 126. Mallen C, Peat G, Thomas E, Croft P. Se- venuti E, Hicks G, Ferrucci L. Epidemiol- P, Kleijnen J. The Development of QUA- verely disabling chronic pain in young ogy of back pain in a representative co- DAS: A tools for the quality assessment adults: prevalence from a population- hort of Italian persons 65 years of age of studies of diagnostic accuracy in- based postal survey in North Stafford- and older: the InCHIANTI study. Spine cluded in systematic reviews. BMC Med shire. BMC Musculoskelet Disord 2005; 2006; 31:1149-1155. Res Methodol 2003; 3:25. 6:42. 139. Edmond SL, Felson DT. Function and 115. http://www.consort-statement.org/ 127. Tripp DA, Vandenkerkhof EG, McAlister back symptoms in older adults. J Am QUOROM.pdf M. Prevalence and determinants of pain Geriatr Soc 2003; 51:1702-1709. 116. Bossuyt PM, Reitsma JB, Bruns DE, Gat- and pain-related disability in urban and 140. Leveille SG, Guralnik JM, Hochberg M, sonis CA, Glasziou PP, Irwig LM, Lijmer rural settings in southeastern Ontario. Hirsch R, Ferrucci L, Langlois J, Ran- JG, Moher D, Rennie D, de Vet HC; Stan- Pain Res Manag 2006; 11:225-233. tanen T, Ling S. Low back pain and dis- dards for Reporting of Diagnostic Accu- 128. Manchikanti L, Boswell MV, Singh V, ability in older women: independent as- racy. Towards complete and accurate Pampati V, Damron KS, Beyer CD. Prev- sociation with difficulty but not inabil- reporting of studies of diagnostic ac- alence of facet joint pain in chronic spi- ity to perform daily living activities. J curacy: The STARD initiative. Clin Chem nal pain of cervical, thoracic, and lum- Gerontol A Biol Sci Med Sci 1999; 54: 2003; 49:1-6. http://www.clinchem. bar regions. BMC Musculoskelet Disord M487-493. org/cgi/content/full/49/1/1 2004; 5:15. 141. Cassidy JD, Côté P, Carroll LJ, Kristman V. 117. Stroup DF, Berlin JA, Morton SC, Olkin 129. Manchukonda R, Manchikanti KN, Cash Incidence and course of low back pain I, Williamson GD, Rennie D, Moher D, KA, Pampati V, Manchikanti L. Fac- episodes in the general population. Becker BJ, Sipe TA, Thacker SB. Meta- et joint pain in chronic spinal pain: an Spine 2005; 30:2817-2823. analysis of observational studies in ep- evaluation of prevalence and false pos- 142. Hestbaek L, Leboeuf-Yde C, Manniche idemiology: A proposal for reporting. itive rate of diagnostic blocks. 2007; in C. Low back pain: what is the long-term JAMA 2000; 283:2008-2012. press. course? A review of studies of general 118. Moher D, Schulz KF, Altman D, for the CON- 130. Jacob T, Zeev A. Are localized low back patient populations. Eur Spine J 2003; SORT Group. The CONSORT statement: re- pain and generalized back pain similar 12:149-165. vised recommendations for improving the entities? Results of a longitudinal com- 143. Croft PR, Lewis M, Papageorgiou AC, quality of report of parallel-group random- munity based study. Disabil Rehabil Thomas E, Jayson MI, Macfarlane GJ, ized trials. JAMA 2001; 285:1987-1991. 2006; 28:369-377. Silman AJ. Risk factors for neck pain: A 119. Verhaak PF, Kerssens JJ, Dekker J, Sor- 131. Cassidy JD, Carroll LJ, Cotê P. The Sas- longitudinal study in the general popu- bi MJ, Bensing JM. Prevalence of chron- katchewan Health and Back Pain Sur- lation. Pain 2001; 93:317-325. ic benign pain disorder among adults: vey. The prevalence of low back pain 144. Côté P, Cassidy JD, Carroll LJ, Kristman A review of the literature. Pain 1998; and related disability in Saskatchewan V. The annual incidence and course of 77:231-239. Adults. Spine 1998; 23:1860-1867. neck pain in the general population: a 120. Gureje O, Von Korff M, Simon GE, Gater 132. Guo HR, Tanaka S, Halperin WE, Cam- population-based cohort study. Pain R. Persistent pain and well-being: a eron LL. Back pain prevalence in US in- 2004; 112:267-273. World Health Organization Study in Pri- dustry and estimates of lost workdays. 145. Enthoven P, Skargren E, Oberg B. Clini- mary Care. JAMA 1998; 280:147-151. Am J Public Health 1999; 89:1029-1035. cal course in patients seeking primary 121. Blyth FM, March LM, Brnabic AJ, Jorm 133. Côté P, Cassidy JD, Carroll L. The Sas- care for back or neck pain: A prospec- LR, Williamson M, Cousins MJ. Chron- katchewan Health and Back Pain Sur- tive 5-year follow-up of outcome and www.painphysicianjournal.com 79 Pain Physician: January 2007:10:7-111

health care consumption with subgroup neck pain: a 1-year follow-up of a pop- chronic and disabling chronic pain analysis. Spine 2004; 29:2458-2465. ulation cohort. Spine 2004; 29:1648- among ageing employees. Pain 2005; 146. Elder LA, Burdorf A. Prevalence, inci- 1654. 114:364-371. dence, and recurrence of low back pain 158. Hestbaek L, Leboeuf-Yde C, Engberg 169. Bunketorp L, Stener-Victorin E, Carlsson in scaffolders during a 3-year follow-up M, Lauritzen T, Bruun NH, Manniche C. J. Neck pain and disability following mo- study. Spine 2004; 29:E101-E106. The course of low back pain in a general tor vehicle accidents—a cohort study. 147. Croft PR, Papageorgiou AC, Thomas E, population. Results from a 5-year pro- Eur Spine J 2005; 14:84-89. Macfarlane GJ, Silman AJ. Short-term spective study. J Manipulative Physiol 170. Frank AO, De Souza LH, Frank CA. Neck physical risk factors for new episodes Ther 2003; 26:213-219. pain and disability: a cross-sectional of low back pain. Prospective evidence 159. Szpalski M, Gunzburg R, Balague F, Nor- survey of the demographic and clini- from the South Manchester Back Pain din M, Melot C. A 2-year prospective lon- cal characteristics of neck pain seen in Study. Spine 1999; 24:1556-1561. gitudinal study on low back pain in pri- a rheumatology clinic. Int J Clin Pract 148. Miedema HS, Chorus AM, Wevers CW, mary school children. Eur Spine J 2002; 2005; 59:173-182. van der Linden S. Chronicity of back 11:459-464. 171. Hartvigsen J, Frederiksen H, Chris- problems during working life. Spine 160. Waxman R, Tennant A, Helliwell P. A pro- tensen K. Physical and mental function 1998; 23:2021-2028. spective follow-up study of low back and incident low back pain in seniors: A 149. Thomas E, Silman AJ, Croft PR, Papa- pain in the community. Spine 2000; population-based two-year prospective georgiou AC, Jayson MI, Macfarlane GJ. 25:2085-2090. study of 1387 Danish twins aged 70 to Predicting who develops chronic low 161. Eriksen J, Ekholm O, Sjogren P, Rasmus- 100 years. Spine 2006; 31:1628-1632. back pain in primary care. A prospective sen NK. Development of and recovery 172. Jacob T. Low back pain incident epi- study. Brit Med J. 1999; 318:1662-1667. from long-term pain. A 6-year follow- sodes: A community-based study. Spine 150. Mortimer M, Pernold G, Wiktorin C. Low up study of a cross-section of the adult J 2006; 6:306-310. back pain in a general population. Nat- Danish population. Pain 2004; 108:154- 173. Takahashi N, Kikuchi S, Konno S, Mori- ural course and influence of physical ex- 162. ta S, Suzukamo Y, Green J, Fukuhara S. ercise – A 5-year follow-up of the Mus- 162. Borghouts JA, Koes BW, Bouter LM. The Discrepancy between disability and the culoskeletal Intervention Center-Nor- clinical course and prognostic factors of severity of low back pain: demograph- rtalje Study. Spine 2006; 31:3045-3051. non-specific neck pain: A systematic re- ic, psychologic, and employment-relat- 151. Jackson JL, Passamonti M. The out- view. Pain 1998; 77:1-13. ed factors. Spine 2006; 31:931-939. comes among patients presenting in pri- 163. Papageorgiou AC, Silman AJ, Macfar- 174. Hestbaek L, Leboeuf-Yde C, Kyvik KO. Is mary care with a physical symptom at 5 lane GJ. Chronic widespread pain in comorbidity in adolescence a predictor years. J Gen Intern Med 2005;20:1032- the population: a seven year follow up for adult low back pain? A prospective 1037. study. Ann Rheum Dis 2002; 61:1071- study of a young population. BMC Mus- 152. Jones GT, Johnson RE, Wiles NJ, Chad- 1074. culoskelet Disord 2006; 7:29. dock C, Potter RG, Roberts C, Symmons 164. Kadam UT, Thomas E, Croft PR. Is chron- 175. Weiner DK, Kim YS, Bonino P, Wang T. DP, Macfarlane GJ. Predicting persistent ic widespread pain a predictor of all- Low back pain in older adults: are we disabling low back pain in general prac- cause morbidity? A 3 year prospective utilizing healthcare resources wisely? tice: a prospective cohort study. Br J population based study in family prac- Pain Med 2006; 7:143-150. Gen Pract 2006; 56:334-341. tice. J Rheumatol. 2005; 32:1341-1348. 176. Ekman M, Jönhagen S, Hunsche E, Jons- 153. Kaaria S, Luukkonen R, Riihimaki H, Kir- 165. Kovacs FM, Fernández C, Cordero A, Mu- son L. Burden of illness of chronic low jonen J, Leino-Arjas P. Persistence of low riel A, Gonzalez-Lujan L, Gil del Real MT; back pain in Sweden: A cross-sectional, back pain reporting among a cohort of Spanish Back Pain Research Network. retrospective study in primary care set- employees in a metal corporation: A Non-specific low back pain in prima- ting. Spine 2005; 30:1777-1785. study with 5-, 10-, and 28-year follow- ry care in the Spanish National Health 177. Ritzwoller DP, Crounse L, Shetterly S, ups. Pain 2006; 120:131-137. Service: A prospective study on clinical Rublee D. The association of comorbid- 154. Leboeuf-Yde C, Gronstvedt A, Borge JA, outcomes and determinants of manage- ities, utilization and costs for patients Lothe J, Magnesen E, Nilsson O, Rosok ment. BMC Health Serv Res 2006; 6:57. identified with low back pain.BMC Mus- G, Stig LC, Larsen K. The Nordic back 166. Holmberg SA, Thelin AG. Primary care culoskelet Disord 2006; 7:72. pain subpopulation program: A 1-year consultation, hospital admission, sick 178. Vogt MT, Kwoh CK, Cope DK, Osial TA, prospective multicenter study of out- leave and disability pension owing to Culyba M, Starz TW. Analgesic usage comes of persistent low-back pain in neck and low back pain: A 12-year pro- for low back pain: impact on health chiropractic patients. J Manipulative spective cohort study in a rural popula- care costs and service use. Spine 2005; Physiol Ther 2005; 28:90-96. tion. BMC Musculoskelet Disord 2006; 30:1075-1081. 7:66. 155. Sjolie AN. Persistence and change in 179. Ricci JA, Stewart WF, Chee E, Leotta C, nonspecific low back pain among- ad 167. Smith BH, Elliott AM, Hannaford PC, Foley K, Hochberg MC. Back pain ex- olescents: A 3-year prospective study. Chambers WA, Smith WC. Factors re- acerbations and lost productive time Spine 2004; 29:2452-2457. lated to the onset and persistence of costs in United States workers. Spine 156. Jacob T, Baras M, Zeev A, Epstein L. A chronic back pain in the community: re- 2006; 31:3052-3060. sults from a general population follow- longitudinal, community-based study 180. Stewart WF, Ricci JA, Chee E, Mor- up study. Spine 2004; 29:1032-1040. of low back pain outcomes. Spine 2004; ganstein D, Lipton R. Lost productive 29:1810-1817. 168. Saastamoinen P, Leino-Arjas P, Laak- time and cost due to common pain con- 157. Hill J, Lewis M, Papageorgiou AC, sonen M, Lahelma E. Socio-economic ditions in the US workforce. JAMA 2003; Dziedzic K, Croft P. Predicting persistent differences in the prevalence of acute, 290:2443-2454.

80 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

181. White AG, Birnbaum HG, Mareva MN, Hassenbusch SJ, Ross E. Cost-effective- 206. Sikirica V, Vallow S, Schein J, Doshi D, Daher M, Vallow S, Schein J, Katz N. Di- ness of long-term intrathecal morphine Katz N, White A, Stang P. Prevalence, rect costs of opioid abuse in an insured therapy for pain associated with failed comorbidities, and utilization of servic- population in the United States. J Man- back surgery syndrome. Clin Ther 1997; es of opioid abusers in a managed care ag Care Pharm 2005; 11:469-479. 19:96-112. plan. Abstract Presented at the AAPM 182. Daffner SD, Hilibrand AS, Hanscom BS, 195. Maniadakis N, Gray A. The econom- Annual Meeting. Pain Med 2005; 6:190. Brislin BT, Vaccaro AR, Albert TJ. Impact ic burden of back pain in the UK. Pain 207. Manchikanti L, Whitfield E, Pallone F. of neck and arm pain on overall health 2000; 84:95-103. Evolution of the National All Schedules status. Spine 2003; 28:2030-2035. 196. Walker BF, Muller R, Grant WD. Low Prescription Electronic Reporting Act 183. Dionne CE, Chenard M. Back-relat- back pain in Australian adults: the eco- (NASPER): A public law for balancing ed functional limitations among full- nomic burden. Asia Pac J Public Health treatment of pain and drug abuse and time homemakers: a comparison with 2003; 15:79-87. diversion. Pain Physician 2005; 8:335- women employed full-time outside the 197. Jhawar BS, Fuchs CS, Colditz GA, Stamp- 347. home. Spine 2004; 29:1375-1382. fer MJ. Cardiovascular risk factors for 208. Manchikanti L, Manchukonda R, Dam- 184. Luo X, Pietrobon R, Sun SX, Liu GG, physician-diagnosed lumbar disc herni- ron KS, Brandon D, McManus CD, Cash Hey L. Estimates and patterns of di- ation. Spine J 2006; 6:684-691. KA. Does adherence monitoring reduce rect health care expenditures among in- 198. Carroll LJ, Cassidy JD, Côté P. Frequency, controlled substance abuse in chron- dividuals with back pain in the United timing, and course of depressive symp- ic pain patients? Pain Physician 2006; States. Spine 2004; 29:79-86. tomatology after whiplash. Spine 2006; 9:57-60. 185. Reyes-Gibby CC, Aday L, Cleeland C. Im- 31:E551-E556. 209. Rivera JJ, Singh V, Fellows B, Pampati pact of pain on self-rated health in the 199. Dersh J, Gatchel RJ, Mayer T, Polatin P, V, Damron KS, McManus CD. Reliabili- community-dwelling older adults. Pain Temple OR. Prevalence of psychiatric ty of psychological evaluation in chron- 2002; 95:75-82. disorders in patients with chronic dis- ic pain in an interventional pain man- 186. Leigh JP, Markowitz SB, Fahs M, Shin C, abling occupational spinal disorders. agement setting. Pain Physician 2005; Landrigan PJ. Occupational injury and Spine 2006; 31:1156-1162. 8:375-383. illness in the United States. Estimates 200. Paulozzi LJ, Budnitz DS, Yongli X. In- 210. Rush AJ, Polatin P, Gatchel RJ. Depres- of costs, morbidity, and mortality. Arch creasing deaths from opioid analgesics sion and chronic low back pain. Spine Intern Med 1997; 157:1557-1568. in the United States. Pharmacoepidemi- 2000; 25:2566-2571. 187. Freedman VA, Martin LG, Schoeni RF. ol Drug Saf 2006; 15:618-627. 211. McWilliams LA, Cox BJ, Enns MW. Mood Recent trends in disability and function- 201. Birnbaum HG, White AG, Reynolds and anxiety disorders associated with ing among older adults in the United JL, Greenberg PE, Zhang M, Vallow S, chronic pain: an examination in a na- States. JAMA 2002; 288:3137-3146. Schein JR, Katz NP. Estimated costs of tionally representative sample. Pain 2003; 106:127-133. 188. Ohayon MM, Schatzberg AF. Using prescription opioid analgesic abuse in chronic pain to predict depressive mor- the United States in 2001: A societal 212. Polatin PB, Kinney RK, Gatchel RJ, Lil- bidity in the general population. Arch perspective. Clin J Pain 2006; 22:667- lo E, Mayer TG. Psychiatric illness and Gen Psychiatry 2003; 60:39-47. 676. chronic low back pain: The mind and the 189. Hurwitz EL, Morgenstern H, Yu F. Cross- 202. Hatten AL, Gatchel RJ, Polatin PB, Stow- spine – which goes first? Spine 1993; sectional and longitudinal associations ell AW. A cost-utility analysis of chron- 18:66-71. of low-back pain and related disabili- ic spinal pain treatment outcomes: con- 213. Manchikanti L, Pampati VS, Fellows ty with psychological distress among verting SF-36 data into quality-adjusted B, Beyer CD, Damron KS, Barnhill RC, patients enrolled in the UCLA Low- life years. Clin J Pain 2006; 22:700-711. Burks T. Characteristics of chronic low Back Pain Study. J Clin Epidemiol 2003; 203. Feder J, Rowland D, Holahan J, Heslam back pain in patients in an intervention- 56:463-471. D. The Medicaid Cost Explosion: Causes al pain management setting: A prospec- 190. Turner JA, Franklin G, Heagerty PJ, Wu R, and Consequences. Henry J. Kaiser Fam- tive evaluation. Pain Physician 2001; Egan K, Fulton-Kehoe D, Gluck JV, Wick- ily Foundation. Menlo Park, CA, 1993, 4:131-142. izer TM. The association between pain pp 18-22. 214. Davis PJ, Reeves JL, Hastie BA, Graff- and disability. Pain 2004; 112:307-314. 204. Manchikanti L. Prescription drug abuse: Radford SB, Naliboff BD. Depression 191. Pai S, Sundaram LJ. The economic bur- What is being done to address this new determines illness conviction and pain den of low back pain: A review of stud- drug epidemic? Testimony before the impact: A structural equation modeling ies published between 1996 and 2001. Subcommittee on Criminal Justice, Drug analysis. Pain Med 2000; 1:238-246. Orthop Clin North Am 2004; 35:1-5. Policy and Human Resources. Pain Phy- 215. Manchikanti L, Fellows B, Pampati VS, 192. Maetzel A, Li L. The economic burden of sician 2006; 9:287-321. Damron KS, Beyer CD, Barnhill RC. low back pain: A review of studies pub- 205. Kentucky All Schedule Prescription Comparison of psychological status of lished between 1996 and 2001. Best Electronic Reporting (KASPER). A Com- chronic pain patients with general pop- Pract Res Clin Rheumatol 2002; 16:23- prehensive Report on Kentucky’s Pre- ulation. Pain Physician 2002; 5:40-48. 30. scription Monitoring Program Prepared 216. Manchikanti L, Pampati VS, Damron 193. Bell G, Kidd D, North R. Cost-effective- by the Cabinet for Health and Family KS, Beyer CD, Barnhill RC. Evaluation of ness analysis of spinal cord stimula- Services Office of the Inspector Gener- psychological status in chronic low back tion in treatment of failed back surgery al, Version 1 – 3/29/2006. chfs.ky.gov/ pain: Comparison with general popula- syndrome. J Pain Symp Manage 1997; NR/rdonlyres/2D46AB2E-FAE8-43DC tion. Pain Physician 2002; 5:149-155. 13:286-295. 9CE6-6BB4B419918F/0/AComprehen- 217. Vindigni D, Walker BF, Jamison JR, Da siveSummaryofKASPERDraft.pdf 194. de Lissovoy G, Brown RE, Halpern M, Costa C, Parkinson L, Blunden S. Low www.painphysicianjournal.com 81 Pain Physician: January 2007:10:7-111

back pain risk factors in a large rural 231. Bogduk N. The zygapophysial joints. In Mechanisms of low back pain: A neuro- Australian Aboriginal community. An Clinical Anatomy of the Lumbar Spine physiologic and neuroanatomic study. opportunity for managing co-morbidi- and Sacrum, Third edition. Churchill Liv- Clin Orthop 1997; 335:166-180. ties? Chiropr Osteopat 2005; 13:21. ingstone, New York, 2005, pp 29-38. 247. Bogduk N, Wilson AS, Tynan W. The hu- 218. Gagliese L, Katz J. Medically unex- 232. Fukui S, Ohseto K, Shiotani M, Ohno K, man lumbar dorsal rami. J Anat 1982; plained pain is not caused by psychopa- Karasawa H, Naganuma Y, Yuda Y. Re- 134:383-397. thology. Pain Res Manage 2000; 5:251- ferred pain distribution of the cervical 248. Ohtori S, Takahashi K, Chiba T, Yamaga- 257. zygapophyseal joints and cervical dor- ta M, Sameda H, Moriya H. Sensory in- 219. Bogduk N, McGuirk B. Causes and sourc- sal rami. Pain 1996; 68:79-83. nervation of the cervical facet joints in es of chronic low back pain. In Medical 233. Dwyer A, Aprill C, Bogduk N. Cervical rats. Spine 2001; 26:147-150. Management of Acute and Chronic Low zygapophyseal joint pain patterns: A 249. Chua WH, Bogduk N. The surgical anat- Back Pain. An Evidence-Based Approach: study in normal volunteers. Spine 1990; Pain Research and Clinical Management, omy of thoracic facet denervation. Acta 15:453-457. Neurochir 1995; 136:140-144. Vol. 13, Elsevier Science BV, Amsterdam, 234. Aprill C, Dwyer A, Bogduk N. The prev- 2002, pp 115-126. 250. Barnsley L, Bogduk N. Medial branch alence of cervical zygapophyseal joint blocks are specific for the diagnosis of 220. Bogduk N, McGuirk B. An algorithm for pain patterns II: A clinical evaluation. precision diagnosis. In Bogduk N, Mc- cervical zygapophyseal joint pain. Reg Spine 1990; 15:458-461. Anesth 1993; 18:343-350. Guirk B, eds. Medical Management of 235. Pawl RP. Headache, cervical spondylo- Acute and Chronic Low Back Pain. An Ev- 251. Zhang J, Tsuzuki N, Hirabayashi S, Saiki sis, and anterior cervical fusion. Surg idence-Based Approach: Pain Research K, Fujita K. Surgical anatomy of the Ann 1977; 9:391-498. and Clinical Management. Amsterdam: nerves and muscles in the posterior cer- Elsevier Science BV 2002; 13:177-186. 236. Windsor RE, Nagula D, Storm S. Electri- vical spine. Spine 2003; 1379-1384. cal stimulation induced cervical medial 221. Deyo RA, Weinstein JN. Low back pain. 252. Dreyfuss P, Schwarzer AC, Lau P, Bog- branch referral patterns. Pain Physician N Engl J Med 2001; 344:363-370. duk N. Specificity of lumbar medi- 2003; 6:411-418. 222. Deyo RA. Fads in the treatment of low al branch and L5 dorsal ramus blocks. 237. Dreyfuss P, Tibiletti C, Dreyer SJ. Thorac- back pain. N Engl J Med 1991; 325:1039- Spine 1997; 22:895-902. ic zygapophyseal joint pain patterns: A 1040. 253. Kaplan M, Dreyfuss P, Halbrook B, Bog- study in normal volunteers. Spine 1994; duk N. The ability of lumbar medial 223. Deyo RA, Rainville J, Kent DL. What can 19:807-811. the history and physical examination branch blocks to anesthetize the zyg- 238. Fukui S, Ohseto K, Shiotani M. Patterns tell us about low back pain? JAMA 1992; apophysial joint. Spine 1998; 23:1847- of pain induced by distending the tho- 268: 760-765. 1852. racic zygapophyseal joints. Reg Anesth 254. Lau P, Mercer S, Govind J, Bogduk N. 224. Bogduk N. Low back pain. Clinical Anat- 1997; 22:332-336. omy of Lumbar Spine and Sacrum. 4th The surgical anatomy of lumbar medial 239. Mooney V, Robertson J. The facet syn- edition. Churchill Livingstone, New branch neurotomy (facet denervation). drome. Clin Orthop 1976; 115:149-156. York, 2005, pp 183-216. Pain Med 2004; 5:289-298. 240. McCall IW, Park WM, O’Brien JP. Induced 225. Carragee EJ. Clinical practice. Persis- 255. Ishikawa T, Miyagi M, Ohtori S, Aoki pain referral from posterior elements tent low back pain. N Engl J Med 2005; Y, Ozawa T, Doya H, Saito T, Moriya H, in normal subjects. Spine 1979; 4:441- 352:1891-1898. Takahashi K. Characteristics of senso- 446. ry DRG neurons innervating the lum- 226. Mooney V. Where is the pain coming 241. Marks R. Distribution of pain provoked bar facet joints in rats. Eur Spine J 2005; from? Spine 1987; 12:754-759. from lumbar facet joints and related 14:559-564. 227. Spitzer WO, LeBlanc FE, Dupuis M. Sci- structures during diagnostic spinal in- 256. Suseki K, Takahashi Y, Takahashi K, Chi- entific approach to the assessment and filtration.Pain 1989; 39:37-40. ba T, Tanaka K, Morinaga T, Nakamu- management of activity-related spinal 242. Fukui S, Ohseto K, Shiotani M, Ohno K, ra S, Moriya H. Innervation of the lum- disorders: A monograph for clinicians. Karasawa H, Naganuma Y. Distribution bar facet joints. Origins and functions. Report of Quebec Task Force on Spinal of referral pain from the lumbar zyg- Spine 1997; 22:477-485. Disorders. Spine 1987; 12:S1-59. apophyseal joints and dorsal rami. Clin 257. Sameda H, Takahashi Y, Takahashi K, 228. Kuslich SD, Ulstrom CL, Michael CJ. The J Pain 1997; 13:303-307. Chiba T, Ohtori S, Moriya H. Primary sen- tissue origin of low back pain and sci- 243. Hirsch C, Ingelmark BE, Miller M. The sory neurons with dichotomizing axons atica: A report of pain response to tis- anatomical basis for low back pain. Acta projecting to the facet joint and the sci- sue stimulation during operation on the Orthop Orthop Scand 1963; 33:1-17. atic nerve in rats. Spine 2001; 26:1105- lumbar spine using local anesthesia. 1109. Orthop Clin North Am 1991; 22:181-187. 244. Windsor RE, King FJ, Roman SJ, Tata N, Cone-Sullivan LA, Thampi S, Acebey 258. Yamada H, Honda T, Kikuchi S, Sugiu- 229. Pang WW, Mok MS, Lin ML, Chang DP, M, Gilhool JJ, Rao R, Sugar R. Electri- ra Y. Direct innervation of sensory fibers Hwang MH. Application of spinal pain cal stimulation induced lumbar medial from the dorsal root ganglion of the cer- mapping in the diagnosis of low back branch referral patterns. Pain Physician vical dura mater of rats. Spine 1998; pain—analysis of 104 cases. Acta An- 2002; 5:347-353. 23:1524-1529. aesthesiol Sin 1998; 36:71-74. 245. Bogduk N. The clinical anatomy of the 259. Johnson GM. The sensory and sympa- 230. Manchikanti L, Singh V, Pampati V, Dam- cervical dorsal rami. Spine 1982; 7:319- thetic nerve supply within the cervical ron K, Barnhill R, Beyer C, Cash K. Eval- 330. spine: review of recent observations. uation of the relative contributions of Man Ther 2004; 9:71-76. various structures in chronic low back 246. Cavanaugh JM, Ozaktay AC, Yamashi- pain. Pain Physician 2001; 4:308-316. ta T, Avramov A, Getchell TV, King AI. 260. Yoganandan N, Knowles SA, Maiman DJ,

82 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

Pintar FA. Anatomic study of the mor- 272. Ohtori S, Moriya H, Takahashi K. Calci- NaN/SNS2. Spine 2002; 27:135-140. phology of human cervical facet joint. tonin gene-related peptide immunore- 284. Igarashi A, Kikuchi S, Konno S, Olmark- Spine 2003; 28:2317-2323. active sensory DRG neurons innervat- er K. Inflammatory cytokines released 261. Konnai Y, Honda T, Sekiguchi Y, Kikuchi ing the cervical facet joints in rats. J Or- from the facet joint tissue in degener- S, Sugiura Y. Sensory innervation of the thop Sci 2002; 7:258-261. ative lumbar spinal disorders. Spine lumbar dura mater passing through the 273. Ohtori S, Takahashi K, Chiba T, Yamaga- 2004; 29:2091-2095. sympathetic trunk in rats. Spine 2000; ta M, Sameda H, Moriya H. Brain-de- 285. Ozaktay AC, Cavanaugh JM, Blagoev DC, 25:776-782. rived neurotrophic factor and vanilloid Getchell TV, King AI. Effects of a carra- 262. Masini M, Paiva WS, Araujo AS Jr. An- receptor subtype 1 immunoreactive geenan-induced inflammation in rabbit atomical description of the facet joint sensory DRG neurons innervating the lumbar facet joint capsule and adjacent innervation and its implication in the lumbar facet joints in rats. Auton Neu- tissues. Neurosci Res 1994; 20:355- treatment of recurrent back pain. J Neu- rosci 2001; 94:132-135. 364. rosurg Sci 2005; 49:143-146. 274. McLain RF, Pickar JG. Mechanoreceptor 286. Ohtori S, Takahashi K, Moriya H. Inflam- 263. Ahmed M, Bjurholm A, Kreicbergs A, endings in human thoracic and lumbar matory pain mediated by a phenotyp- Schultzberg M. Sensory and autonom- facet joints. Spine 1998; 23:168-173. ic switch in brain-derived neurotrophic ic innervation of the facet joint in the 275. McLain RF. Mechanoreceptors ending factor-immunoreactive dorsal root gan- rat lumbar spine. Spine 1993; 18:2121- in human cervical facets joints. Spine glion neurons innervating the lumbar 2126. 1994; 5:495-501. facet joints in rats. Neurosci Lett 2002; 264. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. 276. Boszczyk BM, Boszczyk AA, Putz R, 323:129-132. Pain generation in lumbar and cervical Buttner A, Benjamin M, Milz S. An im- 287. Mayer TG, Gatchel RJ, Keeley J, McGeary facet joints. J Bone Joint Surg Am 2006; munohistochemical study of the dorsal D, Dersh J, Anagnostis C. A randomized 88 Suppl 2:63-67. capsule of the lumbar and thoracic fac- clinical trial of treatment for lumbar seg- 265. Inami S, Shiga T, Tsujino A, Yabuki T, et joints. Spine 2001; 26:E338-E343. mental rigidity. Spine 2004; 29:2199- Okado N, Ochiai N. Immunohistochemi- 277. Yamashita T, Cavanaugh JM, Ozaktay 2205. cal demonstration of nerve fibers in the AC, Avramov AI, Getchell TV, King AI. Ef- 288. Ianuzzi A, Khalsa PS. Comparison of hu- synovial fold of the human cervical fac- fect of substance P on mechanosensi- man lumbar facet joint capsule strains et joint. J Orthop Res 2001; 19:593-596. tive units of tissues around and in the during simulated high-velocity, low- 266. Kallakuri S, Singh A, Chen C, Cavanaugh lumbar facet joint. J Orthop Res 1993; amplitude spinal manipulation versus JM. Demonstration of substance P, cal- 11:205-214. physiological motions. Spine J 2005; citonin gene-related peptide, and pro- 278. Beaman DN, Graziano GP, Glover RA, 5:277-290. tein gene product 9.5 containing nerve Wojtys EM, Chang V. Substance P in- 289. Yang KH, King AI. Mechanism of facet fibers in human cervical facet joint cap- nervation of lumbar spine facet joints. load transmission as a hypothesis for sules. Spine 2004; 29:1182-1186. Spine 1993; 18:1044-1049. low-back pain. Spine 1984; 9:557 -565. 267. Chen C, Lu Y, Kallakuri S, Patwardhan 279. Ohtori S, Takahashi K, Chiba T, Yamaga- 290. Borchgrevink GE, Smevik O, Nordby A, A, Cavanaugh JM. Distribution of A-del- ta M, Sameda H, Moriya H. Phenotyp- Rinck PA, Stiles TC, Lereim I. MR imag- ta and C-fiber receptors in the cervical ic inflammation switch in rats shown ing and radiography of patients with facet joint capsule and their response by calcitonin gene-related peptide im- cervical hypertension-flexion injuries to stretch. J Bone Joint Surg Am 2006; munoreactive dorsal root ganglion neu- after car accidents. Acta Radiol 1995; 88:1807-1816. rons innervating the lumbar facet joints. 36:425-428. 268. Ohtori S, Takahashi K, Moriya H. Cal- Spine 2001; 26:1009-1013. 291. Ronnen HR, de Korte PJ, Brink PR, van citonin gene-related peptide immuno- 280. Chen C, Lu Y, Cavanaugh JM, Kallakuri S, der Bijl HJ, Tonino AJ, Franke CL. Acute reactive DRG neurons innervating the Patwardhan A. Recording of neural ac- whiplash injury: is there a role for MR cervical facet joints show phenotypic tivity from goat cervical facet joint cap- imaging?—a prospective study of 100 switch in cervical facet injury in rats. Eur sule using custom-designed miniature patients. Radiology 1996; 201:93-96. Spine J 2003; 12:211-215. electrodes. Spine 2005; 30:1367-1372. 292. Pennie B, Agambar L. Patterns of inju- 269. Miyagi M, Ohtori S, Ishikawa T, Aoki 281. Lu Y, Chen C, Kallakuri S, Patwardhan ry and recovery in whiplash. Injury 1991; Y, Ozawa T, Doya H, Saito T, Moriya H, A, Cavanaugh JM. Development of an in 22:57-59. Takahashi K. Up-regulation of TNFal- vivo method to investigate biomechan- 293. Siegmund GP, Myers BS, Davis MB, pha in DRG satellite cells following lum- ical and neurophysiological properties Bohnet HF, Winkelstein BA. Mechanical bar facet joint injury in rats. Eur Spine J of spine facet joint capsules. Eur Spine J evidence of cervical facet capsule inju- 2006; 15:953-958. 2005; 14:565-572. ry during whiplash: a cadaveric study 270. Ohtori S, Takahashi K, Chiba T, Yamaga- 282. Lu Y, Chen C, Kallakuri S, Patwardhan A, using combined shear, compression, ta M, Sameda H, Moriya H. Substance P Cavanaugh JM. Neurophysiological and and extension loading. Spine 2001; and calcitonin gene-related peptide im- biomechanical characterization of goat 26:2095-2101. munoreactive sensory DRG neurons in- cervical facet joint capsules. J Orthop 294. Winkelstein BA, Nightingale RW, Rich- nervating the lumbar facet joints in rats. Res 2005; 23:779-787. ardson WJ, Myers BS. Cervical facet joint Auton Neurosci 2000; 86:13-17. 283. Bucknill AT, Coward K, Plumpton C, mechanics: its application to whiplash 271. Suseki K, Takahashi Y, Takahashi K, Chi- Tate S, Bountra C, Birch R, Sandison injury. Stapp Car Crash J. 1999; 43:243- ba T, Tanaka K, Moriya H. CGRP-immu- A, Hughes SP, Anand P. Nerve fibers in 252. noreactive nerve fibers projecting to lumbar spine structures and injured spi- 295. Onan OA, Heggeness MH, Hipp JA. A lumbar facet joints through the paraver- nal roots express the sensory neuron- motion analysis of the cervical facet tebral sympathetic trunk in rats. Neuro- specific sodium channels SNS/PN3 and joint. Spine 1998; 23:430-439. sci Lett 1996; 221:41-44. www.painphysicianjournal.com 83 Pain Physician: January 2007:10:7-111

296. Stemper BD, Yoganandan N, Pintar FA. 308. Manchikanti L, Manchukonda R, Pam- Back Pain, Vol. 2. Eden Press, West- Gender- and region-dependent local pati V, Damron KS, McManus CD. Prev- mount, 1980, pp 23-32. facet joint kinematics in rear impact: alence of facet joint pain in chronic low 322. Lamb DW. The neurology of spinal pain. implications in whiplash injury. Spine back pain in post surgical patients by Phys Ther 1979; 59:971-973. 2004; 29:1764-1771. controlled comparative local anesthetic 323. Wyke B. The neurology of low back pain. 297. Stemper BD, Yoganandan N, Gennarel- blocks. Arch Phys Med Rehabil 2007; in In: Jayson MIV, ed. The Lumbar Spine li TA, Pintar FA. Localized cervical fac- press. and Back Pain, 2nd edn. Tunbridge et joint kinematics under physiologi- 309. Barnsley L, Lord SM, Wallis BJ, Bog- Wells, Pitman, 1980, pp 265-339. cal and whiplash loading. J Neurosurg duk N. The prevalence of chronic cervi- 324. Bogduk N. The anatomy of the lumbar Spine 2005; 3:471-476. cal zygapophyseal joint pain after whip- intervertebral disc syndrome. Med J 298. Mayer T, Robinson R, Pegues P, Kohles lash. Spine 1995; 20:20-26. Aust 1976; 1:878-881. S, Gatchel RJ. Lumbar segmental rigid- 310. Lord SM, Barnsley L, Wallis BJ, Bogduk 325. Bogduk N, Tynan W, Wilson AS. The ity: can its identification with facet- in N. Chronic cervical zygapophysial joint nerve supply to the human lumbar injections and stretching exercises be pain with whiplash: A placebo-con- tervertebral discs. J Anat 1981; 132:39- useful? Arch Phys Med Rehabil 2000; trolled prevalence study. Spine 1996; 56. 81:1143-1150. 21:1737-1745. 326. McCarthy PW, Carruthers B, Martin D, 299. Merskey H, Bogduk N. Classification 311. Manchikanti L, Singh V, Rivera J, Pam- Petts P. Immunohistochemical dem- of Chronic Pain. Descriptions of Chron- pati V. Prevalence of cervical facet joint onstration of sensory nerve fibers and ic Pain Syndromes and Definition of pain in chronic neck pain. Pain Physi- endings in lumbar intervertebral discs Pain Terms, 2nd ed. IASP Press, Seattle, cian 2002; 5:243-249. of the rat. Spine 1991; 16:653-655. 1994. - 312. Speldewinde GC, Bashford GM, David 327. Cavanaugh JM, Kallakuri S, Ozaktay AC. 300. Schwarzer AC, Aprill CN, Derby R, For- son IR. Diagnostic cervical zygapoph- Innervation of the rabbit lumbar inter- tin J, Kine G, Bogduk N. Clinical features yseal joint blocks for chronic cervical vertebral disc and posterior longitu- of patients with pain stemming from pain. Med J Aust 2001; 174:174-176. dinal ligament. Spine 1995; 20:2080- the lumbar zygapophysial joints. Is the 313. Manchikanti L, Singh, V, Pampati V, Bey- 2085. lumbar facet syndrome a clinical entity? er C, Damron K. Evaluation of the prev- Spine 1994; 19:1132-1137. 328. Jackson HC, Winkelmann RK, Bickel WH. alence of facet joint pain in chronic tho- Nerve endings in the human lumbar 301. Schwarzer AC, Aprill CN, Derby R, Fortin racic pain. Pain Physician 2002; 5:354- spinal column and related structures. J J, Kine G, Bogduk N. The relative contri- 359. Bone Joint Surg 1966; 48A:1272-1281. butions of the disc and zygapophyse- 314. Brisby H. Pathology and possible mech- 329. Ehrenhaft JC. Development of the ver- al joint in chronic low back pain. Spine anisms of nervous system response to 1994; 19:801-806. tebral column as related to certain con- disc degeneration. J Bone Joint Surg Am genital and pathological changes. Surg 302. Schwarzer AC, Wang SC, Bogduk N, Mc- 2006; 88 Suppl 2:68-71. Gynecol Obst 1943; 76:282-292. Naught PJ, Laurent R. Prevalence and 315. Zhang Y, Kerns JM, Anderson DG, Lee clinical features of lumbar zygapophy- 330. Roof PG. Innervation of annulus fibro- YS, Chen EY, Tannoury C, An HS. Senso- sus and posterior longitudinal ligament. sial joint pain: A study in an Australian ry neurons and fibers from multiple spi- population with chronic low back pain. Arch Neurol Psychiatry 1940; 44:100- nal cord levels innervate the rabbit lum- 103. Am Rheum Dis 1995; 54:100-106. bar disc. Am J Phys Med Rehabil 2006; 303. Manchikanti L, Pampati V, Fellows B, 85:865-871. 331. Malinsky J. The ontogenetic develop- Bakhit C. Prevalence of lumbar facet ment of nerve terminations in the inter- 316. Miyamoto K, Masuda K, Kim JG, Inoue vertebral discs of man. Acta Anat 1959; joint pain in chronic low back pain. Pain N, Akeda K, Andersson GB, An HS. Intra- 38:96-113. Physician 1999; 2:59-64. discal injections of osteogenic protein- 304. Manchikanti L, Pampati V, Fellows B, 1 restore the viscoelastic properties of 332. Rabischong P, Louis R, Vignaud J, Mas- Bakhit CE. The diagnostic validity and degenerated intervertebral discs. Spine sare C. The intervertebral disc. Anat Clin therapeutic value of medial branch J 2006; 6:692-703. 1978; 1:55-64. blocks with or without adjuvants 317. Bogduk N. Nerves of the lumbar spine. 333. Yoshizawa H, O’Brien JP, Thomas-Smith agents. Curr Rev Pain 2000; 4:337-344. Clinical Anatomy of Lumbar Spine and W, Trumper M. The neuropathology of 305. Manchikanti L, Pampati V, Fellows B, Sacrum. 4th edition. Churchill Living- intervertebral discs removed for low Baha AG. The inability of the clinical stone, New York, 2005, pp 123-139. back pain. J Pathol 1980; 132:95-104. picture to characterize pain from facet 318. Wiberg G. Back pain in relation to the 334. Peng B, Wu W, Hou S, Li P, Zhang C, Yang joints. Pain Physician 2000; 3:158-166. nerve supply of the intervertebral disc. Y. The pathogenesis of discogenic low 306. Manchikanti L, Hirsch JA, Pampati V. Acta Orthop Scand 1947; 19:211-221. back pain. J Bone Joint Surg Br 2005; 87:62-67. Chronic low back pain of facet (zyg- 319. Ikari C. A study of the mechanism of apophysial) joint origin: is there a dif- low-back pain. The neurohistological 335. Freemont AJ, Peacock TE, Goupille P, ference based on involvement of single examination of the disease. J Bone Joint Hoyland JA, O’Brien J, Jayson MI. Nerve or multiple spinal regions? Pain Physi- Surg 1954; 36A:195. ingrowth into diseased intervertebral cian 2003; 6:399-405. disc in chronic back pain. Lancet 1997; 320. Jung A, Brunschwig A. Recherches his- 350:178-181. 307. Manchikanti L, Singh V, Pampati S, tologiques des articulations des corps Damron K, Beyer C, Barnhill R. Is there vertebraux. Presse Med 193; 40:316- 336. Coppes MH, Marani E, Thomeer RT, Ou- correlation of facet joint pain in lum- 317. dega M, Groen GJ. Innervation of annu- bar and cervical spine? Pain Physician lus fibrosus in low back pain. Lancet 321. Anderson J. Pathogenesis of back pain. 2002; 5:365-371. 1990; 336:189-190. In: Grahame R, Anderson JAD, eds. Low

84 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

337. Coppes MH, Marani E, Thomeer RT, nervation of the dorsal portion of the of low back pain. Pain Physician 2004; Groen GJ. Innervation of “painful” lum- lumbar intervertebral discs in rats. 7:63-66. bar discs. Spine 1997; 22:2342-2350. Spine 2001; 26:946-950. 364. Mixter WJ, Barr JS. Rupture of the inter- 338. Bogduk N, Windsor M, Inglis A. The in- 352. Fernstrom U. A discographical study vertebral disc with involvement of the nervation of the cervical intervertebral of ruptured lumbar discs. Acta Chirurg spinal canal. N Eng J Med 1934; 211:210- discs. Spine 1988; 13:2-8. Scand 1960; 258:1-60. 215. 339. Mendel T, Wink CS, Zimny ML. Neural el- 353. Hirsch C. An attempt to diagnose level 365. Rosen S, Falco F. Radiofrequency stimu- ements in human cervical intervertebral of disc lesion clinically by disc puncture. lation of intervertebral discs. Pain Phy- discs. Spine 1992; 17:132-135. Acta Orthop Scand. 1948; 18:132-140. sician 2003; 6:435-438. 340. Nakamura S, Takahashi K, Takahashi Y, 354. Lindblom K. Diagnostic puncture of in- 366. Slipman CW, Plastaras C, Patel R, Isaac Morinaga T, Shimada Y, Moriya H. Ori- tervertebral disks in sciatica. Acta Or- Z, Chow D, Garvan C, Pauza K, Furman gin of nerves supplying the posterior thop Scand 1948; 17:231–239. M. Provocative cervical discography portion of lumbar intervertebral discs in 355. Palmgren T, Gronblad M, Virri J, Seit- symptom mapping. Spine J 2005; 5:381- rats. Spine 1996; 21:917-924. salo S, Ruuskanen M, Karaharju E. Im- 388. 341. Morinaga T, Takahashi K, Yamagata M, munohistochemical demonstration of 367. Schwarzer AC, Aprill CN, Derby R, Fortin Chiba T, Tanaka K, Takahashi Y, Naka- sensory and autonomic nerve terminals J, Kine G, Bogduk N. The prevalence and mura S, Suseki K, Moriya H. Sensory in herniated lumbar disc tissue. Spine clinical features of internal disc disrup- innervation to the anterior portion of 1996; 21:1301-1306. tion in patients with chronic low back lumbar intervertebral disc. Spine 1996; 356. Ohtori S, Inoue G, Koshi T, Ito T, Doya pain. Spine 1995; 20:1878-1883. 21:1848-1851. H, Moriya H, Takahashi K. Substance 368. Ohnmeiss DD, Vanharanta H, Ekholm J. 342. Ohtori S, Takahashi Y, Takahashi K, P-saporin down-regulates substance P Relationship of pain drawings to inva- Yamagata M, Chiba T, Tanaka K, Hiraya- receptor immunoreactive sensory dor- sive tests assessing intervertebral disc ma J, Moriya H. Sensory innervation sal root ganglion neurons innervating pathology. Eur Spine J 1999; 8:126-131. of the dorsal portion of the lumbar in- the lumbar intervertebral discs in rats. 369. Schellhas KP, Smith MD, Gundry CR, tervertebral disc in rats. Spine 1999; Spine 2006; 31:2987-2991. Pollei SR. Cervical discogenic pain: pro- 24:2295-2299. 357. Larsson K, Rydevik B, Olmarker K. Disc spective correlation of magnetic reso- 343. Groen G, Baljet B, Drukker J. Nerves and related cytokines inhibit axonal out- nance imaging and discography in as- nerve plexuses of the human vertebral growth from dorsal root ganglion cells ymptomatic subjects and pain suffer- column. Am J Anat 1990; 188:282-296. in vitro. Spine 2005; 30:621-624. ers. Spine 1996; 21:300-311. 344. Fagan A, Moore R, Vernon Roberts B, 358. Kang JD, Georgescu HI, McIntyre-Larkin 370. Mixter WJ, Ayers JB. Herniation or rup- Blumbergs P, Fraser R. The innervation L, Stefanovic-Racic M, Donaldson WF ture of the intervertebral disc into of the intervertebral disc: A quantitative 3rd, Evans CH. Herniated lumbar inter- the spinal canal. N Engl J Med 1935; analysis. Spine 2003; 28:2570-2576. vertebral discs spontaneously produce 213:385-395. 345. Palmgren T, Gronblad M, Virri J, Kaapa E, matrix metalloproteinases, nitric oxide, 371. Aoki Y, Takahashi Y, Ohtori S, Moriya H, Karaharju E. An immunohistochemical interleukin-6, and prostaglandin E2. Takahashi K. Distribution and immuno- study of nerve structures in the anulus Spine 1996; 21:271-277. cytochemical characterization of dorsal fibrosus of human normal lumbar inter- 359. Ahmed M, Bjurholm A, Kreicbergs A, root ganglion neurons innervating the vertebral discs. Spine 1999; 24:2075- Schultzberg M. Neuropeptide Y, tyro- lumbar intervertebral disc in rats: a re- 2079. sine hydroxylase and vasoactive intesti- view. Life Sci 2004; 74:2627-2642. 346. Ashton IK, Roberts S, Jaffray DC, Polak nal polypeptide-immunoreactive nerve 372. Freemont AJ, Watkins A, Le Maitre C, JM, Eisenstein SM. Neuropeptides in fibers in the vertebral bodies, discs, Baird P, Jeziorska M, Knight MT, Ross the human intervertebral disc. J Orthop dura mater, and spinal ligaments of the ER, O’Brien JP, Hoyland JA. Nerve growth Res 1994; 12:186-192. rat lumbar spine. Spine 1993; 18:268- factor expression and innervation of 347. Shinohara H. Lumbar disc lesion, with 273. the painful intervertebral disc. J Pathol special reference to the histological sig- 360. Ashton IK, Eisenstein SM. The effect of 2002; 197:286-292. nificane of nerve endings of the lumbar substance P on proliferation and pro- 373. Burke JG, Watson RW, McCormack D, discs. J Jap Orthop Assoc 1970; 44:553- teoglycan deposition of cells derived Dowling FE, Walsh MG, Fitzpatrick JM. 570. from rabbit intervertebral disc. Spine Intervertebral discs which cause low 348. Roberts S, Eisenstein SM, Menage J, 1996; 21:421-426. back pain secrete high levels of pro- Evans EH, Ashton IK. Mechanorecep- 361. McCarthy PW. Sparse substance P- inflammatory mediators. J Bone Joint tors in intervertebral discs. Spine 1995; like immunoreactivity in intervertebral Surg Br 2002; 84:196-201. 24:2645-2651. discs. Nerve fibers and endings in the 374. Burke JG, G Watson RW, Conhyea D, 349. Hurri H, Karppinen J. Discogenic pain. rat. Acta Orthop Scand 1993; 64:664- McCormack D, Dowling FE, Walsh MG, Pain 2004; 112:225-228. 668. Fitzpatrick JM. Human nucleus pulpo- 350. Aoki Y, Ohtori S, Takahashi K, Ino H, 362. O’Neill CW, Kurgansky ME, Derby R, sus can respond to a pro-inflammatory Takahashi Y, Chiba T, Moriya H. Innerva- Ryan DP. Disc stimulation and patterns stimulus. Spine 2003; 28:2685-2693. tion of the lumbar intervertebral disc by of referred pain. Spine 2002; 27:2776- 375. Crock HV. A reappraisal of intervertebral nerve growth factor-dependent neurons 2781. disc lesions. Med J Aust 1970; 1:983- related to inflammatory pain. Spine 363. Derby R, Eek B, Lee SH, Seo S, Kim BJ. 989. 2004; 29:1077-1081. Comparison of intradiscal restorative 376. Ohnmeiss DD, Vanharanta H, Ekholm J. 351. Ohtori S, Takahashi K, Chiba T, Yamaga- injections and intradiscal electrother- Degree of disc disruption and lower ex- ta M, Sameda H, Moriya H. Sensory in- mal treatment (IDET) in the treatment tremity pain. Spine 1997; 22:1600-1605. www.painphysicianjournal.com 85 Pain Physician: January 2007:10:7-111

377. Wheeler AH, Murrey DB. Chronic lumbar 1990; 35:416-419. ison of chronic pain behavior following spine and radicular pain: Pathophysiol- 389. Rydevik BL. The effects of compression local application of tumor necrosis fac- ogy and treatment. Curr Pain Headache on the physiology of nerve roots. J Ma- tor alpha to the normal and mechani- Rep 2002; 6:97-105. nipul Physiol Ther 1992; 1:62-66. cally compressed lumbar ganglia in the rat. Pain 2002; 95:239-246. 378. Ashton IK, Walsh DA, Polak JM, Eisen- 390. Olmarker K, Holm S, Rosenqvist AL, stein SM. Substance P in intervertebral Rydevik B. Experimental nerve root 400. Miyamoto H, Saura R, Doita M, Kuro- discs. Binding sites on vascular endo- compression. Presentation of a model saka M, Mizuno K. The role of cycloox- thelium of the human annulus fibrosus. for acute, graded compression of the ygenase-2 in lumbar disc herniation. Acta Orthop Scand 1994; 65:635-639. porcine cauda equina, with analysis Spine 2002; 27:2477-2483. 379. Cervero F. Visceral nociception: periph- of neural and vascular anatomy. Spine 401. Ishii Y, Thomas AO, Guo XE, Hung CT, eral and central aspects of visceral no- 1992; 16:61-69. Chen FH. Localization and distribution ciceptive systems. Philos Trans R Soc 391. Kawakami M, Tamaki T, Hashizume of cartilage oligomeric matrix protein in Lond B Biol Sci 1985; 308:325-337. H, Weinstein JN, Meller ST. The role of the rat intervertebral disc. Spine 2006; 380. McCarron RF, Wimpee MW, Hudkins PG, phospholipase A2 and nitric oxide in 31:1539-1546. Laros GS. The inflammatory effects of pain-related behavior produced by an 402. Haefeli M, Kalberer F, Saegesser D, nucleus pulposus: A possible element allograft of intervertebral disc materi- Nerlich AG, Boos N, Paesold G. The in the pathogenesis of low back pain. al to the sciatic nerve of the rat. Spine course of macroscopic degeneration in Spine 1987; 12:760-764. 1997; 22:1074-1079. the human lumbar intervertebral disc. 381. Olmarker K, Blomquist J, Stromberg J, 392. Saal JS, Franson RC, Dobrow R, Saal JA, Spine 2006; 31:1522-1531. Nannmark U, Thomsen P, Rydevik B. In- White AH, Goldthwaite N. High levels of 403. Wang YJ, Shi Q, Lu WW, Cheung KC, Da- flammatogenic properties of nucleus inflammatory phospholipase A2 activity rowish M, Li TF, Dong YF, Zhou CJ, Zhou pulposus. Spine 1995; 20:665-669. in lumbar disc herniations. Spine 1990; Q, Hu ZJ, Liu M, Bian Q, Li CG, Luk KD, 382. Marshall LL, Trethewie ER, Curtain CC. 15:674-678. Leong JC. Cervical intervertebral disc Chemical radiculitis: A clinical, physio- 393. Yabuki S, Kikuchi S, Olmarker K, My- degeneration induced by unbalanced logical, and immunological study. Clin ers RR. Acute effects of nucleus pulpo- dynamic and static forces: a novel in Orthop Rel Res 1977; 190:61-67. sus on blood flow and endoneurial flu- vivo rat model. Spine 2006; 31:1532- 1538. 383. Olmarker K, Nordborg C, Larsson K, id pressure in rat dorsal root ganglia. Rydevik B. Ultrastructural changes in Spine 1998; 23:2517-2523. 404. Séguin CA, Pilliar RM, Roughley PJ, Kan- spinal nerve roots induced by autolo- 394. Yabuki S, Igarashi T, Kikuchi S. Applica- del RA. Tumor necrosis factor-alpha gous nucleus pulposus. Spine 1996; tion of nucleus pulposus to the nerve modulates matrix production and ca- 27:411-414. root simultaneously reduces blood flow tabolism in nucleus pulposus tissue. Spine 2005; 30:1940-1948. 384. Olmarker K, Rydevik B, Nordborg C. Au- in dorsal root ganglion and correspond- tologous nucleus pulposus induces ing hindpaw in the rat. Spine 2000; 405. Ohtori S, Inoue G, Ito T, Koshi T, Ozawa neurophysiologic and histologic chang- 25:1471-1476. T, Doya H, Saito T, Moriya H, Takahashi es in porcine cauda equina nerve roots. 395. Kang JD, Stefanovic-Racic M, McIntyre K. Tumor necrosis factor-immunoreac- Spine 1993; 18:1425-1432. LA, Georgescu HI, Evans CH. Toward a tive cells and PGP 9.5-immunoreactive nerve fibers in vertebral endplates of 385. Uchida K, Baba H, Maezawa Y, Kubo- biochemical understanding of human patients with discogenic low back pain ta C. Progressive changes in neurofila- intervertebral disc degeneration and and modictype 1 or type 2 changes on ment proteins and growth-associated herniation. Contributions of nitric ox- MRI. Spine 2006; 31:1026-1031. protein-43 immunoreactivities at the ide, interleukins, prostaglandin E2, and site of cervical spinal cord compres- matrix metalloproteinases. Spine 1997; 406. Milette PC, Fontaine S, Lepanto L, Bret- sion in spinal hyperostotic mice. Spine 22:1065-1073. on G. Radiating pain to the lower ex- 2002; 27:480-486. 396. Takahashi H, Suguro T, Okazima Y, Mo- tremities caused by lumbar disc rupture without spinal nerve root involvement. 386. Olmarker K, Rydevik B, Holm S. Edema tegi M, Okada Y, Kakiuchi T. Inflammato- Am J Neuroradiol 1995; 16:1605-1615. formation in spinal nerve roots induced ry cytokines in the herniated disc of the by experimental, graded compression: lumbar spine. Spine 1996; 21:218-224. 407. Crock HV. Isolated lumbar disc resorp- An experimental study on the pig cau- 397. Olmarker K, Rydevik B. Selective inhibition as a cause of nerve root canal ste- da equina with special reference to dif- tion of tumor necrosis factor-alpha pre- nosis. Clin Orthop 1976; 115:109-115. ferences in effects between rapid and vents nucleus pulposus-induced throm- 408. Holm S, Holm AK, Ekstrom L, Karladani slow onset of compression. Spine 1989; bus formation, intraneural edema, and A, Hansson T. Experimental disc degen- 14:569-573. reduction of nerve conduction velocity: eration due to endplate injury. J Spinal 387. Olmarker K, Rydevik B, Holm S, Bagge possible implications for future phar- Disord Tech 2004; 17:64-71. U. Effects of experimental graded com- macologic treatment strategies of sciat- 409. Videman T, Nurminen M. The occur- pression on blood flow in spinal nerve ica. Spine 2001; 26:863-869. rence of anular tears and their relation roots: A vital microscopic study on the 398. Igarashi T, Kikuchi S, Shubayev V, My- to lifetime back pain history: a cadaver- porcine cauda equina. J Orthop Res ers RR. 2000 Volvo Award winner in ba- ic study using barium sulfate discogra- 1989; 7:817-823. sic science studies: Exogenous tumor phy. Spine 2004; 29:2668-2676. 388. Olmarker K, Holm S, Rydevik B. Impor- necrosis factor-alpha mimics nucleus 410. Rajasekaran S, Babu JN, Arun R, Arm- tance of compression onset rate for the pulposus-induced neuropathology. Mo- strong BR, Shetty AP, Murugan S. ISSLS degree of impairment of impulse propa- lecular, histologic, and behavioral com- prize winner: A study of diffusion in hu- gation in experimental compression in- parisons in rats. Spine 2000; 25:2975- man lumbar discs: a serial magnetic jury of the porcine cauda equina. Spine 2980. resonance imaging study documenting 399. Homma Y, Brull SJ, Zhang JM. A compar- the influence of the endplate on diffu-

86 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

sion in normal and degenerate discs. experimentally degenerated nucleus ma T, Fukuoka T, Tokunaga A, Yoshika- Spine 2004; 29:2654-2667. pulposus on nerve root conduction ve- wa H, Noguchi K. Contribution of degen- 411. Boos N, Weissbach S, Rohrbach H, Wei- locity: relevance of previous experimen- eration of motor and sensory fibers to ler C, Spratt KF, Nerlich AG. Classifica- tal investigations using normal nucleus pain behavior and the changes in neu- tion of age-related changes in lumbar pulposus. Spine 2001; 26:1651-1655. rotrophic factors in rat dorsal root gan- intervertebral discs: 2002 Volvo Award 423. Takebayashi T, Cavanaugh JM, Cuneyt glion. Exp Neurol 2004; 188:149-160. in basic science. Spine 2002; 27:2631- Ozaktay A, Kallakuri S, Chen C. Effect of 433. Ohtori S, Takahashi K, Moriya H, Myers 2644. nucleus pulposus on the neural activi- RR. TNF-alpha and TNF-alpha receptor 412. Roberts S, Urban JP, Evans H, Eisenstein ty of dorsal root ganglion. Spine 2001; type 1 upregulation in glia and neurons SM. Transport properties of the human 26:940-945. after peripheral nerve injury: studies cartilage endplate in relation to its com- 424. Aoki Y, Ohtori S, Ino H, Douya H, Ozawa in murine DRG and spinal cord. Spine position and calcification. Spine 1996; T, Saito T, Moriya H, Takahashi K. Disc 2004; 29:1082-1088. 21:415-420. inflammation potentially promotes axo- 434. Kobayashi S, Kokubo Y, Uchida K, Yaya- 413. Kauppila LI, McAlindon T, Evans S, Wil- nal regeneration of dorsal root ganglion ma T, Takeno K, Negoro K, Nakajima H, son PW, Kiel D, Felson DT. Disc degen- neurons innervating lumbar interverte- Baba H, Yoshizawa H. Effect of lumbar eration/back pain and calcification of bral disc in rats. Spine 2004; 29:2621- nerve root compression on primary sen- the abdominal aorta. A 25-year follow- 2626. sory neurons and their central branch- up study in Framingham. Spine 1997; 425. Snider WD, McMahon SB. Tackling pain es: changes in the nociceptive neuro- 22:1642-1647. at the source: new ideas about nocicep- peptides substance P and somatosta- 414. Peng BG, Wu WW, Hou SX, Zhang CL, tors. Neuron 1998; 20:629-632. tin. Spine 2005; 30:276-282. Yang Y, Wang XH, Fu XB. The pathogen- 426. Ohtori S, Inoue G, Koshi T, Ito T, Doya 435. Bogduk N. The sacroiliac joint. Clinical esis of discogenic low back pain. Zhon- H, Saito T, Moriya H, Takahashi K. Up- Anatomy of Lumbar Spine and Sacrum. ghua Wai Ke Za Zhi 2004; 42:720-724. regulation of acid-sensing ion channel 3 4th edition. Churchill Livingstone, New 415. Bogduk N, Aprill C. On the nature of in dorsal root ganglion neurons follow- York, 2005; pp 173-181. neck pain, discography, and cervical ing application of nucleus pulposus on 436. Forst SL, Wheeler MT, Fortin JD, Vilensky zygapophyseal joint blocks. Pain 1993; nerve root in rats. Spine 2006; 31:2048- JA. The sacroiliac joint: anatomy, phys- 54:213-217. 2052. iology and clinical significance. Pain Physician 2006; 9:61-67. 416. Aota Y, Onari K, An HS, Yoshikawa K. 427. Inoue G, Ohtori S, Aoki Y, Ozawa T, Doya Dorsal root ganglia morphologic fea- H, Saito T, Ito T, Akazawa T, Moriya H, 437. Cohen SP. Sacroiliac joint pain: A com- tures in patients with herniation of Takahashi K. Exposure of the nucleus prehensive review of anatomy, diagno- the nucleus pulposus. Assessment us- pulposus to the outside of the anulus fi- sis and treatment. Anesth Analg 2005; ing magnetic resonance myelography brosus induces nerve injury and regen- 101:1440-1453. and clinical correlation. Spine 2001; eration of the afferent fibers innervating 438. Zelle BA, Gruen GS, Brown S, George 26:2125-2132. the lumbar intervertebral discs in rats. S. Sacroiliac joint dysfunction: Evalua- 417. Rydevik BL, Myers RR, Powell HC. Pres- Spine 2006; 31:1433-1438. tion and management. Clin J Pain 2005; sure increase in the dorsal root gangli- 428. Murata Y, Rydevik B, Takahashi K, Lars- 21:446-455. on following mechanical compression: son K, Olmarker K. Incision of the inter- 439. Hansen HC, Helm S. Sacroiliac joint pain Closed compartment syndrome in nerve vertebral disc induces disintegration and dysfunction. Pain Physician 2003; roots. Spine 1989; 14:574-576. and increases permeability of the dor- 6:179-189. 418. Weinstein J. Mechanisms of spinal pain: sal root ganglion capsule. Spine 2005; 440. Foley BS, Buschbacher RM. Sacroiliac The dorsal root ganglion and its role as 30:1712-1716. joint pain: anatomy, biomechanics, di- a pain mediator of low-back pain. Spine 429. Aoki Y, Ohtori S, Takahashi K, Ino H, agnosis, and treatment. Am J Phys Med 1986; 11:999-1001. Douya H, Ozawa T, Saito T, Moriya H. Rehabil 2006; 85:997-1006. 419. Byrod G, Otani K, Brisby H, Rydevik B, Expression and co-expression of VR1, 441. Bernard TN, Cassidy JD. The sacroiliac Olmarker K. Methylprednisolone reduc- CGRP, and IB4-binding glycoprotein in syndrome. Pathophysiology, diagnosis es the early vascular permeability in- dorsal root ganglion neurons in rats: and management. In: Frymoyer JW, ed. crease in spinal nerve roots induced by differences between the disc afferents The adult spine: principles and practice. epidural nucleus pulposus application. and the cutaneous afferents. Spine Raven, New York, 1991; pp 2107–2130. 2005; 30:1496-1500. J Orthop Res 2000; 18:983-987. 442. Grob KR, Neuhuber WL, Kissling RO. In- 420. Harrington JF, Messier AA, Bereiter D, 430. Onda A, Murata Y, Rydevik B, Larsson nervation of the sacroiliac joint of the Barnes B, Epstein MH. Herniated lum- K, Kikuchi S, Olmarker K. Nerve growth human. Z Rheumatol 1995; 54:117-122. bar disc material as a source of free glu- factor content in dorsal root ganglion as related to changes in pain behavior in a 443. Murata Y, Takahashi K, Yamagata M, tamate available to affect pain signals Takahashi Y, Shimada Y, Moriya H. Or- through the dorsal root ganglion. Spine rat model of experimental lumbar disc herniation. Spine 2005; 30:188-193. igin and pathway of sensory nerve fi- 2000; 25:929-936. bers to the ventral and dorsal sides of 421. Cavanaugh JM, Ozaktay AC, Vaidyana- 431. Hammond DL, Ackerman L, Holdsworth the sacroiliac joint in rats. J Orthop Res than S. Mechano- and chemosensitivity R, Elzey B. Effects of spinal nerve liga- 2001; 19:379-383. of lumbar dorsal roots and dorsal root tion on immunohistochemically identified neurons in the L4 and L5 dorsal 444. Pitkin HC, Pheasant HC. Sacrarthrogen- ganglia: An in vitro study. Trans Orthop ic telalgia I: a study of referred pain. J Res Soc 1994; 19:109. root ganglia of the rat. J Comp Neurol 2004; 475:575-589. Bone Joint Surg 1936; 18:111–133. 422. Iwabuchi M, Rydevik B, Kikuchi S, Ol- 432. Obata K, Yamanaka H, Dai Y, Mizushi 445. Solonon K. The sacroiliac joint in light of marker K. Effects of anulus fibrosus and - www.painphysicianjournal.com 87 Pain Physician: January 2007:10:7-111

anatomical, roentgenological, and clin- raphy technique. Part II: Clinical evalua- sue24/07-25-06. ical studies. Act Orthop Scand Suppl tion. Spine 1994; 19:1483-1489. 473. Deyo RA, Nachemson A, Mirza SK. Spi- 1957; 27:1-27. 459. Slipman CW, Jackson HB, Lipetz JS, nal fusion surgery – The case for re- 446. Ikeda R. Innervation of the sacroili- Chan KT, Lenrow D, Vresilovic EJ. Sacro- straint. N Engl J Med 2004; 350:722- ac joint. Macroscopical and histologi- iliac joint pain referral zones. Arch Phys 726. cal studies. Nippon Ika Daigaku Zasshi Med Rehabil 2000; 81:334-337. 474. Deyo RA, Mirza SK. Trends and varia- 1991; 58:587-596. 460. Schwarzer AC, Aprill CN, Bogduk M. The tions in the use of spine surgery. Clin 447. Sakamoto N, Yamashita T, Takebayashi sacroiliac joint in chronic low back pain. Orthop Relat Res 2006; 443:139-146. T, Sekine M, Ishii S. Mechanoreceptors Spine 1995; 20:31-37. 475. McCrory DC, Turner DA, Patwardhan in the sacroiliac joint. Trans Orthop Res 461. Maigne JY, Aiviliklis A, Pfefer F. Results MB, Richardson WL.. Spinal fusion for Soc 1999; 24:988. of sacroiliac joint double block and val- degenerative disc disease affecting the 448. Sakamoto N, Yamashita T, Takebayashi ue of sacroiliac pain provocation test in lumbar spine [draft evidence report/ T, Sekine M, Ishii S. An electrophysio- 54 patients with low back pain. Spine technology review prepared for the logic study of mechanoreceptors in the 1996; 21:1889-1892. Medicare Coverage Advisory Commit- sacroiliac joint and adjacent tissues. 462. Irwin RW, Watson T, Minick RP, Ambrosi- tee meeting], 2006; as yet unpublished; Spine 2001; 26:E468-E471. us WT. Age, body mass index, and gen- www.cms.hhs.gov/determinationproc- 449. Yamashita T, Minaki Y, Oota I, Yoko- der differences in sacroiliac joint pa- ess/downloads/id41ta.pdf. gushi K, Ishii S. Mechanosensitive af- thology. Am J Phys Med Rehabil 2007; 476. Weinstein JN, Lurie JD, Olson PR, Bron- ferent units in the lumbar intervertebral 86:37-44. ner KK, Fisher ES. United States’ trends disc and adjacent muscle. Spine 1993; 463. Ebraheim NA, Elgafy H, Semaan HB. and regional variations in lumbar 18:2252-2256. Computed tomographic findings in pa- spine surgery: 1992-2003. Spine 2006; 450. Minaki Y, Yamashita T, Ishii S. An elec- tients with persistent sacroiliac pain 31:2707-2714. trophysiological study on the mecha- after posterior iliac graft harvesting. 477. Logroscino C, Sgrambiglia R. Pointillart noreceptors in the lumbar spine and Spine 2000; 25:2047-2051. V. Intermediate follow-up after treat- adjacent tissues. Neurol Orthop 1996; 464. Katz V, Schofferman J, Reynolds J. The ment of degenerative disc disease with 20:23-35. sacroiliac joint: a potential cause of Bryan Cervical Disc Prosthesis: single 451. Fortin JD, Kissling RO, O’Connor BL, pain after lumbar fusion to the sacrum. level and bilevel. Spine 2003; 28:2673- Vilensky JA. Sacroiliac joint innervation J Spinal Disord Tech 2003;16:96-99. 2678. and pain. Am J Orthop 1999; 28:687- 465. Maigne JY, Planchon CA. Sacroiliac joint 478. Edwards mL 2nd, Karpitskaya Y, Cha C, 690. pain after lumbar fusion. A study with Heller JG, Lauryssen C, Yoon ST, Riew 452. Bowen V, Cassidy JD. Macroscopic and anesthetic blocks. Eur Spine J 2005; KD. Accurate identification of adverse microscopic anatomy of the sacroili- 14:654-658. outcomes after cervical spine surgery. J Bone Joint Surg Am 2004; 86A:251- ac joint from embryonic life until the 466. Schofferman J, Reynolds J, Herzog R, 256. eighth decade. Spine 1981; 6:620-628. Covington E, Dreyfuss P, O’Neill C. Failed 453. Yin W, Willard F, Carreiro J, Dreyfuss P. back surgery: etiology and diagnostic 479. Ross JS, Robertson JT, Frederickson RC, Sensory stimulation-guided sacroil- evaluation. Spine J 2003; 3:400-403. Petrie JL, Obuchowski N, Modic MT, de- Tribolet N. Association between peridu- iac joint radiofrequency neurotomy: 467. Slipman CW, Shin CH, Patel RK, Isaac ral scar and recurrent radicular pain af- Technique based on neuroanatomy of Z, Huston CW, Lipetz JS, Lenrow DA, ter lumbar discectomy: Magnetic reso- the dorsal sacral plexus. Spine 2003; Braverman DL, Vresilovic EJ Jr. Etiolo- nance evaluation. Neurosurgery 1996; 28:2419-2425. gies of failed back surgery syndrome. 38:855-863. 454. Vallejo R, Benyamin RM, Kramer J, Stan- Pain Med 2002; 3:200-214. 480. Fritsch EW, Heisel J, Rupp S. The failed ton G, Joseph NJ. Pulsed radiofrequen- 468. Waguespack A, Schofferman J, Slosar back surgery syndrome. Reasons, in- cy denervation for the treatment of sac- P, Reynolds J. Etiology of long-term fail- traoperative findings, and long-term re- roiliac joint syndrome. Pain Med 2006; ures of lumbar spine surgery. Pain Med sults: A report of 182 operative treat- 7:429-434. 2002; 3:18-22. ments. Spine 1996; 21:626-633. 455. Dar G, Peleg S, Masharawi Y, Steinberg 469. Sampath P, Bendebba M, Davis JD, 481. North RB, Campbell JN, James CS, N, Rothschild BM, Peled N, Hershkovitz Ducker T. Outcome in patients with cer- Conover-Walker MK, Wang H, Pianta- I. Sacroiliac joint bridging: demograph- vical radiculopathy. Prospective, multi- dosi S, Rybock JD, Long DM. Failed back ical and anatomical aspects. Spine center study with independent clinical surgery syndrome: 5-year follow-up in 2005; 30:E429-E432. review. Spine 1999; 24:591-597. 102 patients undergoing repeated oper- 456. Fortin JD, Washington WJ, Falco FJ. Three 470. Waddell G, Kummel EG, Lotto WN, Gra- ation. Neurosurgery 1991; 28:685-691. pathways between the sacroiliac joint ham JD, Hall H, McCulloch JA. Failed 482. Brox JI, Sørensen R, Friis A, Nygaard Ø, and neural structures. AJNR Am J Neu- lumbar disc surgery and repeat surgery Indahl A, Keller A, Ingebrigtsen T, Erik- roradiol 1999; 20:1429-1434. following industrial injury. J Bone Joint sen HR, Holm I, Koller AK, Riise R, Reik- 457. Fortin JD, Dwyer AP, West S, Pier J. Sac- Surg Am 1979; 61:201-207. erås O. Randomized clinical trial of lum- roiliac joint: Pain referral maps upon 471. Lieberman IH. Disc bulge bubble: Spine bar instrumented fusion and cognitive applying a new injection/arthrography economics 101. Spine J 2004; 4:609- intervention and exercises in patients technique. Part I: Asymptomatic volun- 613. with chronic low back pain and disc de- teers. Spine 1994; 19:1475-1482. 472. Eisner W. Spinal fusion: CMS says “show generation. Spine 2003; 28:1913-1921. 458. Fortin JD, Aprill CN, Ponthieux B, Pier us the evidence in November,” Ortho- 483. Katz JN. Lumbar spinal fusion. Surgical J. Sacroiliac joints: Pain referral maps pedics This Week, July 26, 2006; www. rates, costs, and complications. Spine upon applying a new injection/arthrog- ryortho.com/newsletters/volume2/is- 1995; 20:78S-83S.

88 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

484. Hacker RJ, Miller CG. Failed anterior cer- ga GS. Reduction of leg pain and low- 30:621-630. vical foraminotomy. J Neurosurg Spine er-extremity weakness for 1 year with 510. Maliszewski M, Tymowski M, Lelek P, 2003; 98:126-130. Oxiplex/SP gel following laminectomy, Bierzynska-Macyszyn G, Majchrzak H. 485. Osterman H, Sund R, Seitsalo S, Keski- laminotomy, and discectomy. Neuro- An attempt to use Gore-Tex surgical maki I. Risk of multiple reoperations af- surg Focus 2004; 17:ECP1. membrane in lumbar disc surgery. Neu- ter lumbar discectomy: a population- 497. Manchikanti L, Bakhit CE, Pampati V. rol Neurochir Pol 2004; 38:271-277. based study. Spine 2003; 28:621-627. Role of epidurography in caudal neuro- 511. Kayaoglu CR, Calikoglu C, Binler S. Re- 486. Bono CM, Lee CK. Critical analysis of plasty. Pain Digest 1998; 8:277-281. operation after lumbar disc surgery: re- trends in fusion for degenerative disc 498. Manchikanti L, Pampati V, Baha A, Fel- sults in 85 cases. J Int Med Res 2003; disease over the past 20 years: influ- lows B, Damron K, Barnhill R. Contribu- 31:318-323. ence of technique of fusion rate and tion of facet joints to chronic low back 512. Anderson SR. A rationale for the treat- clinical outcome. Spine 2004; 29:455- pain in postlumbar laminectomy syn- ment algorithm of failed back surgery 463. drome: A controlled comparative prev- syndrome. Curr Rev Pain 2000; 4:395- 487. Cherkin DC, Deyo RA, Loeser JD, Bush T, alence evaluation. Pain Physician 2001; 406. Waddell G. An international comparison 4:175-180. 513. Zoidl G, Grifka J, Boluki D, Willburg- of back surgery rates. Spine 1994; 19: 499. Viesca C, Racz G, Day M. Spinal tech- er RE, Zoidl C, Kramer J, Dermietzel R, 1201-1206. niques in pain management: lysis of ad- Faustmann PM. Molecular evidence for 488. Law JD, Lehman RAW, Kirsch WM. Reop- hesions. Anesthesiol Clin North Ameri- local denervation of paraspinal mus- eration after lumbar intervertebral disc ca 2003; 21:745-766. cles in failed-back surgery/post discot- surgery. J Neurosurg 1978; 48:259-263. 500. Manchikanti L, Bakhit CE. Percutaneous omy syndrome. Clin Neuropathol 2003; 489. Kuntz KM, Snider RK, Weinstein JN, lysis of epidural adhesions. Pain Physi- 22:71-77. Pope MH, Katz JN. Cost-effectiveness cian 2000; 3:46-64. 514. Amundsen T, Weber H, Nordal HJ, Mag- of fusion with and without instrumen- 501. McCarron RF. Epidural fibrosis: Exper- naes B, Abdelnoor M, Lilleas F. Lumbar tation for patients with degenerative imental model and therapeutic alter- spinal stenosis: Conservative or surgi- spondylolisthesis and spinal stenosis. natives. In Racz GB (ed). Techniques of cal management? Spine 2000; 25:1424- Spine 2000; 25:1132-1139. Neurolysis. Kluwer Academic Publish- 1436. 490. Massie JB, Huang B, Malkmus S, Yaksh ers, Boston, 1989; pp 87-94. 515. Morishita Y, Hida S, Naito M, Arimizu J, TL, Kim CW, Garfin SR, Akeson WH. A 502. LaRocca H, Macnab I. The laminecto- Matsushima U, Nakamura A. Measure- preclinical post laminectomy rat mod- my membrane: Studies in its evolution, ment of the local pressure of the inter- el mimics the human post laminectomy characteristics, effects and prophylax- vertebral foramen and the electrophys- syndrome. J Neurosci Methods 2004; is in dogs. J Bone Joint Surg BR 1974; iologic values of the spinal nerve roots 137:283-289. 56:545-550. in the vertebral foramen. Spine 2006; 491. Massie JB, Schimizzi AL, Huang B, Kim 503. Cooper RG, Freemont AJ, Hoyland JA, 31:3076-3080. CW, Garfin SR, Akeson WH. Topical high Jenkins JP, West CG, Illingworth KJ, Jay- 516. Yuan P, Albert T. Nonsurgical and surgi- molecular weight hyaluronan reduces son MI. Herniated intervertebral disc- cal management of lumbar spinal ste- radicular pain post laminectomy in a rat associated periradicular fibrosis and nosis. J Bone Joint Surg 2004; 10:2320- model. Spine J 2005; 5:494-502. vascular abnormalities occur without 2330. 492. Harrington JF, Messier AA, Hoffman L, Yu inflammatory cell infiltration. Spine 517. Naderi S, Mertol T. Simultaneous cer- E, Dykhuizen M, Barker K. Physiological 1995; 20:591-598. vical and lumbar surgery for combined and behavioral evidence for focal noci- 504. Hoyland JA, Freemont AJ, Jayson MI. In- symptomatic cervical and lumbar spi- ception induced by epidural glutamate tervertebral foramen venous obstruc- nal stenoses. J Spin Disord Tech 2002; infusion in rats. Spine 2005; 30:606- tion. A cause of periradicular fibrosis? 15:229-232. 612. Spine 1989; 14:558-568. 518. Fritz JM, Delitto A, Welch WC, Erhard 493. Haq I, Cruz-Almeida Y, Siqueira EB, No- 505. Songer M, Ghosh L, Spencer D. Effects RE. Lumbar spinal stenosis: A review renberg M, Green BA, Levi AD. Postop- of sodium hyaluronate on peridural fi- of current concepts in evaluation, man- erative fibrosis after surgical treatment brosis after lumbar laminectomy and agement, and outcome measurements. of the porcine spinal cord: a compari- discectomy. Spine 1990; 15:550-554. Arch Phys Med Rehabil 1998; 79:700- son of dural substitutes. Invited sub- 506. Pawl RP. Arachnoiditis and epidural fi- 708. mission from the Joint Section Meeting brosis: The relationship to chronic pain. 519. Drew R, Bhandari M, Kulkarni AV, Louw on Disorders of the Spine and Periph- Curr Rev Pain 1998; 2:93-99. D, Reddy K, Dunlop B. Reliability in grad- eral Nerves, March 2004. J Neurosurg 507. Cervellini P, Curri D, Volpin L, Bernardi L, ing the severity of lumbar spinal steno- Spine 2005; 2:50-54. Pinna V, Benedetti A. Computed tomog- sis. J Spinal Disord 2000; 13:253-258. 494. Buvanendran A, Kroin JS, Kerns JM, Na- raphy of epidural fibrosis after discec- 520. Treatment of degenerative lumbar spi- galla SN, Tuman KJ. Characterization of tomy. A comparison between symptom- nal stenosis. Evidence Report/Technol- a new animal model for evaluation of atic and asymptomatic patients. Neuro- ogy Assessment No. 32 University of persistent postthoracotomy pain. Anes- surgery 1988; 6:710-713. North Carolina: Agency for Healthcare th Analg 2004; 99:1453-1460. 508. Benoist M, Ficat C, Baraf P, Cauchoix J. Research and Quality. AHRQ Publica- 495. Faustmann PM. Neuroanatomic basis Post operative lumbar epiduroarach- tion No. 01-E048; March 2001. for discogenic pain. Z Orthop Ihre Gren- noiditis: Diagnostic and therapeutic as- 521. Tong HC, Haig AJ, Geisser ME, Yamaka- zgeb 2004; 142:706-708. pects. Spine 1980; 5:432-436. wa KS, Miner JA. Comparing pain sever- 496. Kim KD, Wang JC, Robertson DP, Brodke 509. Key JA, Ford LT. Experimental interverte- ity and functional status of older adults DS, BenDebba M, Block KM, diZere- bral disc lesions. J Bone Joint Surg 1948; without spinal symptoms, with lumbar www.painphysicianjournal.com 89 Pain Physician: January 2007:10:7-111

spinal stenosis, and with axial low back 1997; 22:59-65. 548. Boas RA. Nerve blocks in the diagnosis pain. Gerontology 2006; 53:111-115. 534. Lundin A, Magnuson A, Axelsson K, Nils- of low back pain. Neurosurg Clin N Am 522. Fox EJ, Melzack R. Transcutaneous elec- son O, Samuelsson L. Corticosteroids 1991; 2:806-816. trical stimulation to acupuncture. Com- preoperatively diminishes damage to 549. Barnsley L, Lord S, Bogduk N. Compar- parison of treatment of low back pain. the C-fibers in microscopic lumbar disc ative local anesthetic blocks in the di- Pain 1976; 2:141-148. surgery. Spine 2005; 30:2362-2367. agnosis of cervical zygapophysial joints 523. Flower RJ, Blackwell GJ. Anti-inflamma- 535. McLain RF, Kapural L, Mekhail NA. Epi- pain. Pain 1993; 55:99-106. tory steroid induced biosynthesis of a dural steroid therapy for back and leg 550. Lord SM, Barnsley L, Bogduk N. The phospholipase A2 inhibitor which pre- pain: mechanisms of action and effica- utility of comparative local anesthet- vents prostaglandin generation. Nature cy. Spine J 2005; 5:191-201. ic blocks versus placebo-controlled 1979; 278:456-459. 536. Muramoto T, Atsuta Y, Iwahara T, Sato blocks for the diagnosis of cervical zyg- 524. Devor M, Govrin-Lippmann R, Raber P. M, Takemitsu Y. The action of prosta- apophysial joint pain. Clin J Pain 1995; Corticosteroids suppress ectopic neural glandin E2 and triamcinolone aceton- 11:208-213. discharges originating in experimental ide on the firing activity of lumbar nerve 551. Hogan QH, Abram SE. Neural blockade neuromas. Pain 1985; 22:127-137. roots. Int Orthop 1997; 21:172-175. for diagnosis and prognosis. Anesthesi- 525. Johansson A, Hao J, Sjolund B. Local 537. Merskey H, Thompson EN. Nerve blocks ology 1997; 86:216-241. corticosteroid application blocks trans- and cognitive therapy: A beneficial fail- 552. Hildebrandt J. Relevance of nerve blocks mission in normal nociceptor C-fibers. ure. Pain Res Manage 2002; 7:175-176. in treating and diagnosing low back Acta Anaesthesiol Scand 1990; 34:335- 538. McCormack K. Signal transduction in pain – is the quality decisive? Schmerz 338. neuropathic pain, with special empha- 2001; 15:474-483. 526. Olmarker K, Byrod G, Cornefjord M, Nor- sis on the analgesic role of opioids – 553. Nachemson A, Vingård E. Assessment dborg C, Rydevik B. Effects of methyl- Part I: The basic science of phenotype of patients with neck and back pain: A prednisolone on nucleus pulposus-in- expression in normal and regenerating best-evidence synthesis. In Nachemson duced nerve root injury. Spine 1994; nerves. Pain Rev 1999; 6:3-33. A, Jonsson E (eds). Neck and back pain. 19:1803-1808. 539. McCormack K. Signal transduction in The Scientific Evidence of Causes, Di- 527. Nicol GD, Klingberg DK, Vasko MR. Pros- neuropathic pain, with special empha- agnosis and Treatment. Lippincott Wil- taglandin E2 enhances calcium conduc- sis on the analgesic role of opioids – liams & Wilkins, Philadelphia, 2000; pp tance and stimulates release of sub- Part II: Moving basic science towards a 189-236. stance P in avian sensory neurons. J new pharmacotherapy. Pain Rev 1999; 554. North RB, Kidd DH, Zahurak M, Pianta- Neurosci 1992; 12:1917-1927. 6:99-131. dosi S. Specificity of diagnostic nerve 528. Hua SY, Chen YZ. Membrane receptor- 540. Watkins L, Milligan ED, Maier SF. Spi- blocks: a prospective, randomized mediated electrophysiological effects nal glia: New players in pain. Pain 2001; study of sciatica due to lumbosacral of glucocorticoid on mammalian neu- 93:201-205. spine disease. Pain 1996; 65:77-85. rons. Endocrinology 1989; 124:687- 541. Kim SH, Na HS, Sheen K, Chung JM. Ef- 555. Jaeschke R, Guyatt G, Lijmer J. Diagnos- 691. fects of sympathetectomy on a rat mod- tic tests. In Guyatt G, Rennie D (eds). 529. Hayashi N, Weinstein JN, Meller ST, Lee el of peripheral neuropathy. Pain 1993; Users’ Guides to the Medical Literature HM, Spratt KF, Gebhart GF. The effect of 55:85-92. – A Manual for Evidence-Based Clinical epidural injection of betamethasone or Practice. AMA Press, Chicago, 2002; pp 542. Bogduk N, McGuirk B. Sources and 121-140. bupivacaine in a rat model of lumbar causes of neck pain. In Management radiculopathy. Spine 1998; 23:877-885. of Acute and Chronic Neck Pain. An Evi- 556. Cohen SP, Larkin TM, Chang AS, Sto- 530. Lee HM, Weinstein JN, Meller ST, Hayas- dence-Based Approach. Elsevier, 2006, janovic MP. The causes of false-posi- hi N, Spratt KF, Gebhart GF. The role pp 9-20. tive medial branch (facet joint) blocks in soldiers and retirees. Mil Med 2004; of steroids and their effects on phos- 543. Bogduk N, McGuirk B. Acute neck pain: 169:781-786. pholipase A2. An animal model of algorithm for acute neck pain. In Man- radiculopathy. Spine 1998; 23:1191- agement of Acute and Chronic Neck 557. Raj PP, Shah RV, Kay AD, Denaro S, 1196. Pain. An Evidence-Based Approach. Hoover JM. Bleeding risk in interven- 531. Minamide A, Tamaki T, Hashizume H, Elsevier, 2006, pp 69-77. tional pain practice: Assessment, man- Yoshida M, Kawakami M, Hayashi N. Ef- 544. Bogduk N, Lord S. Cervical zygapophy- agement, and review of the literature. fects of steroids and lipopolysaccharide sial joint pain. Neurosurg Q 1998; 8:107- Pain Physician 2004; 6:3-52. on spontaneous resorption of herniat- 117. 558. Horlocker TT, Wedel DJ, Benzon H, ed intervertebral discs. An experience 545. Schwarzer AC, Derby R, Aprill CN, For- Brown DL, Enneking FK, Heit JA, Mulroy study in the rabbit. Spine 1998; 23:870- tin J, Kine G, Bogduk N. The value of the MF, Rosenquist RW, Rowlingson J, Try- 876. provocation response in lumbar zyg- ba M, Yuan CS. Regional anesthesia in 532. Kingery WS, Castellote JM, Maze M. apophysial joint injections. Clin J Pain the anticoagulated patient: defining the Methylprednisolone prevents the de- 1994; 10:309-313. risks (the second ASRA Consensus Con- velopment of autotomy and neuro- ference on Neuraxial Anesthesia and 546. Bogduk N. Diskography. APS J 1994; Anticoagulation). Reg Anesth Pain Med pathic edema in rats, but has no effect 3:149-154. on nociceptive thresholds. Pain 1999; 2003; 28:172-197. 547. Bonica JJ, Buckley FP. Regional analge- 80:555-566. 559. Windsor RE, Storm S, Sugar R. Preven- sia with local anesthetics. In Bonica JJ tion and management of complications 533. Johansson A, Bennett GJ. Effect of local (ed). The Management of Pain. Lea & methylprednisolone on pain in a nerve resulting from common spinal injec- Febiger, Philadelphia, 1990; pp 1883- tions. Pain Physician 2003; 6:473-484. injury model. A pilot study. Reg Anesth 1966.

90 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

560. Revel M, Poiraudeau S, Auleley GR, Pay- prospective study of 216 patients with cervical and lumbar regions. Pain Phy- an C, Denke A, Nguyen M, Chevrot A, Fer- lumbopelvic pain. BMC Musculoskelet sician 2006; 9:47-52. manian J. Capacity of the clinical picture Disord 2005; 6:28 . 584. Manchikanti L, Pampati V, Fellows B, Ri- to characterize low back pain relieved 572. Schwarzer AC, Wang SC, O’Driscoll D, vera J, Damron K, Beyer C, Cash K. In- by facet joint anesthesia. Proposed cri- Harrington T, Bogduk N, Laurent R. fluence of psychological factors on the teria to identify patients with painful The ability of computed tomography to ability of diagnose chronic low back facet joints. Spine 1998; 23:1972-1977. identify a painful zygapophysial joint pain of facet joint origin. Pain Physician 561. Schwarzer AC, Derby R, Aprill CN, Fortin in patients with chronic low back pain. 2001; 4:349-357. J, Kine G, Bogduk N. Pain from the lum- Spine 1995; 20:907-912. 585. Manchikanti L, Singh V, Fellows B, Pam- bar zygapophysial joints: A test of two 573. Binet EF, Moro JJ, Marangola JP, Hodge pati V. Evaluation of influence of -gen models. J Spinal Disord 1994; 7:331- CJ. Cervical spine tomography in trau- der, occupational injury, and smoking 336. ma. Spine 1977; 2:163-172. on chronic low back pain of facet joint 562. Laslett M, Oberg B, Aprill CN, McDonald 574. Abel MS. Occult traumatic lesions of the origin: A subgroup analysis. Pain Physi- B. Zygapophysial joint blocks in chron- cervical vertebrae. Critical Rev Clin Ra- cian 2002; 5:30-35. ic low back pain; a test of Revel’s model diol Nuclear Med 1975; 6:469-553. 586. Manchikanti L, Pampati V, Rivera J, Fel- as a screening test. BMC Musculoskelet 575. Woodring JH, Goldstein SJ. Fractures of lows B, Beyer C, Damron K. Role of fac- Disord 2004; 5:43. the articular processes of the cervical et joints in chronic low back pain in the 563. Pneumaticos SG, Chatziioannou SN, spine. Am J Roentgenol 1982; 139:341- elderly: A controlled comparative prev- Hipp JA, Moore WH, Esses SI. Low back 344. alence study. Pain Practice 2001; 1:332- pain: prediction of short-term outcome 576. Kim KYA, Wang MY. Magnetic resonance 337. of facet joint injection with bone scintig- image-based morphological predictors 587. Bogduk N, Holmes S. Controlled zyg- raphy. Radiology 2006; 238:693-698. of single photon emission computed to- apophysial joint blocks: The travesty 564. Young S, Aprill C, Laslett M. Correlation mography-positive facet arthropathy in of cost-effectiveness. Pain Med 2000; of clinical examination characteristics patients with axial back pain. Neurosur- 1:24-34. with three sources of chronic low back gery 2006; 59:147-155. 588. Manchikanti L, Singh V. An algorithmic pain. Spine J 2003; 460-465. 577. Houseni M, Chamroonrat W, Zhuang H, approach to diagnosis and manage- 565. Seffinger MA, Najm WI, Mishra SI,- Ad Alavi A. Facet joint arthropathy dem- ment of low back pain. In Manchikanti ams A, Dickerson VM, Murphy LS, Re- onstrated on FDG-PET. Clin Nucl Med L, Slipman CW, Fellows B (eds), Inter- insch S. Reliability of spinal palpation 2006; 31:418-419. ventional Pain Management: Low Back for diagnosis of back and neck pain: 578. Schwarzer AC, Aprill CN, Derby R, Fortin Pain – Diagnosis and Treatment. ASIPP a systematic review of the literature. J, Kine G, Bogduk N. The false-positive Publishing, Paducah, KY 2002, 597- Spine 2004; 29:E413-E425. rate of uncontrolled diagnostic blocks 604. 566. Sandmark H, Nisell R. Validity of five of the lumbar zygapophysial joints. 589. Manchikanti L, Rivera JJ, Pampati V, Bey- common manual neck pain provok- Pain 1994; 58:195-200. er C, Damron K, Barnhill R. Effectiveness ing tests. Scand J Rehabil Med 1995; 579. Barnsley L, Lord S, Wallis B, Bogduk of clinical guidelines in intervention- 27:131-136. N. False-positive rates of cervical zyg- al pain management. Pain Physician 567. Schwarzer AC, Scott AM, Wang SC, Ho- apophysial joint blocks. Clin J Pain 2002; 5:127-132. schl R, Wiseman JC, Copper RA. The role 1993; 9:124-130. 590. Heckmann JG, Maihofner C, Lanz S, of bone scintigraphy in chronic low back 580. Manchikanti L, Singh V, Pampati V. Are Rauch C, Neundorfer B. Transient tet- pain: A comparison of SPECT and planar diagnostic lumbar medial branch blocks raplegia after cervical facet joint injec- images and zygapophysial joint injec- valid? Results of 2-year follow up. Pain tion for chronic neck pain administered tion. Aust NZJ Med 1992; 22:185. Physician 2003; 6:147-153. without imaging guidance. Clin Neurol Neurosurg 2006; 108:709-711. 568. Haig AJ, Tong HC, Yamakawa KS, Parres 581. Manchikanti L, Damron KS, Rivera J, Mc- C, Quint DJ, Chiodo A, Miner JA, Phalke Manus C, Jackson S, Barnhill R, Martin 591. Orpen NM, Birch NC. Delayed presenta- VC, Hoff JT, Geisser ME. Predictors of J. Evaluation of effect of sedation as a tion of septic arthritis of a lumbar fac- pain and function in persons with spinal confounding factor in the diagnostic va- et joint after diagnostic facet joint injec- stenosis, low back pain, and no back lidity of lumbar facet joint pain: A pro- tion. J Spinal Disord Tech 2003; 16:285- pain. Spine 2006; 31:2950-2957. spective, randomized, double-blind, 287. 569. Laslett M, McDonald B, Aprill CN, Tropp placebo-controlled evaluation. Pain 592. Alcock E, Regaard A, Browne J. Fac- H, Oberg B. Clinical predictors of screen- Physician 2004; 7:411-417. et joint injection: A rare form cause of ing lumbar zygapophyseal joint blocks: 582. Manchikanti L, Pampati V, Damron KS, epidural abscess formation. Pain 2003; development of clinical prediction rules. McManus C, Jackson S, Barnhill R, Mar- 103:209-210. Spine J 2006; 6:370-379. tin J. A randomized, prospective, dou- 593. Dreyfuss P, Kaplan M, Dreyer SJ. Zyg- 570. Petersen T, Olsen S, Laslett M, Thorsen ble-blind, placebo-controlled evalua- apophyseal joint injection techniques H, Manniche C, Ekdahl C, Jacobsen S. In- tion of the effect of sedation on diag- in the spinal axis. In Lennard T (ed.) ter-tester reliability of a new diagnostic nostic validity of cervical facet joint Pain Procedures in Clinical Practice, 2nd classification system for patients with pain. Pain Physician 2004; 7:301-310. ed. Hanley & Belfus, Inc., Philadelphia, non-specific low back pain. Aust J Phys- 583. Manchikanti L, Pampati V, Damron KS, 2000; pp 276-308. iother 2004; 50:85-94. McManus CD, Jackson SD, Barnhill RC, 594. Falagas ME, Bliziotis IA, Mavrogenis 571. Laslett M, McDonald B, Tropp H, Aprill Martin JC. The effect of sedation on di- AF, Papagelopoulos PJ. Spondylodisci- CN, Oberg B. Agreement between diag- agnostic validity of facet joint nerve tis after facet joint steroid injection: A noses reached by clinical examination blocks: An evaluation to assess similar- case report and review of the literature. and available reference standards: A ities in population with involvement in Scand J Infect Dis 2006; 38:295-299. www.painphysicianjournal.com 91 Pain Physician: January 2007:10:7-111

595. Okada F, Takayama H, Doita M, Harada Hematogenous pyogenic facet joint in- by discograms. J Bone Joint Surg BR T, Yoshiya S, Kurosaka M. Lumbar fac- fection of the subaxial cervical spine. 1986; 68:36-41. et joint infection associated with epidu- A report of two cases and review of 620. Yasuma T, Ohno R, Yamauchi Y. False- ral and paraspinal abscess: a case re- the literature. J Neurosurg Spine 2001; negative lumbar discograms: Corre- port with review of the literature. J Spi- 95:135-138. lation of discographic and histolog- nal Disord Tech 2005; 18:458-461. 608. Zhou Y, Singh N, Abdi S, Wu J, Crawford ic findings in postmortem and surgical 596. Gaul C, Neundorfer B, Winterholler M. J, Furgang F. Fluoroscopy radiation safe- specimens. J Bone Joint Surg AM 1988; Iatrogenic (para-) spinal abscesses and ty for spine interventional pain proce- 70:1279-1290. meningitis following injection therapy dures in university teaching hospitals. 621. Yu SW, Haughton VM, Sether LA, Wag- for low back pain. Pain 2005; 116:407- Pain Physician 2005; 8:49-53. ner M. Comparison of MR and discogra- 410. 609. Cook NJ, Hanrahan P, Song S. Paraspi- phy in detecting radial tears of the an- 597. Willburger RE, Knorth H, Haaker R. Side nal abscess following facet joint injec- nulus: A post-mortem study. AJNR Am J effects and complications of injection tion. Clin Rheumatol 1999; 18:52-53. Neuroradiol 1989; 10:1077-1081. therapy for degenerative spinal dis- 610. Coscia MF, Trammell TR. Pyogenic lum- 622. Saternus KS, Bornscheuer HH. Com- orders. Z Orthop Ihre Grenzgeb 2005; bar facet joint arthritis with intradural parative radiologic and pathologic-ana- 143:170-174. extension: a case report. J Spinal Disord tomic studies on the value of discogra- 598. Dizdar O, Alyamac E, Onal IK, Uzun O. Tech 2002; 15:526-528. phy in the diagnosis of acute intraverte- Group B streptococcal facet joint arthri- 611. Abdelwahab IF, Gould ES. The role of bral disk injuries in the cervical spine. tis: case report. Spine 2005; 30:E414- diskography after negative postmyelog- Fortschr Geb Rontgenstr Nuklearmed E416. raphy CT scans: retrospective review. 1983; 139:651-657. 599. Ogura T, Mikami Y, Hase H, Mori M, AJNR Am J Neuroradiol 1988; 9:187-190. 623. Viikari-Juntura E, Raininko R, Videman T, Hayashida T, Kubo T. Septic arthritis of 612. Wood KB, Schellhas KP, Garvey TA, Aep- Porkka L. Evaluation of cervical disc de- a lumbar facet joint associated with epi- pli D. Thoracic discography in healthy generation with ultralow field MRI and dural and paraspinal abscess. Orthope- individuals. A controlled prospective discography. An experimental study on dics 2005; 28:173-175. study of magnetic resonance imaging cadavers. Spine 1989; 14:616-619. 600. Daivajna S, Jones A, O’Malley M, Mehdi- and discography in asymptomatic and 624. Agorastides ID, Lam KS, Freeman BJ, an H. Unilateral septic arthritis of a lum- symptomatic individuals. Spine 1999; Mulholland RC. The Adams classifica- bar facet joint secondary to acupunc- 24:1548-1555. tion for cadaveric discograms: Inter- ture treatment – A case report. Acu- 613. Walsh TR, Weinstein JN, Spratt KF, and intra-observer error in the clinical punct Med 2004; 22:152-155. Lehmann TR, Aprill C, Sayre H. Lumbar setting. Eur Spine J 2002; 11:76-79. 601. Manchikanti L, Cash KA, Moss TL, Pam- discography in normal subjects. J Bone 625. Antti-Poika I, Soini J, Tallroth K, Yrjonen pati V. Effectiveness of protective mea- Joint Surg AM 1990; 72:1081-1088. T, Konttinen YT. Clinical relevance of dis- sures in reducing risk of radiation ex- 614. Maigne JY, Lapeyre E, Morvan G, Chat- cography combined with CT scanning. A posure in interventional pain manage- ellier G. Pain immediately upon sitting study of 100 patients. J Bone Joint Surg ment: A prospective evaluation. Pain down and relieved by standing up is of- Br 1990; 72:480-485. Physician 2003; 6:301-305. ten associated with radiologic lumbar 626. Jackson RP, Becker GJ, Jacobs RR, Mon- 602. Manchikanti L, Cash KA, Moss TL, Pam- instability or marked anterior loss of tesano PX, Cooper BR, McManus GE. pati V. Radiation exposure to the phy- disc space. Spine 2003; 28:1327-1334. The neuroradiographic diagnosis of sician in interventional pain manage- 615. Laslett M, Aprill CN, McDonald B, Oberg lumbar herniated nucleus pulposus: I. ment. Pain Physician 2002; 5:385-393. B. Clinical predictors of lumbar provoca- A comparison of computed tomography 603. Manchikanti L, Cash K, Moss T, Rivera JJ, tion discography: a study of clinical pre- (CT), myelography, CT-myelography, Pampati V. Risk of whole body radiation dictors of lumbar provocation discogra- discography, and CT-discography. Spine exposure and protective measures in phy. Eur Spine J 2006; 15:1473-1484. 1989; 14:1356-1361. fluoroscopically guided interventional 616. Laslett M, Oberg B, Aprill CN, McDonald 627. Gresham JL, Miller R. Evaluation of the techniques: A prospective evaluation. B. Centralization as a predictor of prov- lumbar spine by diskography and its BMC Anesthesiol 2003; 3:2. ocation discography results in chronic use in selection of proper treatment of 604. Magee M, Kannangara S, Dennien B, low back pain, and the influence of dis- the herniated disk syndrome. Clin Or- Lonergan R, Emmett L, van der Wall H. ability and distress on diagnostic pow- thop 1969; 67:29-41. Paraspinal abscess complicating fac- er. Spine J 2005; 5:370-380. 628. Brodsky AE, Binder WF. Lumbar discog- et joint injection. Clin Nucl Med 2000; 617. Yrjama M, Tervonen O, Vanharanta H. raphy: Its value in diagnosis and treat- 25:71-73. Ultrasonic imaging of lumbar discs ment of lumbar disc lesions. Spine 605. Uribe J, Moza K, Jimenez O, Green B, combined with vibration pain provoca- 1979; 4:110-120. Levi AD. Delayed postoperative spi- tion compared with discography in the 629. Birney TJ, White JJ Jr, Berens D, Kuhn G. nal epidural hematomas. Spine J 2003; diagnosis of internal anular fissures of Comparison of MRI and discography in 3:125-129. the lumbar spine. Spine 1996; 21:571- the diagnosis of lumbar degenerative 606. Doita M, Nishida K, Miyamoto H, Yoshi- 575. disease. J Spin Disord 1992; 5:417-423. ya S, Kurosaka M, Nabeshima Y. Septic 618. Ohnmeiss DD, Guyer RD, Mason SL. The 630. Bernard TN Jr. Repeat lumbar spine arthritis of bilateral lumbar facet joints: relation between cervical discographic surgery: Factors influencing outcome. report of a case with MRI findings in the pain responses and radiographic imag- Spine 1993; 18:2196-2200. early stage. Spine 2003; 28:E198-E202. es. Clin J Pain 2000; 16:1-5. 631. Southern EP, Fye MA, Panjabi MM, Pa- 607. Muffolerro AJ, Nader R, Westmark RM, 619. Adams MA, Dolan P, Hutton WC. The tel TC, Cholewicki J. Disc degeneration: Nauta HJ, Garges KJ, Hadjipavlou AG. stages of disc degeneration as revealed A human cadaveric study correlation

92 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

lation with discography. Spine 1987; magnetic resonance imaging and quan- sheep. Spine 2002; 27:2806-2810. 12:276-282. titative discomanometry. Spine 2000; 657. Ricketson R, Simmons JW, Hauser BO. 25:2171-2175. 645. Whitecloud TS, Seago RA. Cervical dis- The prolapsed intervertebral disc. The cogenic syndrome: results of operative 632. Simmons JW, Emery SF, McMillin JN, high-intensity zone with discography intervention in patients with positive Landa D, Kimmich SJ. Awake discogra- correlation. Spine 1996; 21:2758-2762. discography. Spine 1987; 12:313-316. phy. A comparison study with magnet- 658. Peng B, Hou S, Wu W, Zhang C, Yang Y. ic resonance imaging. Spine 1991; 16: 646. Horton WC, Daftari TK. Which disc as vi- The pathogenesis and clinical signifi- S216-S221. sualized by magnetic resonance imag- cance of a high-intensity zone (HIZ) of ing is actually a source of pain? A corre- 633. Simmons EH, Segil CM. An evaluation of lumbar intervertebral disc on MR imag- lation between magnetic resonance im- discography in the localization of symp- ing in the patient with discogenic low aging and discography. Spine 1992; 17: tomatic levels in discogenic disease of back pain. Eur Spine J 2006; 15:583- S164-S171. the spine. Clin Orthop 1975; 108:57-69. 587. 647. Zucherman J, Derby R, Hsu K, Picetti G, 634. Holt EP Jr. Fallacy of cervical discogra- 659. Carragee EJ, Paragiodakis SJ, Khurana Kaiser J, Schofferman J, Goldthwaite N, phy. Report of 50 cases in normal sub- S. Lumbar high-intensity zone and dis- White A. Normal magnetic resonance jects. JAMA 1964; 188:799-801. cography in subjects without low back imaging with abnormal discography. problems. Spine 2000; 25:2987-2992. 635. Jackson RP, Glah JJ. Foraminal and ex- Spine 1988; 13:1355-1359. traforaminal lumbar disc herniation: 660. Lam KS, Carlin D, Mulholland RC. Lum- 648. Parfenchuck TA, Janssen ME. A correla- Diagnosis and treatment. Spine 1987; bar disc high-intensity zone: The value tion of cervical magnetic resonance im- 12:577-585. and significance of provocative discog- aging and discography/computed to- raphy in the determination of the dis- 636. Grubb SA, Lipscomb HJ, Guilford WB. mographic discograms. Spine 1994; cogenic pain source. Eur Spine J 2000; The relative value of lumbar roentgen- 19:2819-2825. 9:36-41. ograms, metrizamide myelography, and 649. Huang TS, Zucherman JF, Hsu KY, Sha- discography in the assessment of pa- 661. Bogduk N. Cervical disc stimulation piro M, Lentz D, Gartland J. Gadopen- tients with chronic low back syndrome. (provocation discography). In Practice tetate dimeglumine as an intradiscal Guidelines for Spinal Diagnostic and Spine 1987; 12:282-286. contrast agent. Spine 2002; 27:839- Treatment Procedures, 1st edition. In- 637. Winter RB, Schellhas KP. Painful adult 843. ternational Spine Intervention Society, thoracic Scheuermann’s disease. Di- 650. Shin DA, Kim HI, Jung JH, Shin DG, Lee 2004, pp 95-111. agnosis by discography and treatment JO. Diagnostic relevance of pressure- 662. Bogduk N. Thoracic provocation discog- by combined arthrodesis. Am J Orthop controlled discography. J Korean Med raphy. In Practice Guidelines for Spinal 1996; 25:783-786. Sci 2006; 21:911-916. Diagnostic and Treatment Procedures, 638. Wiley JJ, Macnab I, Wortzman G. Lum- 651. Zheng Y, Liew SM, Simmons ED. Val- 1st edition. International Spine Inter- bar discography and its clinical applica- ue of magnetic resonance imaging and vention Society, 2004, pp 287-294. tions. Can J Surg 1968; 11:280-289. discography in determining the level of 663. Bogduk N. Lumbar disc stimulation 639. Sachs BL, Vanharanta H, Spivey MA, cervical discectomy and fusion. Spine (provocation discography). In Practice Guyer RD, Videman T, Rashbaum RF, 2004; 29:2140-2146. Guidelines for Spinal Diagnostic and Johnson RG, Hochschuler SH, Mooney 652. Aprill C, Bogduk N. High-intensity zone: Treatment Procedures, 1st edition. In- V. Dallas discogram description: A new A diagnostic sign of painful lumbar disc ternational Spine Intervention Society, classification of CT/discography in low- on magnetic resonance imaging. Br J 2004, pp 20-46. back disorders. Spine 1987; 12:287- Radiol 1992; 65:361-369. 664. Grubb SA, Kelly CK. Cervical discogra- 294. 653. Schellhas KP, Pollei SR, Gundry CR, phy: Clinical implications from 12 years 640. Lehmer SM, Dawson MH, O’Brien JP. De- Heithoff KB. Lumbar disc high-intensi- of experience. Spine 2000; 25:1382- layed pain response after lumbar dis- ty zone. Correlation of magnetic reso- 1389. cography. Eur Spine J 1994; 3:28-31. nance imaging and discography. Spine 665. Connor PM, Darden BV II. Cervical dis- 641. Milette PC, Raymond J, Fontaine S. Com- 1996; 21:79-86. cography complications and clinical ef- parison of high-resolution computed to- 654. Saifuddin A, Braithwaite I, White J, ficacy.Spine 1993; 18:2035-2038. mography with discography in the eval- Taylor BA, Renton P. The value of lum- 666. Holt EP Jr. The question of lumbar dis- uation of lumbar disc herniations. Spine bar spine magnetic resonance imaging cography. J Bone Joint Surg Am 1968; 1990; 15:525-533. in the demonstration of anular tears. 50:720-726. 642. Lim CH, Jee WH, Son BC, Kim DH, Ha KY, Spine 1998; 23:453-457. 667. Simmons JW, Aprill CN, Dwyer AP, Brod- Park CK. Discogenic lumbar pain: asso- 655. Smith BM, Hurwitz EL, Solsberg D, Ru- sky AE. A reassessment of Holt’s data ciation with MR imaging and CT discog- binstein D, Corenman DS, Dwyer AP, on: “The question of lumbar discogra- raphy. Eur J Radiol 2005; 54:431-437. Kleiner J. Interobserver reliability of de- phy.” Clin Orthop 1988; 237:120-124. 643. Gibson MJ, Buckley J, Mawhinney R, tecting lumbar intervertebral disc high- 668. Milette PC, Fontaine S, Lepanto L, Cardi- Mulholland RC, Worthington BS. Mag- intensity zone on magnetic resonance nal E, Breton G. Differentiating lumbar netic resonance imaging and discogra- imaging and association of high-inten- disc protrusions, disc bulges, and discs phy in the diagnosis of disc degenera- sity zone with pain and anular disrup- with normal contour but abnormal sig- tion: A comparative study of 50 discs. J tion. Spine 1998; 23:2074-2080. nal intensity: Magnetic resonance im- Bone Joint Surg BR 1986; 68:369-373. 656. Lappalainen AK, Kääpä E, Lamminen A, aging with discographic correlations. 644. Schneiderman G, Flannigan B, Kings- Laitinen OM, Gronblad M. The diagnos- Spine 1999; 24:44-53. ton S, Thomas J, Dillin WH, Watkins RG. tic value of contrast-enhanced magnet- 669. Ito M, Incorvaia KM, Yu SF, Fredrickson Magnetic resonance imaging in the di- ic resonance imaging in the detection of BE, Yuan HA, Rosenbaum AE. Predictive agnosis of disc degeneration: Corre- experimentally induced anular teras in signs of discogenic lumbar pain on mag- www.painphysicianjournal.com 93 Pain Physician: January 2007:10:7-111

netic resonance imaging with discogra- gee JM. Discographic, MRI, and psycho- 70:267-271. phy correlation. Spine 1998; 23:1252- social determinants of low back pain 692. Zeidman SM, Thompson K, Ducker TB. 1260. disability and remission: a prospective Complications of cervical discography: 670. Osti OL, Fraser RD. MRI and discogra- study in subjects with benign persistent Analysis of 4400 diagnostic disc injec- phy of anular tears and intervertebral back pain. Spine J 2005; 5:24-35. tions. Neurosurgery 1995; 37:414-417. disc degeneration. A prospective clin- 681. Carragee EJ, Alamin TF, Carragee JM. 693. Fraser RD, Osti OL, Vernon-Roberts B. ical comparison. J Bone Joint Surg BR Low-pressure positive discography Discitis after discography. J Bone Joint 1992; 74:431-435. in subjects asymptomatic of signifi- Surg 1987; 69-B:26-35. cant low back pain illness. Spine 2006; 671. Greenspan A, Amparo EG, Gorczyca DP, 694. Lownie SP, Ferguson GG. Spinal subdu- 31:505-509. Montesano PX. Is there a role of discog- ral empyema complicating cervical dis- raphy in the era of magnetic resonance 682. Carragee EJ, Lincoln T, Parmar VS, Al- cography. Spine 1989; 14:1415-1417. imaging? Prospective correlation and amin T. A gold standard evaluation of 695. Schreck RI, Manion WL, Kambin P, Sohn quantitative analysis of computed to- the “discogenic pain” diagnosis as de- M. Nucleus pulposus pulmonary embo- mography-diskography, magnetic reso- termined by provocative discography. lism. A case report. Spine 1997; 22:927- nance imaging, and surgical findings. J Spine 2006; 31:2115-2123. 928. Spinal Disord 1992; 5:26-31. 683. Carragee EJ, Paragioudakis SJ, Khura- 696. Laun A, Lorenz R, Agnoli NL. Complica- 672. Buirski G, Silberstein M. The symptom- na S. 2000 Volvo Award winner in clini- tions of cervical discography. J Neuro- atic lumbar disc in patients with low- cal studies: Lumbar high-intensity zone surg Sci 1981; 25:17-20. back pain: Magnetic resonance imag- and discography in subjects without low ing appearances in both a symptomat- back problems. Spine 2000; 25:2987- 697. Tsuji N, Igarashi S, Koyama T. Spinal epi- ic and control population. Spine 1993; 2992. dural abscess. No Shinkei Geka 1987; 15:1079-1085. 18:1808-1811. 684. Derby R, Howard MW, Grant JM, Lettice 673. Gill K, Blumenthal SL. Functional results JJ, Van Peteghem PK, Ryan DP. The abil- 698. Junila J, Niinimäki T, Tervonen O. Epidu- after anterior lumbar fusion at L5/S1 in ity of pressure-controlled discography ral abscess after lumbar discography. patients with normal fusion at L5/S1 in to predict surgical and nonsurgical out- Spine 1997; 22:2191-2193. patients with normal and abnormal MRI comes. Spine 1999; 24:364-371. 699. Weingarten TN, Hooten WM, Huntoon scans. Spine 1992; 17:940-942. 685. O’Neill C, Kurgansky M. Subgroups of MA. Septic facet joint arthritis after a 674. Carragee EJ, Tanner CM, Khurana S, positive discs on discography. Spine corticosteroid facet injection. Pain Med Hayward C, Welsh J, Date E, Truong T, 2004; 29:2134-2139. 2006; 7:52-56. Rossi M, Hagle C. The rates of false- 686. Derby R, Lee SH, Kim BJ, Chen Y, Aprill 700. Johnson RG. Does discography injure positive lumbar discography in select C, Bogduk N. Pressure-controlled lum- normal discs? An analysis of repeat dis- patients without low back symptoms. bar discography in volunteers with low cograms. Spine 1989; 14:424-426. Spine 2000; 25:1373-1380. back pain symptoms. Pain Med 2005; 701. Heggeness MH, Doherty BJ. Discogra- 675. Carragee EJ, Chen Y, Tanner CM, Hay- 6:213-221. phy causes end plate deflection. Spine ward C, Rossi M, Hagle C. Can discog- 687. Derby R, Kim BJ, Lee SH, Chen Y, Seo 1993; 18:1050-1053. raphy cause long-term back symptoms KS, Aprill C. Comparison of discograph- 702. Reitman CA, Hipp JA, Kirking BC, Haas S, in previously asymptomatic subjects? ic findings in asymptomatic subject Esses SI. Posterior annular strains dur- Spine 2000; 25:1803-1808. discs and negative discs of chronic LBP ing discography. J Spinal Disord 2001; 676. Carragee EJ, Barcohana B, Alamin T, patients: Can discography distinguish 14:347-352. van den Haak E. Prospective controlled asymptomatic discs among morpho- 703. Willems PC, Jacobs W, Duinkerke ES, study of the development of lower back logically abnormal discs? Spine J 2005; De Kleuver M. Lumbar discography: pain in previously asymptomatic sub- 5:389-394. should we use prophylactic antibiotics? jects undergoing experimental discog- 688. Derby R, Kim BJ, Chen Y, Seo KS, Lee SH. A study of 435 consecutive discograms raphy. Spine 2004; 29:1112-1117. The relation between annular disrup- and a systematic review of the litera- 677. Carragee EJ, Alamin TF, Miller J, Grafe M. tion on computed tomography scan and ture. J Spinal Disord Tech 2004; 17:243- Provocative discography in volunteer pressure-controlled diskography. Arch 247. subjects with mild persistent low back Phys Med Rehabil 2005; 86:1534-1538. 704. Guiboux JP, Cantor JB, Small SD, Zervos pain. Spine J 2002; 2:25-34. 689. Manchikanti L, Singh V, Pampati V, Fel- M, Herkowitz HN. The effect of prophy- 678. Carragee EJ, Chen Y, Tanner CM, Truong lows B, Beyer C, Damron K, Cash K. Pro- lactic antibiotics on iatrogenic interver- T, Lau E, Brito JL. Provocative discog- vocative discography in low back pain tebral disc infections. A rabbit model. raphy in patients after limited lumbar patients with or without somatization Spine 1995; 20:685-688. discectomy: A controlled, randomized disorder: A randomized prospective 705. Koroglu A, Acar O, Ustun ME, Tiras B, study of pain response in symptomat- evaluation. Pain Physician 2001; 4:227- Eser O. The penetration of cefopera- ic and asymptomatic subjects. Spine 239. zone and sulbactam into the lumbar in- 2000; 25:3065-3071. 690. Cohen SP, Larkin T, Fant GV, Oberfoell tervertebral discs. J Spinal Disord 2001; 679. Carragee EJ, Tanner CM, Yang B, Brito R, Stojanovic M. Does needle insertion 14:453-454. JL, Truong T. False-positive findings on site affect diskography results? A retro- 706. Boswell M, Wolfe J. Intrathecal cefazo- lumbar discography. Reliability of sub- spective analysis. Spine 2002; 27:2279- lin-induced seizures following attempt- jective concordance assessment during 2283. ed discography. Pain Physician 2004; provocative disc injection. Spine 1999; 691. Colhoun E, McCall IW, Williams L, Cas- 7:103-106. 24:2542-2547. sar Pullicino VN. Provocation discogra- 707. Steindler A. Luck JV. Differential diagno- 680. Carragee EJ, Alamin TF, Miller JL, Carra- phy as a guide to planning operations sis of pain in the low back: Allocation of on the spine. J Bone Joint Surg Br 1988; the source of the pain by the procaine

94 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

hydrochloride method. JAMA 1938; 722. Wolff AP, Groen GJ, Crul BJ. Diagnostic 735. Tajima T, Furukawa K, Kuramochi E. Se- 110:106-113. lumbosacral segmental nerve blocks lective lumbosacral radiculography and 708. MacNab I. Negative disc exploration: An with local anesthetics: A prospective block. Spine 1980; 1:68-77. analysis of the causes of nerve root in- double-blind study on the variability 736. Brouwers PJ, Kottink EJ, Simon MA, Pre- volvement in sixty-eight patient. J Bone and interpretation of segmental effects. vo RL. A cervical anterior spinal artery Joint Surg AM 1971; 53:5891-5903. Reg Anesth Pain Med 2001; 26:147- syndrome after diagnostic blockade 155. 709. Bogduk N. Lumbar medial branch of the right C6-nerve root. Pain 2001; blocks. In Practice Guidelines for Spinal 723. Pfirrmann CW, Oberholzer PA, Zanetti 91:397-399. Diagnostic and Treatment Procedures, M, Boos N, Trudell DJ, Resnick D, Hodler 737. Nash TP. Comment on A cervical ante- 1st edition. International Spine Inter- J. Selective nerve root blocks for the rior spinal artery syndrome after diag- vention Society, 2004, pp 47-65. treatment of sciatica: Evaluation of in- nostic blockade of the right C6-nerve 710. Schutz H, Lougheed WM, Wortzman G, jection site and effectiveness – a study root. Pain 2002; 91:217-218. Awerbuck BG. Intervertebral nerve-root with patients and cadavers. Radiology 738. Stohr M, Mayer K. Nerve-root dam- in the investigation of chronic lumbar 2001; 221:704-711. age from local injections. Dtsch Med disc disease. Can J Surg 1973; 16:217- 724. Slipman CW, Plastaras CT, Palmitier RA, Wochenschr 1976; 101:1218-1220. Huston CW, Sterenfeld EB. Symptom 221. 739. Schultz D. Risk of transforaminal epi- 711. Krempen JF, Smith BS. Nerve root injec- provocation of fluoroscopically guided dural injections. Pain Physician 2004; tion: A method for evaluating the eti- cervical nerve root stimulation. Are dy- 7:289-290. ology of sciatica. J Bone Joint Surg AM natomal maps identical to dermatomal maps? Spine 1998; 23:2235-2242. 740. Helm S, Jasper J, Racz G. Complications 1974; 56:1435-1444. of transforaminal epidural injections. 712. Haueisen DC, Smith BS, Myers SR, 725. Anderberg L, Annertz M, Brandt L, Save- Pain Physician 2003; 6:389-390. Pryce ML. The diagnostic accuracy of land H. Selective diagnostic cervical nerve root block – correlation with clini- 741. Baker R, Dreyfuss P, Mercer S, Bogduk spinal nerve injection studies. Clin Or- N. Cervical transforaminal injection or thop 1985; 198:179-183. cal symptoms and MRI pathology. Acta Neurochir 2004; 146:559-565. corticosteroids into a radicular artery: A 713. Dooley JF, McBroom RJ, Taguchi T, possible mechanism for spinal cord in- Macnab I. Nerve root infiltration in the 726. Nachemson A. Newest knowledge of jury. Pain 2003; 109:211-215. diagnosis of radicular pain. Spine 1988; low back pain: A critical look. Clin Or- thop Rel Res 1992; 279:8-20. 742. Rozin L, Rozin R, Koehler SA, Shakir 13:79-83. A, Ladham S, Barmada M, Dominick J, 714. Stanley D, McLaren MI, Euinton HA, Get- 727. Anderberg L, Saveland H, Annertz M. Wecht CH. Death during transforaminal ty CJ. A prospective study of nerve root Distribution patterns of transforaminal epidural steroid nerve root block (C7) infiltration in the diagnosis of -sciati injections in the cervical spine evalu- due to perforation of the left vertebral ca: A comparison with radiculography, ated by multi-slice computed tomogra- artery. Am J Forensic Med Pathol 2003; computed tomography, and operative phy. Eur Spine J 2006; 15:1465-1471. 24:351-355. findings.Spine 1990; 6:540-543. 728. Faraj AA, Mulholland RC. The value of 743. Glaser SE, Falco F. Paraplegia follow- 715. Derby R, Kine G, Saal JA, Reynolds J, nerve root infiltration for leg pain when ing a thoracolumbar transforaminal epi- Goldthwaite N, White AH, Hsu K, Zuch- used with a nerve stimulator. Eur Spine dural Steroid injection. Pain Physician erman J. Response to steroid and dura- J 2006; 15:1495-1499. 2005; 8:309-314. tion of radicular pain as predictors of 729. Wolff AP, Groen GJ, Wilder-Smith OH, 744. Beckman WA, Mendez RJ, Paine GF, surgical outcome. Spine 1992; 17 (Sup- Richardson J, van Edmond J, Crul BJ. Do Mazzilli MA. Cerebellar herniation af- pl):176-183. diagnostic segmental nerve root blocks ter cervical transforaminal epidural in- 716. Castro WH, van Akkerveeken PF. Der di- in chronic low back pain patients with jection. Reg Anesth Pain Med 2006; agn ostische Wert der selektiven lum- radiation to the leg lack distinct senso- 31:282-285. balen Nervenwurzelblockde. Z orthop ry effects? A preliminary study. Br J An- aesth 2006; 96:253-258. 745. Ludwig MA, Burns SP. Spinal cord in- Ihre Grenzgeb 1991; 129:374-379. farction following cervical transforam- 717. Kikuchi S, Hasue M, Nishiyama K. An- 730. Wolff AP, Groen GJ, Wilder-Smith OH. In- inal epidural injection: a case report. atomic and clinical studies of radicular fluence of needle position on lumbar Spine 2005; 30:E266-E268. symptoms. Spine 1984; 9:23-30. segmental nerve root block selectivi- ty. Reg Anesth Pain Med 2006; 31:523- 746. Karasek M, Bogduk N. Temporary neu- 718. Van Akkerveeken PF. The diagnostic val- 530. rologic deficit after cervical transforam- ue of nerve root sheath infiltration.Acta inal injection of local anesthetic. Pain 731. Koning HM, Koning AJ. Prolonged pain Orthop Scand 1993; 251:61-63. Med 2004; 5:202-205. relief following selective nerve root in- 719. Herron LD. Selective nerve root block filtration.Pain Clinic 2003; 14:225-233. 747. Huntoon MA. Anatomy of the cervical in patient selection for lumbar surgery: intervertebral foramina: vulnerable ar- Surgical results. J Spinal Disord 1989; 732. White A. Injection techniques for the di- teries and ischemic neurologic injuries 2:75-79. agnosis and treatment of low back pain. after transforaminal epidural injections. Orthop Clin N Am 1983; 14:553-567. 720. Hoppenstein R. A new approach to Pain 2005; 117:104-111. the failed back syndrome. Spine 1980; 733. Elias M. A rare cause of radiculopathy 748. Hoeft MA, Rathmell JP, Monsey RD, Fon- 5:371-379. following transforaminal epidural ste- da BJ. Cervical transforaminal injection roid injection. Pain Clinic 1998; 11:159- 721. Strobel K, Pfirrmann CW, Schmid M, and the radicular artery: variation in an- 160. Hodler J, Boos N, Zanetti M. Cervi- atomical location within the cervical in- cal nerve root blocks: indications and 734. Houten JK, Errico TJ. Paraplegia after tervertebral foramina. Reg Anesth Pain role of MR imaging. Radiology 2004; lumbosacral nerve root block: Report of Med 2006; 31:270-274. 233:87-92. three cases. Spine J 2002; 2:70-75. 749. Ma DJ, Gilula LA, Riew KD. Complica- www.painphysicianjournal.com 95 Pain Physician: January 2007:10:7-111

1994; 19:1138-1143. tions of fluoroscopically guided extrafo- 777. Laslett M, Young SB, Aprill CN, McDon- raminal cervical nerve blocks. An analy- 763. Slipman CW, Sterenfeld EB, Chou LH, ald B. Diagnosing painful sacroiliac sis of 1036 injections. J Bone Joint Surg Herzog R, Vresilovic E. The predictive joints: A validity study of a McKenzie Am 2005; 87:1025-1030. value of provocative sacroiliac joint evaluation and sacroiliac provocation 750. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. stress maneuvers in the diagnosis of tests. Aust J Physiother 2003; 49:89- Complications following cervical epidu- sacroiliac joint syndrome. Arch Phys 97. Med Rehab 1998; 79:288-292. ral steroid injections by expert interven- 778. Laslett M, Aprill CN, McDonald B, Young tionalists in 2003. Pain Physician 2004; 764. Broadhurst NA, Bond MJ. Pain provoca- SB. Diagnosis of sacroiliac joint pain: 7:445-449. tion tests for the assessment of sacroili- validity of individual provocation tests 751. Huston CW, Slipman CW, Garvin C. Com- ac joint dysfunction. J Spin Disord 1998; and composites of tests. Man Ther plications and side effects of cervical 11:341-345. 2005; 10:207-218. and lumbosacral selective nerve root in- 765. Meijne W, van Neerbos K, Aufdemkampe 779. Kokmeyer DJ, van der Wurff P, Aufdem- jections. Arch Phys Med Rehabil 2005; G, van der Wurff P. Intraexaminer and in- kampe G, Fickenscher TC. The reliabili- 86:277-283. terexaminer reliability of the Gillet test. ty of multitest regimens with sacroiliac 752. Dietrich CL, Smith CE. Epidural granu- J Man Phys Ther 1999; 22:4-9. pain provocation tests. J Manipulative loma and intracranial hypotension re- 766. Ebraheim NA, Mekhail AO, Wiley WF, Physiol Ther 2002; 25:42-48. sulting from cervical epidural steroid in- Jackson WT, Yeasting RA. Radiology 780. Levin U, Stenstrom CH. Force and time jection. Anesthesiology 2004; 100:445- of the sacroiliac joint. Spine 1997; 22: recording for validating the sacroili- 447. 869-876. ac distraction test. Clin Biomech 2003; 753. Saigal G, Donovan Post MJ, Kozic D. 767. Vogler JB 3rd, Brown WH, Helms CA, 18:821-826. Thoracic intradural Aspergillus abscess Genant HK. The normal sacroiliac joint: 781. van der Wurff P, Buijs EJ, Groen GJ. In- formation following epidural steroid in- A CT study of asymptomatic patients. tensity mapping of pain referral areas in jection. AJNR Am J Neuroradiol 2004; Radiology 1984; 151:433-437. sacroiliac joint pain patients. J Manipu- 25:642-644. 768. Resnik CS, Resnick D. Radiology of dis- lative Physiol Ther 2006; 29:190-195. 754. Bose B. Quadriparesis following cervi- orders of the sacroiliac joints. JAMA 782. van der Wurff P, Meyne W, Hagmeijer cal epidural steroid injections: case re- 1985; 253:2863-2866. RH. Clinical tests of the sacroiliac joint. port and review of the literature. Spine J 769. Slipman CW, Sterenfeld EB, Chou LH, Man Ther 2000; 5:89-96. 2005; 5:558-563. Herzog R, Vresilovic E. The value of ra- 783. van der Wurff P, Buijs EJ, Groen GJ. A 755. Bilir A, Gulec S. Cauda equina syndrome dionuclide imaging in the diagnosis of multitest regimen of pain provocation after epidural steroid injection: A case sacroiliac joint syndrome. Spine 1996; tests as an aid to reduce unnecessari- report. J Manipulative Physiol Ther 21:2251-2254. ly minimally invasive sacroilac joint pro- 2006; 29:492-494. 770. Maigne JY, Boulahdour H, Charellier G. cedures. Arch Phys Med Rehabil 2006; 756. Tripathi M, Nath SS, Gupta RK. Paraple- Value of quantitative radionuclide bone 87:10-14. gia after intracord injection during at- scanning in the diagnosis of sacroiliac 784. McGrath MC. Palpation of the sacroiliac tempted epidural steroid injection in joint syndrome in 32 patients with low joint: An anatomical and sensory chal- an awake-patient. Anesth Analg 2005; back pain. Eur Spine J 1998; 7:328-331. lenge. Int J Osteopath Med 2006; 9:103- 101:1209-1211. 771. Goldberg RP, Genant HK, Shimshak R, 107. 757. Finn KP, Case JL. Disk entry: a compli- Shames D. Applications and limitations 785. Berthelot JM, Labat JJ, Le Goff B, Gouin cation of transforaminal epidural injec- of quantitative sacroiliac joint scintigra- F, Maugars Y. Provocative sacroiliac joint tion–a case report. Arch Phys Med Re- phy. Radiology 1978; 128:683-686. maneuvers and sacroiliac joint block habil 2005; 86:1489-1491. 772. Lantto T. The scintigraphy of sacroili- are unreliable for diagnosing sacroil- 758. Hooten WM, Mizerak A, Carns PE, Hunt- ac joints: A comparison of 99-mTc-VPB iac joint pain. Joint Bone Spine 2006; oon MA. Discitis after lumbar epidural and 99mTc-MDP. Eur J Nucl Med 1990; 73:17-23. corticosteroid injection: a case report 16:677-681. 786. Malanga GA, Nadler SF. Physical exami- and analysis of the case report litera- 773. Lentle BC, Russell AS, Percy JS, Jack- nation of the sacroiliac joint. In Muscu- ture. Pain Med 2006; 7:46-51. son FI. The scintigraphic investigation loskeletal Physical Examination: An Ev- 759. Kabbara A, Rosenberg SK, Untal C. of sacroiliac disease. J Nucl Med 1977; idence-Based Approach. Elsevier, Phila- Methicillin-resistant Staphylococcus 6:529-533. delphia, 2006; pp 227-250. aureus epidural abscess after transfo- 774. Verlooy H, Mortelmans L, Vleugels S, 787. Simpson R, Gemmell H. Accuracy of spi- raminal epidural steroid injection. Pain De Roo M. Quantitative scintigraphy of nal orthopaedic tests: A systematic re- Physician 2004; 7:269-272. the sacroiliac joints. Clin Imaging 1992; view. Chiropr Osteopat 2006; 14:26. 760. Browning DJ. Acute retinal necrosis fol- 16:230-233. 788. Rosenberg JM, Quint TJ, de Rosayro AM. lowing epidural steroid injections. Am J 775. Hanly JG, Mitchell MJ, Barnes DC, Mac- Computerized tomographic localization Ophthalmol 2003; 36:192-194. Millan L. Early recognition of sacroiliitis of clinically-guided sacroiliac joint in- 761. Dreyfuss P, Michaelsen M, Pauza K, by magnetic resonance imaging and sin- jections. Clin J Pain 2000; 16:18-21. McLarty J, Bogduk N. The value of medi- gle photon emission computed tomog- 789. Hansen H. Is fluoroscopy necessary for cal history and physical examination in raphy. J Rheum 1994; 21:2088-2095. sacroiliac joint injections? Pain Physi- diagnosing sacroiliac joint pain. Spine 776. Bredella MA, Steinbach LS, Morgan S, cian 2003; 6:155-158. 1996; 21:2594-2602. Ward M, Davis JC. MRI of the sacroiliac 790. Fortin J, Tolchin R. Sacroiliac arthro- 762. Dreyfuss P, Dryer S, Griffin J, Hoffman joints in patients with moderate to se- grams and post-arthrography com- J, Walsh N. Positive sacroiliac screen- vere ankylosing spondylitis. AJR Am J puterized tomography. Pain Physician ing tests in asymptomatic adults. Spine Roentgenol 2006; 187:1420-1426. 2003; 6:287-290.

96 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

791. Fortin JD, Vilensky JA, Merkel GF. Can Ross JS. Magnetic resonance imaging bar facet joint. Trans Orthop Res Soc the sacroiliac joint cause sciatica? Pain of the lumbar spine in people without 1991; 16:353. Physician 2003; 6:269-271. back pain. N Engl J Med 1994; 331:69- 815. Bogduk N, Marsland A. The cervical zyg- 73. 792. Weinstein JN, Tosteson TD, Lurie JD, apophysial joints as a source of neck Tosteson AN, Hanscom B, Skinner JS, 802. Magora A, Bigos SJ, Stolov WC, Tomsli pain. Spine 1988; 13:610-617. Abdu WA, Hilibrand AS, Boden SD, MA, Magora F, Vatine JJ. The significance 816. Revel ME, Listrat VM, Chevalier XJ, Dou- Deyo RA. Surgical vs nonoperative of medical imaging findings in low back gados M, N’guyen MP, Vallee C, Wybier treatment for lumbar disk herniation: pain. Pain Clinic 1994; 7:99-105. M, Gires F, Amor B. Facet joint block for the Spine Patient Outcomes Research 803. Murtagh FR. Computed tomography and low back pain: Identifying predictors of Trial (SPORT): A randomized trial. JAMA fluoroscopy guided anesthesia and ste- a good response. Arch Phys Med Reha- 2006; 296:2441-2450. roid injection in facet syndrome. Spine bil 1992; 73:824-829 793. Weinstein JN, Tosteson TD, Lurie JD, 1988; 13:686-689. 817. Bogduk N. Management of chronic low Tosteson AN, Hanscom B, Skinner JS, 804. Videman T, Battie MC, Gibbons LE, back pain. Med J Aust 2004; 180:79-83. Abdu WA, Hilibrand AS, Boden SD, Deyo Maravilla K, Manninen H, Kaprio J. As- 818. Bogduk N. Diagnostic nerve blocks in RA. Surgical and nonsurgical manage- sociations between back pain history chronic pain. Best Pract Res Clin Anaes- ment of sciatica secondary to a lumbar and lumbar MRI findings. Spine 2003; thesiol 2002; 16:565-578. disc herniation: 10 year results from the 28:582-588. maine lumbar spine study. Spine 2005; 819. Dreyfuss P, Dreyer SJ, NASS. Lumbar 805. Kleinstuck F, Dvorak J, Mannion AF. Are zygapophysial (facet) joint injections. 30:927-935. “structural abnormalities” on magnetic Spine J 2003; 3:50S-59S. 794. Carragee E. Surgical treatment of lumbar resonance imaging a contraindication disk disorders. JAMA 2006; 296:2485- to the successful conservative treat- 820. Dreyfuss PH, Dreyer SJ, Herring SA. Lum- 2487. ment of chronic nonspecific low back bar zygapophysial (facet) joint injec- 795. Weinstein JN, Lurie JD, Tosteson TD, pain? Spine 2006; 31:2250-2257. tions. Spine 1995; 20:2040-2047. Skinner JS, Hanscom B, Tosteson AN, 806. Haig AJ, Tong HC, Yamakawa KS, Quint 821. Jackson RP. The facet syndrome: Myth Herkowitz H, Fischgrund J, Cammisa FP, DJ, Hoff JT, Chiodo A, Miner JA, Choksi or reality? Clin Orthop 1992; 279:110- Albert T, Deyo RA. Surgical vs nonoper- VR, Geisser ME, Parres CM. Spinal ste- 121. ative treatment for lumbar disk herni- nosis, back pain, or no symptoms at all? 822. Jackson RP, Jacobs RR, Montesano PX. ation: the Spine Patient Outcomes Re- A masked study comparing radiologic Facet joint injection in low back pain. search Trial (SPORT) observational co- and electrodiagnostic diagnoses to the A prospective statistical study. Spine hort. JAMA 2006; 296:2451-2459. clinical impression. Arch Phys Med Re- 1988; 13:966-971. 796. Boden SD, McCowin PR, Davis DO, Dina habil 2006; 87:897-903. 823. Bogduk N. A narrative review of intra- TS, Wiesel S. Abnormal magnetic-reso- 807. Kwan O, Friel J. Critical appraisal of fac- articular corticosteroid injections for nance scans of the cervical spine in as- et joints injections for chronic whiplash. low back pain. Pain Med 2005; 6:287- ymptomatic subjects. A prospective in- Med Sci Monit 2002; 8:RA191-195. 296. vestigation. J Bone Joint Surg Am 1990; 808. Yang SC, Yang PH. Significance of the 824. Bogduk N. Diagnostic blocks: A truth 72:1178-1184. bright facet sign on T2W MRI of the lum- serum for malingering. Clin J Pain 2004; 797. Boden SD, Davis DO, Dina TS, Patronas bar facet joint. Mid-Taiwan J Med 2005; 20:409-414. NJ, Wiesel SW. Abnormal magnetic-res- 10:150-154. 825. Hooten WM, Martin DP, Huntoon MA. onance scans of the lumbar spine in as- 809. Manchikanti L, Pampati V, Singh V, Bey- Radiofrequency neurotomy for low back ymptomatic subjects. A prospective in- er C, Damron K, Fellows B. Evaluation pain: evidence-based procedural guide- vestigation. J Bone Joint Surg Am 1990; of role of facet joints in persistent low lines. Pain Med 2005; 6:129-138. 72:403-408. back pain in obesity: A controlled, per- 826. Carette S, Marcoux S, Truchon R, Gron- 798. Borenstein DG, O’Mara JW Jr., Boden spective, comparative evaluation. Pain din C, Gagnon J, Allard Y, Latulippe M. SD, Lauerman WC, Jacobson A, Platen- Physician 2001; 4:266-272. A controlled trial of corticosteroid in- berg C, Schellinger D, Wiesel SW. The 810. Kim TK, Kim KH, Kim CH, Shin SW, Kwon jections into facet joints for chronic low value of magnetic resonance imaging JY, Kim HK, Baik SW. Percutaneous ver- back pain. N Engl J Med 1991; 325:1002- of the lumbar spine to predict low-back tebroplasty and facet joint block. J Kore- 1007. pain in asymptomatic subjects: A sev- an Med Sci 2005; 20:1023-1028. 827. Barnsley L, Lord SM, Wallis BJ, Bogduk en-year follow-up study. J Bone Joint N. Lack of effect of intra-articular corti- Surg Am 2001; 83-A:1306-1311. 811. Ackerman WE, Munir MA, Zhang JM, Ghaleb A. Are diagnostic lumbar facet costeroids for chronic pain in the cervi- 799. Wood KB, Garvey TA, Gundry C, Heithoff injections influenced by pain of muscu- cal zygapophyseal joints. N Engl J Med KB. Magnetic resonance imaging of the lar origin? Pain Pract 2004; 4:286-291. 1994; 330:1047-1050. thoracic spine. Evaluation of asymp- 828. Marks RC, Houston T, Thulbourne T. Fac- tomatic individuals. J Bone Joint Surg 812. Bogduk N. Diagnosing lumbar zyg- et joint injection and facet nerve block. Am 1995; 77:1631-1638. apophysial joint pain. Pain Med 2005; 6:139-142. A randomized comparison in 86 pa- 800. Matsumoto M, Fujimura Y, Suzuki N, Ni- 813. Yamashita T, Cavanaugh JM, el-Bohy AA, tients with chronic low back pain. Pain shi Y, Nakamura M, Yabe Y, Shiga H. MRI 1992; 49:325-328. of cervical intervertebral discs in as- Getchell TV, King AI. Mechanosensitive 829. Nash TP. Facet joints. Intra-articular ste- ymptomatic subjects. J Bone Joint Surg afferent units in the lumbar facet joint. J roids or nerve blocks? Pain Clinic 1990; Br 1998; 80:19-24. Bone Joint Surg Am 1990; 72:865-870. 3:77-82. 801. Jensen MC, Brant-Zawadzki MN, Obu- 814. Özaktay AC, Yamashita T, Cavanaugh 830. Lilius G, Laasonen EM, Myllynen P, chowski N, Modic MT, Malkasian D, JM, King AI. Fine nerve fibers and endings in the fibrous capsule of the lum- Harilainen A, Gronlund G. Lumbar facet www.painphysicianjournal.com 97 Pain Physician: January 2007:10:7-111

joint syndrome. A randomized clinical 844. Manchikanti L, Damron KS, Cash KA, Knape JT, Groen GJ. Radiofrequency de- trial. J Bone Joint Surg Br 1989; 71:681- Manchukonda R, Pampati V. Evalua- nervation of lumbar facet joints in the 684. tion of lumbar facet joint nerve blocks treatment of chronic low back pain: a 831. Fuchs S, Erbe T, Fischer HL, Tibesku CO. in the management of chronic low back randomized, double-blind, sham le- Intraarticular hyaluronic acid versus pain: a preliminary report of a random- sion-controlled trial. Clin J Pain 2005; glucocorticoid injections for nonradicu- ized, double-blind controlled trial. Clini- 21:335-344. lar pain in the lumbar spine. J Vasc In- cal Trial NCT00355914. 2007; in press. 855. Barnsley L. Percutaneous radiofrequen- terv Radiol 2005; 16:1493-1498. 845. Manchikanti L, Manchikanti KN, Dam- cy neurotomy for chronic neck pain: 832. Shih C, Lin GY, Yueh KC, Lin JJ. Lumbar ron KS, Pampati V. Effectiveness of cer- outcomes in a series of consecutive pa- zygapophyseal joint injections in pa- vical medial branch blocks in chron- tients. Pain Med 2005; 6:282-286. tients with chronic lower back pain. J ic neck pain: A prospective outcome 856. Shin WR, Kim HI, Shin DG, Shin DA. Radio- Chin Med Assoc 2005; 68:59-64. study. Pain Physician 2004; 7:195-202. frequency neurotomy of cervical medial 833. Gorbach C, Schmid MR, Elfering A, 846. Manchikanti L, Manchikanti KN, Man- branches for chronic cervicobrachialgia. J Hodler J, Boos N. Therapeutic efficacy of chukonda R, Pampati V, Cash KA. Eval- Korean Med Sci 2006; 21:119-125. facet joint blocks. AJR Am J Roentgenol uation of therapeutic thoracic medi- 857. Birkenmaier C, Veihelmann A, Trouil- 2006; 186:1228-1233. al branch block effectiveness in chron- lier H, Hausdorf J, Devens C, Wegener ic thoracic pain: A prospective outcome 834. Schulte TL, Pietila TA, Heidenreich J, B, Jansson V, von Schulze Pellengahr C. Brock M, Stendel R. Injection therapy study with minimum 1-year follow up. Percutaneous cryodenervation of lum- of lumbar facet syndrome: A prospec- Pain Physician 2006; 9:97-105. bar facet joints: a prospective clinical tive study. Acta Neurochir (Wien) 2006; 847. Lord SM, Barnsley L, Wallis BJ, McDon- trial. Int Orthop 2006; Aug 23. [Epub 148:1165-1172. ald GJ, Bogduk N. Percutaneous radio- ahead of print]. frequency neurotomy for chronic cervi- 835. Kim KH, Choi SH, Kim TK, Shin SW, Kim 858. Staender M, Maerz U, Tonn JC, Steude CH, Kim JI. Cervical facet joint injections cal zygapophyseal joint pain. N Engl J U. Computerized tomography-guided in the neck and shoulder pain. J Korean Med 1996; 335:1721-1726. kryorhizotomy in 76 patients with lum- Med Sci 2005; 20:659-662. 848. van Kleef M, Barendse GA, Kessels A, bar facet joint syndrome. J Neurosurg 836. Folman Y, Livshitz A, Shabat S, Gepstein Voets HM, Weber WE, de Lange S. Ran- Spine 2005; 3:444-449. R. Relief of chronic cervical pain after domized trial of radiofrequency lumbar 859. Mogalles AA, Dreval’ ON, Akatov OV, selective blockade of zygapophyseal facet denervation for chronic low back Kuznetsov AV, Rynkov IP, Plotnikov VM, joint. Harefuah 2004; 143:339-341, 391. pain. Spine 1999; 24:1937-1942. Minaev VP. Percutaneous laser dener- 837. Destouet JM, Gilula LA, Murphy WA, 849. Gallagher J, Vadi PLP, Wesley JR. Radio- vation of the zygapophyseal joints in Monsees B. Lumbar facet joint injec- frequency facet joint denervation in the the pain facet syndrome. Zh Vopr Nei- tion: Indication, technique, clinical cor- treatment of low back pain – A prospec- rokhir Im N N Burdenko 2004; 1:20-25. relation, and preliminary results. Radi- tive controlled double-blind study to 860. Martinez-Suarez JE, Camblor L, Salva ology 1982; 145:321-325. assess efficacy. Pain Clinic 1994; 7:193- S, De Jongh WA. Thermocoagulation of 198. 838. Lynch MC, Taylor JF. Facet joint injec- lumbar facet joints. Experience in 252 tion for low back pain. A clinical study. 850. Sanders M, Zuurmond WWA. Percutane- patients. Revista de la Sociedad Espa- J Bone Joint Surg Br 1986; 68:138-141. ous intraarticular lumbar facet joint de- nola del Dolor 2005; 12:425-428. nervation in the treatment of low back 839. Lippitt AB. The facet joint and its role 861. Sapir D, Gorup JM. Radiofrequency me- pain: A comparison with percutaneous dial branch neurotomy in litigant and in spine pain. Management with facet extra-articular lumbar facet denerva- joint injections. Spine 1984; 9:746-750. nonlitigant patients with cervical whip- tion. Pain Clinic 1999; 11:329-335. lash. Spine 2001; 26:E268-E273. 840. Lau LS, Littlejohn GO, Miller MH. Clini- 851. Leclaire R, Fortin L, Lambert R, Bergeron cal evaluation of intra-articular injec- 862. McDonald GJ, Lord SM, Bogduk N. Long- YM, Rossignol M. Radiofrequency fac- term follow-up of patients treated with tions for lumbar facet joint pain. Med J et joint denervation in the treatment Aust 1985; 143:563-565. cervical radiofrequency neurotomy for of low back pain: a placebo-controlled chronic neck pain. Neurosurgery 1999; 841. Manchikanti L, Pampati V, Bakhit C, Ri- clinical trial to assess efficacy. Spine 45:61-68. vera J, Beyer C, Damron K, Barnhill R. Ef- 2001; 26:1411-1416. 863. Tzaan WC, Tasker RR. Percutaneous ra- fectiveness of lumbar facet joint nerve 852. Buijs EJ, van Wijk RM, Geurts JW, Wee- blocks in chronic low back pain: A ran- diofrequency facet rhizotomy – expe- seman RR, Stolker RJ, Groen GG. Radio- rience with 118 procedures and reap- domized clinical trial. Pain Physician frequency lumbar facet denervation: a 2001; 4: 101-117. praisal of its value. Can J Neurol Sci comparative study of the reproducibil- 2000; 27:125-130. 842. Manchikanti KN, Pampati V, Damron KS, ity of lesion size after 2 current radio- 864. Schaerer JP. Radiofrequency facet rhi- McManus C. A double-blind, controlled frequency techniques. Reg Anesth Pain evaluation of the value of Sarapin in zotomy in the treatment of chronic neck Med 2004; 9:400-407. and low back pain. Int Surg 1978; 63:53- neural blockade. Pain Physician 2004; 853. Haspeslagh SR, Van Suijlekom HA, 7:59-62. 59. Lame IE, Kessels AG, van Kleef M, We- 865. Dreyfuss P, Halbrook B, Pauza K, Joshi 843. Manchikanti L, Damron KS, Cash KA, ber WE. Randomised controlled trial Manchukonda R, Pampati V. Therapeu- A, McLarty J, Bogduk N. Efficacy and of cervical radiofrequency lesions as a validity of radiofrequency neurotomy tic medial branch blocks in managing treatment for cervicogenic headache chronic neck pain: A preliminary report for chronic lumbar zygapophysial joint [ISRCTN07444684]. BMC Anesthesiol pain. Spine 2000; 25:1270-1277. of a randomized, double-blind, con- 2006; 6:1. trolled trial: Clinical Trial NCT0033272. 866. Schofferman J, Kine G. Effectiveness of 854. Van Wijk RM, Geurts JW, Wynne HJ, repeated radiofrequency neurotomy for Pain Physician 2006; 9:333-346. Hammink E, Buskens E, Lousberg R,

98 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

lumbar facet pain. Spine 2004; 29:2471- facet joint radiofrequency denervation 893. Meadeb J, Rozenberg S, Duquesnoy B, 2473. procedures. Pain Med 2002; 3:175-176. Kuntz JL, Le Loet X, Sebert JL, Le Goff P, 867. Vad V, Cano W, Basrai D, Lutz G, Bhat A. 881. Kornick CA, Kramarich SS, Lamer TJ, Fallut M, Marty M, Blevin S, Guggenbuhl Role of radiofrequency denervation in Sitzman BT. Complications of lum- P, Chales G, Duvauferrier R. Forceful sa- lumbar zygapophyseal joint synovitis in bar facet radiofrequency denervation. crococcygeal injections in the treatment baseball pitchers: A clinical experience. Spine 2004; 29:1352-1354. of postdiscectomy sciatica. A controlled Pain Physician 2003; 6:307-312. 882. Manchikanti L, Pampati V, Beyer C, Dam- study versus glucocorticoid injections. Joint Bone Spine 2001; 68:43-49. 868. North RB, Han M, Zahurak M, Kidd DH. ron KS, Cash KA, Moss TL. The effect of Radiofrequency lumbar facet dener- neuraxial steroids on weight and bone 894. Breivik H, Hesla PE, Molnar I, Lind B. vation: analysis of prognostic factors. mass density: A prospective evaluation. Treatment of chronic low back pain and Pain 1994; 57:77-83. Pain Physician 2000; 3:357-366. sciatica. Comparison of caudal epidur- 883. Thomson SJ, Lomax DM, Collett BJ. al injections of bupivacaine and meth- 869. Stolker RJ, Vervest AC, Groen GJ. Per- ylprednisolone with bupivacaine fol- cutaneous facet denervation in chron- Chemical meningism after lumbar facet joint nerve block with local anesthetic lowed by saline. In Bonica JJ, Albe-Fes- ic thoracic spinal pain. Acta Neurochir ard D (eds). Advances in Pain Research (Wien) 1993; 122:82-90. and steroids. Anesthesia 1993; 46:563- 564. and Therapy. Raven Press, New York, 870. Mikeladze G, Espinal R, Finnegan R, 1976; pp 927-932. 884. Nelson DA, Landau WM. Intraspinal ste- Routon J, Martin D. Pulsed radiofre- 895. Bush K, Hillier S. A controlled study of quency application in treatment of roids: History, efficacy, accidentality, and controversy with review of United caudal epidural injections of triamcin- chronic zygapophyseal joint pain. Spine olone plus procaine for the manage- J 2003; 3:360-362. States Food and Drug Administration reports. J Neurol Neurosurg Psychiatry ment of intractable sciatica. Spine 1991; 871. Lindner R, Sluijter ME, Schleinzer W. 2001; 70:433-443. 16:572-575. Pulsed radiofrequency treatment of the 885. Berrigan T. Chemical meningism after 896. Mathews JA, Mills SB, Jenkins VM, lumbar medial branch for facet pain: a Grimes SM, Morkel MJ, Mathews W, retrospective analysis. Pain Med 2006; lumbar facet joint block. Anesthesia 1992; 7:905-906. Scott CM, Sittampalam Y. Back pain 7:435-439. and sciatica: Controlled trials of ma- 886. Bogduk N, Christophidis N, Cherry D. 872. Jerosch J. Facet syndrome. 2. Percuta- nipulation, traction, sclerosant and epi- Epidural use of steroids in the man- neous facet coagulation. Chirurgische dural injections. Brit J Rheumatol 1987; agement of back pain. Report of work- Praxis 2005; 65:43-55. 26:416-423. ing party on epidural use of steroids in 873. Bogduk N. Lumbar radiofrequency neu- the management of back pain. Nation- 897. Beliveau P. A comparison between epi- rotomy. Clin J Pain 2006; 22:409. al Health and Medical Research Council. dural anesthesia with and without cor- 874. Gofeld M. Radiofrequency facet dener- Canberra, Commonwealth of Australia, ticosteroids in the treatment of sciatica. vation: a randomized control place- 1994; pp 1-76. Rheum Phys Med 1971; 11:40-43. bo versus sham procedure. Clin J Pain 887. Rozenberg S. Glucocorticoid therapy in 898. Czarski Z. Leczenie rwy kulszowej 2006; 22:410-411. common lumbar spinal disorders. Rev wstrzykiwaniem hydrokortyzonu inowo- 875. van Kleef M, Weber WE, Kessels A, Drey- Rhum Engl Ed 1998; 65:649-655. kainy do rozworu kryzowego. Przeglad Kekarski 1965; 21:511-513. fuss P, Pauza K, Bogduk N. Re: Efficacy 888. Watts RW, Silagy CA. A meta-analysis on and validity of radiofrequency neurot- the efficacy of epidural corticosteroids 899. Hesla PE, Breivik H. Epidural analgesia omy for chroniclumbar zygapophysial in the treatment of sciatica. Anaesth In- and epidural steroid injection for treat- joint pain (Spine 2000; 25:1270-1277). tensive Care 1995; 23:564-569. ment of chronic low back pain and sci- Spine 2001; 26:E163-E164. atica. Tidsskr Nor Laegeforen 1979; 889. Dashfield AK, Taylor MB, Cleaver JS, 99:936-939. 876. Dreyfuss P, Baker R, Leclaire R, Fortin L, Farrow D. Comparison of caudal ste- Lambert R, Bergeron Y, Rossignol M. Ra- roid epidural with targeted steroid 900. Manchikanti L, Pampati V, Rivera JJ, Bey- diofrequency facet joint denervation in placement during spinal endoscopy for er C, Damron K, Barnhill R. Caudal epi- the treatment of low back pain: a place- chronic sciatica: a prospective, random- dural injections with Sarapin or steroids bo-controlled clinical trial to assess effi- ized, double-blind trial. Br J Anaesth in chronic low back pain. Pain Physician cacy. Spine 2002; 27:556-567. 2005; 94:514-559. 2001; 4:322-335. 877. Bogduk N. Percutaneous radiofrequen- 890. Anwar A, Zaidah I, Rozita R. Prospective 901. Manchikanti L, Singh V, Rivera J, Pam- cy cervical medial branch neurotomy. In randomized single blind study of epidu- pati V, Beyer C, Damron K, Barnhill R. Practice Guidelines for Spinal Diagnos- ral steroid injection comparing triam- Effectiveness of caudal epidural injec- tic and Treatment Procedures, 1st edi- cinalone acetonide with methylprednis- tions in discogram positive and nega- tion, International Spine Intervention olone acetate. APLAR J Rheumatology tive chronic low back pain. Pain Physi- Society, 2004, pp 249-284. 2005; 8:1-53. cian 2002; 5:18-29. 878. Smith M, Ferretti G, Mortazavi S. Ra- 891. McGregor AH, Anjarwalla NK, Stambach 902. Yates DW. A comparison of the types diographic changes induced after cer- T. Does the method of injection alter the of epidural injection commonly used in vical facet radiofrequency denervation. outcome of epidural injections? J Spinal the treatment of low back pain and sci- Spine J 2005; 5:668-671. Disord 2001; 14:507-510. atica. Rheum Rehab 1978; 17:181-186. 879. Manchikanti L. Role of neuraxial ste- 892. Revel M, Auleley GR, Alaoui S, Nguyen 903. Waldman SD. The caudal epidural ad- roids in interventional pain manage- M, Duruoz T, Eck-Michaud S, Roux C, ministration of steroids in combina- ment. Pain Physician 2002; 5:182-199. Amor B. Forceful epidural injections for tion with local anesthetics in the palli- 880. Kornick CA, Kramarich SS, Sitzman BT, the treatment of lumbosciatic pain with ation of pain secondary to radiograph- Marshall KA, Santiago-Palma J, Lamer post-operative lumbar spinal fibrosis. ically documented lumbar herniated TJ. Complication rate associated with Rev Rhum Engl Ed 1996; 63:270-277. disc: A prospective outcome study with www.painphysicianjournal.com 99 Pain Physician: January 2007:10:7-111

6-months follow-up. Pain Clinic 1998; Booth RE Jr, Rothman RH, Pickens GT. jection in the conservative manage- 11:43-49. The use of epidural steroid in the treatment of sciatica. Clin Orth Rel Res 2000; 904. Ciocon JO, Galindo-Ciocon D, Ama- ment of radicular pain. J Bone Joint Surg 375:149-156. ranath L, Galindo D. Caudal epidural AM 1985; 67:63-66. 928. Valat JP, Giraudeau B, Rozenberg S, blocks for elderly patients with lumbar 916. Dilke TFW, Burry HC, Grahame R. Ex- Goupille P, Bourgeois P, Micheau-Beau- canal stenosis. J Am Geriatr Soc 1994; tradural corticosteroid injection in the gendre V, Soubrier M, Richard S, Thom- 42:593-596. management of lumbar nerve root com- as E. Epidural corticosteroid injec- 905. Manchikanti L, Pakanati RR, Pampati V. pression. Br Med J 1973; 2:635-637. tions for sciatica: a randomised, dou- Comparison of three routes of epidural 917. Serrao JM, Marks RL, Morley SJ, Good- ble blind, controlled clinical trial. Ann steroid injections in low back pain. Pain child CS. Intrathecal midazolam for the Rheum Dis 2003; 62:639-643. Digest 1999; 9:277-285. treatment of chronic mechanical low 929. Kraemer J, Ludwig J, Bickert U, Owcza- 906. Barre L, Lutz GE, Southern D, Cooper G. back pain: A controlled comparison rek V, Traupe M. Lumbar epidural peri- Fluoroscopically guided caudal epidu- with epidural steroid in a pilot study. neural injection: A new technique. Eur ral steroid injections for lumbar spinal Pain 1992; 48:5-12. Spine J 1997; 6:357-361. stenosis: A retrospective evaluation of 918. Klenerman L, Greenwood R, Davenport 930. Bush K, Hillier S. Outcome of cervical long-term efficacy.Pain Physician 2004; HT, White DC, Peskett S. Lumbar epidur- radiculopathy treated with periradicu- 7:187-193. al injections in the treatment of sciatica. lar/epidural corticosteroid injections: 907. Banaszkiewicz PA, Kader D, Wardlaw D. Br J Rheumatol 1984; 23:35-38. A prospective study with independent The role of caudal epidural injections in 919. Rocco AG, Frank E, Kaul AF, Lipson SJ, clinical review. Eur Spine J 1996; 5:319- the management of low back pain. Bull Gallo JP. Epidural steroids, epidural 325. Hosp Jt Dis 2003; 61:127-131. morphine and epidural steroids com- 931. Caglar S, Erdine S, Aldemir T. The re- 908. Bronfort G, Evans RL, Maiers M, Ander- bined with morphine in the treatment of sults of the epidural steroid injections son AV. Spinal manipulation, epidur- postlaminectomy syndrome. Pain 1989; in patients with radiculopathies due to al injections, and self-care for sciatica: 36:297-303. lumbar disc herniations. Fiz Tedavi Re- a pilot study for a randomized clinical 920. Ridley MG, Kingsley GH, Gibson T, Gra- habil Derg 1995; 19:186-190. trial. J Manipulative Physiol Ther 2004; hame R. Outpatient lumbar epidural 932. Dallas TL, Lin RL, Wu WH, Wolskee P. 278:503-508. corticosteroid injection in the manage- Epidural morphine and methylprednis- 909. Wilson-MacDonald J, Burt G, Griffin D, ment of sciatica. Br J Rheumatol 1988; olone for low-back pain. Anesthesiolo- Glynn C. Epidural steroid injection for 27:295-299. gy 1987; 67:408-411. nerve root compression. A randomised, 921. Rogers P, Nash T, Schiller D, Norman J. 933. Rivest C, Katz JN, Ferrante FM, Jamison controlled trial. J Bone Joint Surg Br Epidural steroids for sciatica. Pain Clin- RN. Effects of epidural steroid injection 2005; 87:352-355. ic 1992; 5:67-72. on pain due to lumbar spinal stenosis 910. Arden NK, Price C, Reading I, Stubbing 922. Castagnera L, Maurette P, Pointillart V, or herniated discs: A prospective study. J, Hazelgrove J, Dunne C, Michel M, Rog- Vital JM, Erny P, Senegas J. Long-term Arthritis Care Res 1998; 11:291-297. ers P, Cooper C, WEST Study Group. A results of cervical epidural steroid in- 934. Koning HM, Koning AJ, Bruinen TCM; multicentre randomized controlled trial jection with and without morphine in Koster HG; Heybroek E. The period of of epidural corticosteroid injections for chronic cervical radicular pain. Pain pain relief following a successful epidu- sciatica: the WEST study. Rheumatolo- 1994; 58:239-243. ral steroid injection for low back pain. gy (Oxford) 2005; 44:1399-1406. 923. Hernandez R, Lopez F. Assessment of Pain Clinic 2002; 13:331-338. 911. Price C, Arden N, Coglan L, Rogers P. pain intensity in patients with diabetic 935. Andersen KH, Mosdal C. Epidural ap- Cost-effectiveness and safety of epidur- polyneuropathy treated with peridural plication of corticosteroids in low-back al steroids in the management of sciati- 2% lidocaine methylprednisolone ace- pain and sciatica. Acta Neurochir 1987; ca. Health Technol Assess 2005; 9:1-58, tate vs peridural 2% lidocaine. Aneste- 87:52-53. iii. sia en Mexico 1999; 11:65-69. 936. Warfield CA, Crews DA. Epidural steroid 912. Pirbudak L, Karakurum G, Oner U, Gu- 924. Kikuchi A, Kotani N, Sato T, Takamura K, injection as a predictor of surgical out- lec A, Karadasli H. Epidural corticoste- Sakai I, Matsuki A. Comparative thera- come. Surg Gyn Obstet 1987; 164:457- roid injection and amitriptyline for the peutic evaluation of intrathecal versus 458. treatment of chronic low back pain as- epidural methylprednisolone for long- 937. Fukusaki M, Kobayashi I, Hara T, Sumi- sociated with radiculopathy. Pain Clinic term analgesia in patients with intracta- kawa K. Symptoms of spinal stenosis 2003; 15:247-253. ble postherpetic neuralgia. Reg Anesth do not improve after epidural steroid in- 913. Carette S, Leclaire R, Marcoux S, Morin Pain Med 1999; 24:287-293. jection. Clin J Pain 1998; 14:148-151. F, Blaise GA, St-Pierre A, Truchon R, Par- 925. Helliwell M, Robertson JC, Ellia RM. Out- 938. Ferrante FM, Wilson SP, Iacobo C, Orav ent F, Levesque J, Bergeron V, Montminy patient treatment of low back pain and EJ, Rocco AG, Lipson S. Clinical classifi- P, Blanchette C. Epidural corticosteroid sciatica by a single extradural cortico- cation as a predictor of therapeutic out- injections for sciatica due to herniated steroid injection. Br J Clin Pract 1985; come after cervical epidural steroid in- nucleus pulposus. N Engl J Med 1997; 39:228-231. jection. Spine 1993; 18:730-736. 336:1634-1640. 926. Stav A, Ovadia L, Sternberg A, Kaadan 939. Stav A, Ovadia L, Landau M, Weksler N, 914. Snoek W, Weber H, Jorgensen B. Dou- M, Weksler N. Cervical epidural steroid Berman M. Epidural steroid injection in ble-blind evaluation of extradural meth- injection for cervicobrachialgia. Acta the treatment of lumbar and cervical ylprednisolone for herniated lumbar Anaesthesiol Scand 1993; 37:562-566. pain syndromes. A preliminary retro- disc. Acta Orthop Scand 1977; 48:635- 927. Buchner M, Zeifang F, Brocai DR, Schil- spective comparison. Pain Clinic 1991; 641. tenwolf M. Epidural corticosteroid in- 4:95-112. 915. Cuckler JM, Bernini PA, Wiesel SW,

100 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

940. Shulman M. Treatment of neck pain Pain 1999; 15:132-135. tori JM. Fluoroscopy guided L5-S1 trans- with cervical epidural steroid injection. 954. Kolsi I, Delecrin J, Berthelot JM, Thomas foraminal injection as a treatment for s1 Reg Anesth Pain Med 1986; 11:92-94. L, Prost A, Maugars Y. Efficacy of nerve radiculopathy. J Radiol 2004; 85:1937- 941. Catchlove RFH, Braha R. The use of cer- root versus interspinous injections of 1941. vical epidural nerve blocks in the man- glucocorticoids in the treatment of disc- 965. Lutz GE, Vad VB, Wisneski RJ. Fluoro- agement of chronic head and neck pain. related sciatica. A pilot, prospective, scopic transforaminal lumbar epidural Can Anaesth Soc J 1984; 31:188-191. randomized, double-blind study. Joint steroids: An outcome study. Arch Phys 942. Purkis IE. Cervical epidural steroids. Bone Spine 2000; 67:113-118. Med Rehabil 1998; 79:1362-1366. Pain Clinic 1986; 1:3-7. 955. Vad VB, Bhat AL, Lutz GE, Cammisa F. 966. Dreyfuss P, Baker R, Bogduk N. Compar- 943. Rowlingson JC, Kirschenbaum LP. Epi- Transforaminal epidural steroid injec- ative effectiveness of cervical transfo- dural analgesic techniques in the man- tions in lumbosacral radiculopathy; A raminal injections with particulate and agement of cervical pain. Anesth Analg prospective randomized study. Spine nonparticulate corticosteroid prepara- 1986; 65:938-942. 2002; 27:11-16. tions for cervical radicular pain. Pain Med 2006; 7:237-242. 944. Warfield CA, Biber MP, Crews DA, Dwara- 956. Thomas E, Cyteval C, Abiad L, Picot MC, kanath, GK. Epidural steroid injection as Taourel P, Blotman F. Efficacy of transfo- 967. Rull BM, Miralles M, Aure S. Thera- a treatment for cervical radiculitis. Clin J raminal versus interspinous corticoste- peutic epidural infiltrations in the lum- Pain 1988; 4:201-204. roid injection in discal radiculalgia – A bar nerve roots. Rev Orthop Traumatol prospective, randomised, double-blind 1996; 40:209-217. 945. Cicala RS, Thoni K, Angel JJ. Long-term study. Clin Rheumatol 2003; 22:299- results of cervical epidural steroid injec- 968. Berger O, Dousset V, Delmer O, Pointil- 304. tions. Clin J Pain 1989; 5:143-145. lart V, Vital JM, Caille JM. Evaluation of 957. Anderberg L, Annertz M, Persson L, the efficacy of foraminal infusions of 946. Pawl RP, Anderson W, Shulman M. Effect Brandt L, Saveland H. Transforami- corticosteroids guided by computed to- of epidural steroids in the cervical and nal steroid injections for the treatment mography in the treatment of radicu- lumbar region on surgical intervention of cervical radiculopathy: a prospec- lar pain by foraminal injection. J Radiol for discogenic spondylosis. Clin J Pain tive and randomised study. Eur Spine J 1999; 80:917-925. 1985; 1:181-185. 2006; Epub ahead of print. 969. Melzer A, Seibel RM. Magnetic reso- 947. Ozyalcin S, Yucel A, Erdine S. Epidural 958. Ng L, Chaudhary N, Sell P. The efficacy nance (MR)-guided percutaneous pain steroid injection in the treatment of cer- of corticosteroids in periradicular infil- therapy of degenerative spinal diseas- vical pain syndromes: A retrospective tration for chronic radicular pain: a ran- es. Semin Interv Radiol 1999; 16:143- follow up study. Angri Dergisi 1996; 8:9- domized, double-blind, controlled trial. 150. 14. Spine 2005; 30:857-862. 970. Sequeiros RB, Ojala RO, Klemola R, 948. Schaufele MK, Hatch L, Jones W. Inter- 959. Kolstad F, Leivseth G, Nygaard OP. Trans- Vaara TJ, Jyrkinen L, Tervonen OA. MRI- laminar versus transforaminal epidur- foraminal steroid injections in the treat- guided periradicular nerve root infiltra- al injections for the treatment of symp- ment of cervical radiculopathy. A pro- tion therapy in low-field (0.23-T) MRI tomatic lumbar intervertebral disc her- spective outcome study. Acta Neurochir system using optical instrument track- niations. Pain Physician 2006; 9:361- (Wien) 2005; 147:1065-1070. ing. Eur Radiol 2002; 12:1331-1337. 366. 960. Yang SC, Fu TS, Lai PL, Niu CC, Chen 971. Zennaro H, Dousset V, Viaud B, Allard 949. Lin EL, Lieu V, Halevi L, Shamie AN, LH, Chen WJ. Transforaminal epidur- M, Dehais J, Senegas J, Caille JM. Peri- Wang JC. Cervical epidural steroid injec- al steroid injection for discectomy can- ganglionic foraminal steroid injections tions for symptomatic disc herniations. didates: an outcome study with a min- performed under CT control. Am J Neu- J Spinal Disord Tech 2006; 19:183-186. imum of two-year follow-up. Chang roradiol 1998; 19:349-352. 950. Riew KD, Yin Y, Gilula L, Bridwell KH, Gung Med J 2006; 29:93-99. 972. Groenemeyer DH, Gevargez A, Schindler Lenke LG, Lauryssen C, Goette K. The ef- 961. Riew KD, Park JB, Cho YS, Gilula L, Pa- O, Schirp S, Braun M. CT-guided peri- fect of nerve-root injections on the need tel A, Lenke LG, Bridwell KH. Nerve root radicular injections of corticoste- for operative treatment of lumbar radic- blocks in the treatment of lumbar radic- roids in the management of lumbar ular pain. J Bone Joint Surg AM 2000; ular pain. A minimum five-year follow- radiculopathy associated with disk her- 82: 1589-1593. up. J Bone Joint Surg Am 2006; 88:1722- niation. J Radiol 2002; 1-12. 951. Karppinen J, Malmivaara A, Kurunlahti 1725. 973. Buttermann GR. The effect of spinal ste- M, Kyllonen E, Pienimaki T, Nieminen 962. Ng LC, Sell P. Outcomes of a prospective roid injections for degenerative disc dis- P, Ohinmaa A, Tervonen O, Vanharanta cohort study on peri-radicular infiltra- ease. Spine J 2004; 4:495-505. H. Periradicular infiltration for sciatica. tion for radicular pain in patients with Spine 2001; 26:1059-1067. 974. Buttermann GR. Treatment of lumbar lumbar disc herniation and spinal ste- disc herniation: epidural steroid injec- 952. Karppinen J, Ohinmaa A, Malmivaara nosis. Eur Spine J 2004; 13:325-329. tion compared with discectomy. A pro- A, Kurunlahti M, Kyllonen E, Pienimaki 963. Karaeminogullari O, Sahin O, Boyvat F, spective, randomized study. J Bone Joint T, Nieminen P, Tervonen O, Vanharan- Akgun RC, Gurun U, Demirors H, Tuncay Surg Am 2004; 86-A:670-679. ta H. Cost effectiveness of periradicu- IC, Tandogan RN. Transforaminal epidu- lar infiltration for sciatica. Spine 2001; 975. Cyteval C, Thomas E, Decoux E, Sarra- ral steroid injection under computed to- 26:2587-2595. bere MP, Cottin A, Blotman F, Taourel P. mography guidance in relieving lumbo- Cervical radiculopathy: Open study on 953. Devulder J, Deene P, De Laat M, Van sacral radicular pain. Acta Orthop Trau- percutaneous periradicular foraminal Bastelaere M, Brusselmans G, Rolly G. matol Turc 2005; 39:416-420. steroid infiltration performed under CT Nerve root sleeve injections in patients 964. Michel JL, Lemaire S, Bourbon H, Reyni- control in 30 patients. AJNR Am J Neuro- with failed back surgery syndrome: A er C, Lhoste A, Soubrier S, Dubost JJ, Ris- radiol 2004; 25:441-445. comparison of three solutions. Clin J www.painphysicianjournal.com 101 Pain Physician: January 2007:10:7-111

976. Tong HC, Williams JC, Haig AJ, Geisser Pain Med 2002; 27:214-216. blocks–comparison of effectiveness of ME, Chiodo A. Predicting outcomes of 988. Rosenberg SK, Grabinsky A, Kooser C, triamcinolone and betamethasone in- transforaminal epidural injections for Boswell M. Effectiveness of transforam- jectable suspensions. Radiology 2005; sciatica. Spine J 2003; 3:430-434. inal epidural steroid injections in low 237:738-741. 977. Botwin KP, Gruber RD, Bouchlas CG, back pain: A one year experience. Pain 999. Waldman SD. Complications of cervi- Torres-Ramos FM, Sanelli JT, Freeman Physician 2002; 5:266-270. cal epidural nerve blocks with steroids: ED, Slaten WK, Rao S. Fluoroscopical- 989. Wang JC, Lin E, Brodke DS, Youssef JA. A prospective study of 790 consecutive ly guided lumbar transformational epi- Epidural injections for the treatment of blocks. Reg Anesth 1989; 14:149-151. dural steroid injections in degenerative symptomatic lumbar herniated discs. J 1000. Furman MB, Giovanniello MT, O’Brien lumbar stenosis: an outcome study. Am Spinal Disord Tech 2002; 15:269-272. EM. Incidence of intravascular penetra- J Phys Med Rehabil 2002; 81:898-905. 990. Botwin KP, Sakalkale DP. Epidural ste- tion in transforaminal cervical epidural 978. Slipman CW, Lipetz JS, Jackson HB, Rog- roid injections in the treatment of symp- steroid injections. Spine 2003; 28:21- ers DP, Vresilovic EJ. Therapeutic se- tomatic lumbar spinal stenosis associ- 25. lective nerve root block in the nonsur- ated with epidural lipomatosis. Am J 1001. Furman MB, O’Brien EM, Zgleszewski gical treatment of atraumatic cervical Phys Med Rehabil 2004; 83:926-930. TM. Incidence of intravascular penetra- spondylotic radicular pain: A retrospec- 991. Schmid G, Vetter S, Gottmann D, Streck- tion in transforaminal lumbosacral epi- tive analysis with independent clinical er EP. CT-guided epidural/perineural in- dural steroid injections. Spine 2000; review. Arch Phys Med Rehabil 2000; jections in painful disorders of the lum- 25:2628-2632. 81:741-746. bar spine: Short- and extended-term re- 1002. Botwin KP, Gruber RD, Bouchlas CG, 979. Slipman CW, Lipetz JS, DePalma MJ, sults. Cardiovasc Intervent Radiol 1999; Torres-Ramos FM, Freeman TL, Slaten Jackson HB. Therapeutic selective nerve 22:493-498. WK. Complications of fluoroscopically root block in the nonsurgical treatment 992. Groenmeyer DH, Seibel R, Schindler guided transforaminal lumbar epidu- of traumatically induced cervical spon- O, Schattauer K, Lange S, Schmidt A. ral injections. Arch Phys Med Rehabil dylotic radicular pain. Am J Phys Med Microinvasive CT guided periradicu- 2000; 81:1045-1050. Rehabil 2004; 83:446-454. lar therapy for treatment of chronical 1003. Botwin KP, Castellanos R, Rao S, Han- 980. Slipman CW, Lipetz JS, Jackson HB, functional disorders of the spine. Wein- na AF, Torres-Ramos FM, Gruber RD, Plastaras CT, Vresilovic EJ. Outcomes of er Medizinische Wochenschrift 1995; Bouchlas CG, Fuoco GS. Complications therapeutic selective nerve root blocks 145:129-139. of fluoroscopically guided interlaminar for whiplash induced cervical radicular 993. Cooper G, Lutz GE, Boachie-Adjei O, Lin cervical epidural injections. Arch Phys pain. Pain Physician 2001; 4:167-174. J. Effectiveness of transforaminal epi- Med Rehabil 2003; 84:627-633. 981. Lutze M, Stendel R, Vesper J, Brock M. dural steroid injections in patients with 1004. Huang RC, Shapiro GS, Lim M, Sandhu Periradicular therapy in lumbar radic- degenerative lumbar scoliotic steno- HS, Lutz GE, Herzog RJ. Cervical epidu- ular syndromes: Methodology and re- sis and radiculopathy. Pain Physician ral abscess after epidural steroid injec- sults. Acta Neurochir 1997; 139:719- 2004; 7:311-317. tion. Spine 2004; 29:E7-E9. 724. 994. Lee JW, Kim SH, Choi JY, Yeom JS, Kim 1005. Hooten WM, Kinney MO, Huntoon MA. 982. Uhlenbrock D, Arlinghaus J. Results of KJ, Chung SK, Kim HJ, Kim C, Kwack KS, Epidural abscess and meningitis after CT-guided periradicular pain therapy. Kwon JW, Moon SG, Jun WS, Kang HS. epidural corticosteroid injection. Mayo Rofo Fortschr Geb Rontgenstr Neuen Transforaminal epidural steroid injec- Clin Proc 2004; 79:682-686. Bildgeb Verfahr 1997; 166:528-534. tion for lumbosacral radiculopathy: 1006. Stitz MY, Sommer HM. Accuracy of 983. Le Chevallier PL, Videgrain M, Roulleau preganglionic versus conventional ap- blind versus fluoroscopically guided P, Delvert JC, Valat JP, Castaing J. Injec- proach. Korean J Radiol 2006; 7:139- caudal epidural injection. Spine 1999; tion of the sacrolumbar roots: A com- 144. 24:1371-1376. plementary method of staging sciati- 995. Lee JW, Kim SH, Lee IS, Choi JA, Choi 1007. Williams KN, Jackowski A, Evans PJ. ca. 18 cases. Rev Rhum Mal Osteoartic JY, Hong SH, Kang HS. Therapeutic ef- Epidural hematoma requiring surgi- 1978; 45:473-477. fect and outcome predictors of sciati- cal decompression following repeated 984. Devulder J. Transforaminal nerve root ca treated using transforaminal epidu- cervical epidural steroid injections for sleeve injection with corticosteroids, ral steroid injection. AJR Am J Roentgen- chronic pain. Pain 1990; 42:197-199. hyaluronidase, and local anesthetic in ol 2006; 187:1427-1431. 1008. Reitman CA, Watters W. Subdural he- the failed back surgery syndrome. J Spi- 996. Lee KS, Lin CL, Hwang SL, Howng SL, matoma after cervical epidural steroid nal Disord 1998; 11:151-154. Wang CK. Transforaminal periradicular injection. Spine 2002; 27:E174-E176. 985. Weiner BK, Fraser RD. Foraminal injec- infiltration guided by CT for unilateral 1009. Bromage RP, Benumof JL. Paraplegia tion for lateral lumbar disc herniation. J sciatica–an outcome study. Clin Imag- following intracord injection during at- Bone Joint Surg 1997; 79-B:804-807. ing 2005; 29:211-214. tempted epidural anesthesia under 986. Narozny M, Zanetti M, Boos N. Thera- 997. Sasso RC, Macadaeg K, Nordmann D, general anesthesia. Reg Anesth Pain peutic efficacy of selective nerve root Smith M. Selective nerve root injections Med 1998; 23:104-107. blocks in the treatment of lumbar ra- can predict surgical outcome for lumbar 1010. MacLean CA, Bachman DT. Documented dicular leg pain. Swiss Med Wkly 2001; and cervical radiculopathy: comparison arterial gas embolism after spinal epi- 131:75-80. to magnetic resonance imaging. J Spinal dural injection. Ann Emerg Med 2001; 987. Friedman R, Li V, Mehrotra D, Mosuro Disord Tech 2005;18:471-478. 38:592-595. Y, Atkinson G. Foraminal injection of a 998. Blankenbaker DG, De Smet AA, Stanc- 1011. Yue WM, Tan SB. Distant skip level dis- painful sacral nerve root using an epi- zak JD, Fine JP. Lumbar radiculopathy: citis and vertebral osteomyelitis after dural catheter: Case report. Reg Anesth treatment with selective lumbar nerve caudal epidural injection: A case report

102 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

of a rare complication of epidural injec- 113:309-313. ous epidural neuroplasty. Prospective tions. Spine 2003; 28:E209-E211. 1025. Tiso RL, Cutler T, Catania JA, Whalen evaluation of 0.9% NaCl versus 10% 1012. McMillan MR, Crumpton C. Cortical K. Adverse central nervous system se- NaCl with or without hyaluronidase. blindness and neurologic injury compli- quelae after selective transforaminal Reg Anesth Pain Med 1999; 24:202- cating cervical transforaminal injection block: the role of corticosteroids. Spine 207. for cervical radiculopathy. Anesthesiol- J 2004; 4:468-474. 1038. Racz GB, Heavner JE, Raj PP. Percuta- ogy 2003; 99:509-511. 1026. Huntoon MA, Martin DP. Paralysis af- neous epidural neuroplasty. Prospec- 1013. Hodges SD, Castleberg RL, Miller T, ter transforaminal epidural injection tive one-year follow up. Pain Digest Ward R, Thornburg C. Cervical epidur- and previous spinal surgery. Reg Anes- 1999; 9:97-102. al steroid injection with intrinsic spinal th Pain Med 2004; 29:494-495. 1039. Manchikanti L, Rivera JJ, Pampati V, cord damage. Two case reports. Spine 1027. Huntoon MA. The ascending and deep Damron KS, MCManus CD, Brandon DE, 1998; 23:2137-2142. cervical arteries are vulnerable to injury Wilson SR. One day lumbar epidural ad- 1014. Mateo E, Lopez-Alarcon MD, Moliner S, during cervical transforaminal epidural hesiolysis and hypertonic saline neu- Calabuig E, Vivo M, De Andres J, Grau injections: An anatomic study. Present- rolysis in treatment of chronic low back F. Epidural and subarachnoid pneumo- ed at the ASA Annual Meeting, October pain: A randomized, double-blind trial. cephalus after epidural technique. Eur J 23-27, 2004, Las Vegas, Nevada. Pain Physician 2004; 7:177-186 Anesthesiol 1999; 16:413-417. 1028. Nishimura H, Uemura Y, Fukuda S, Ka- 1040. Manchikanti L, Pampati V, Fellows B, 1015. Katz JA, Lukin R, Bridenbaugh PO, Gun- mada Y, Moriwaki T. Two cases of pyo- Rivera JJ, Beyer CD, Damron KS. Role of zenhauser L. Subdural intracranial air: genic cervical discitis presenting tetra- one day epidural adhesiolysis in man- An unusual cause of headache after paresis. No Shinkei Geka 2000; 28:631- agement of chronic low back pain: A epidural steroid injection. Anesthesiol- 637. randomized clinical trial. Pain Physician ogy 1991; 74:615-618. 1029. McHaourab AS. Cervical epidural ste- 2001; 4:153-166. 1016. Benzon HT, Wong HY, Siddiqui T, Ondra roid injection: impact of cervical epi- 1041. Veihelmann A, Devens C, Trouiller H, S. Caution in performing epidural injec- dural anatomy. Anesthesiology 2004; Birkenmaier C, Gerdesmeyer L, Refior tions in patients on several antiplatelet 101:1238-1239. HJ. Epidural neuroplasty versus physio- drugs. Anesthesiology 1999; 91:1558- 1030. Botwin KP, Baskin M, Rao S. Adverse therapy to relieve pain pain in patients 1559. effects of fluoroscopically guided in- with sciatica: a prospective randomized 1017. Waldman SD. Cervical epidural ab- terlaminar thoracic epidural steroid in- blinded clinical trial. J Orthop Science scess after cervical epidural nerve block jections. Am J Phys Med Rehabil 2006; 2006; 11:365-369. with steroids (Letter). Anesth Anal 1991; 85:14-23. 1042. Gerdesmeyer L, Rechl H, Wagenpfeil S, 72:717. 1031. Ziai WC, Ardelt AA, Llinas RH. Brainstem Ulmer M, Lampe R, Wagner K. Minimally invasive epidural neurolysis in chronic 1018. Mamourian AC, Dickman CA, Dray- stroke following uncomplicated cervical er BP, Sonntag VK. Spinal epidural ab- epidural steroid injection. Arch Neurol radiculopathy. A prospective controlled scess: Three cases following spinal epi- 2006; 63:1643-1646. study to prove effectiveness. Der Orho- pade 2003; 32:869-876. dural injection demonstrated with mag- 1032. Pizzimenti JJ, Daniel KP. Central serous netic resonance imaging. Anesthesiolo- chorioretinopathy after epidural ste- 1043. Gerdesmeyer L, Lampe R, Veihelmann gy 1993; 78:204-207. roid injection. Pharmacotherapy 2005; A, Burgkart R, Gobel M, Gollwitzer H, 1019. Knight JW, Cordingley JJ, Palazzo MG. 25:1141-1146. Wagner K. Chronic radiculopathy. Use of minimally invasive percutaneous epi- Epidural abscess following epidural ste- 1033. Botwin KP, Gruber RD, Bouchlas CG, dural neurolysis according to Racz. Der roid and local anesthetic injection. An- Torres-Ramos FM, Hanna A, Rittenberg Schmerz 2005; 19:285-295. aesthesia 1997; 52:576-578. J, Thomas SA. Complications of fluoro- 1020. Kaul S, Meena AK, Sundaram C, Reddy scopically guided caudal epidural in- 1044. Manchikanti L, Pakanati R, Bakhit CE, JM, Naik RT, Murthy JM. Spinal extradu- jections. Am J Phys Med Rehabil 2001; Pampati V. Role of adhesiolysis and hy- ral abscess following local steroid injec- 80:416-424. pertonic saline neurolysis in management of low back pain. Evaluation of tion. Neurol India 2000; 48:181-183. 1034. Quintero N, Laffont I, Bouhmidi L, Rech modification of Racz protocol. Pain Di- C, Schneider AE, Gavardin T, Dizien O. 1021. Tekkok IH, Carter DA, Brinker R. Spinal gest 1999; 9:91-96. subdural hematoma as a complication Transforaminal epidural steroid injec- of immediate epidural blood patch. Can tion and paraplegia: case report and 1045. Manchikanti L, Pampati V, Bakhit CE, J Anaesth 1996; 43:306-309. bibliographic review. Ann Readapt Med Pakanati RR. Non-endoscopic and en- Phys 2006; 49:242-247. doscopic adhesiolysis in post lumbar 1022. Sabel M, Felsberg J, Neuen-Jacob E, Li- laminectomy syndrome. A one-year out- 1035. Chiang HL, Chia YY, Chen YS, Hung CC, chota A, Schnitzler A, Herdmann J. En- come study and cost effective analysis. Liu K, Lo Y. Epidural abscess in an ob- largement of a chronic aseptic lum- Pain Physician 1999; 2:52-58. bar epidural abscess by intraspinal in- stetric patient with patient-controlled jections—a rare cause of progressive epidural analgesia–a case report. Int J 1046. Manchikanti L, Pampati V, Rivera J, Fel- paraparesis. Zentralbl Neurochir 2000; Obstet Anesth 2005; 14:242-245. lows B, Beyer CD, Damron KS, Cash KA. Effectiveness of percutaneous adhe- 61:111-114. 1036. Manchikanti L, Saini B, Singh V. Lumbar siolysis and hypertonic saline neurol- epidural adhesiolysis. In Manchikanti 1023. Gutknecht DR. Chemical meningitis fol- ysis in refractory spinal stenosis. Pain L, Slipman CW, Fellows B (eds), Inter- lowing epidural injections of corticoste- Physician 2001; 4:366-373. roids (Letter). Am J Med 1987; 82:570. ventional Pain Management: Low Back Pain – Diagnosis and Treatment. ASIPP 1047. Racz GB, Holubec JT. Lysis of adhe- 1024. Kusher FH, Olson JC. Retinal hemor- Publishing, Paducah KY 2002; 353-390. sions in the epidural space. In Racz GB rhage as a consequence of epidural ste- (ed). Techniques of Neurolysis. Kluwer roid injection. Arch Opthalmol 1995; 1037. Heavner JE, Racz GB, Raj P. Percutane- www.painphysicianjournal.com 103 Pain Physician: January 2007:10:7-111

Academic Press, Boston, 1989; pp 57- 1059. Lewandowski EM. The efficacy of solu- neuroplasty. Agri 2005; 17:40-43. 72. tions used in caudal neuroplasty. Pain 1074. Luukkainen RK, Wennerstrand PV, 1048. Hammer M, Doleys D, Chung O. Trans- Digest 1997; 7:323-330. Kautiainen HH, Sanila MT, Asikainen foraminal ventral epidural adhesiolysis. 1060. Aldrete JA, Zapata JC, Ghaly R. Arach- EL. Efficacy of periarticular corticoste- Pain Physician 2001; 4: 273-279. noiditis following epidural adhesioly- roid treatment of the sacroiliac joint in 1049. Devulder J, Bogaert L, Castille F, Mo- sis with hypertonic saline report of two non-spondylarthropathic patients with erman A, Rolly G. Relevance of epidu- cases. Pain Digest 1996; 6:368-370. chronic low back pain in the region of rography and epidural adhesiolysis in 1061. Hitchcock ER, Prandini MN. Hyperton- the sacroiliac joint. Clin Exp Rheumatol chronic failed back surgery patients. ic saline in management of intractable 2002; 20:52-54. Clin J Pain 1995; 11:147-150. pain. Lancet 1973; 1:310-312. 1075. Maugars Y, Mathis C, Berthelot JM, 1050. Arthur J, Racz GB, Heinrich R, Diede JH, 1062. Lucas JT, Ducker TB, Perot PL. Adverse Charlier C, Prost A. Assessment of the McCann M, Wilson E, Heavner J C., Noe reactions to intrathecal saline injec- efficacy of sacroiliac corticosteroid in- C. Epidural space. Identification of fill- tions for control of pain. J Neurosurg jections spondyloarthropathies: a dou- ing defects in lysis of adhesions in the 1975; 42:557-561. ble blind study. Br J Rheumatol 1996; 35:767-770. treatment of chronic painful conditions. 1063. Dagi TF. Comments on myelopathy af- In: Abstracts, 7th World Congress of ter the intrathecal administration of hy- 1076. Fischer T, Biedermann T, Hermann KG, Pain. Paris, IASP Publications, 1993, pp pertonic saline. Neurosurgery 1988; Diekmann F, Braun J, Hamm B, Bollow 557. 22:944-945. M. Sacroiliitis in children with spondyloarthropathy: therapeutic effect of CT- 1051. Manchikanti L, Singh V. Epidural lysis of 1064. Lundy JS, Essex HE, Kernohan JW. Ex- guided intra-articular corticosteroid in- adhesions and myeloscopy. Curr Pain periments with anesthetics. IV. Lesions jection. Rofo 2003; 175:814-821. Headache Rep 2002; 6:427-435. produced in the spinal cord of dogs by 1052. Manchikanti L, Rivera JJ, Pampati V, a dose of procaine hydrochloride suffi- 1077. Luukkainen R, Nissila M, Asikainen Damron KS, Beyer CD, Brandon DE, Wil- cient to cause permanent and fatal pa- E, Sanila M, Lehtinen K, Alanaatu A, son SR. Spinal endoscopic adhesiolysis ralysis. JAMA 1936; 101: 1546-1550. Kautianen H. Periarticular corticosteroid treatment of the sacroiliac joint in in the management of chronic low back 1065. Gentili ME, Samii K. Accidental epidu- patients with seronegative spondylo- pain: A preliminary report of a random- ral injection of hypertonic sodium chlo- arthropathy. Clin Exp Rheumatol 1999; ized, double-blind trial. Pain Physician ride solution. Ann Fr Anesth Reanim 17:88-90. 2003; 6:259-268. 1991; 10:401-403. 1078. Karabacakoglu A, Karakose S, Ozer- 1053. Manchikanti L, Boswell MV, Rivera JJ, 1066. Manchikanti L, Bakhit CE. Removal of bil OM, Odev K. Fluoroscopy-guided Pampati V, Damron KS, McManus CD, torn Racz catheter from lumbar epidu- intraarticular corticosteroid injection Brandon DE, Wilson SR. A randomized, ral space. Reg Anesth Pain Med 1997; into the sacroiliac joints in patients controlled trial of spinal endoscopic ad- 22:579-581. hesiolysis in chronic refractory low back with ankylosing spondylitis. Acta Radi- 1067. Tabandeh H. Intraocular hemorrhages ol 2002; 43:425-427. and lower extremity pain. BMC Anesthe- associated with endoscopic spinal sur- 1079. Hanly JG, Mitchell M, MacMillan L, siol 2005; 5:10 gery. Am J Ophthalmol 2000; 129:688- Mosher D, Sutton E. Efficacy of sacroil- 1054. Geurts JW, Kallewaard JW, Richardson 690. J, Groen. Targeted methylprednisolone iac corticosteroid injections in patients 1068. Hammer M. Safety of spinal endos- with inflammatory spondyloarthrop- acetate/hyaluronidase/clonidine injec- copy is contingent on basic image in- tion after diagnostic epiduroscopy for athy: Results of a 5-month controlled terpretation. Letter to the editor. Reg study. J Rheum 2000; 27:719-722. chronic sciatica: a prospective, 1-year Anesth Pain Med 2002; 27:621. follow-up study. Reg Anesth Pain Med 1080. Maugars Y, Mathis C, Vilon P, Prost A. 2002; 27:343-352. 1069. Talu GK, Erdine S. Complications of epi- Corticosteroid injection of the sacroil- dural neuroplasty: a retrospective eval- 1055. Igarashi T, Hirabayashi Y, Seo N, Saitoh iac joint in patients with seronegative uation. Neuromodulation 2003; 6:237- spondylarthropathy. Arthritis Rheum K, Fukuda H, Suzuki H. Lysis of adhe- 347. sions and epidural injection of ste- 1992; 35:564-568. roid/local anesthetic during epiduros- 1070. Perkins WJ, Davis DH, Huntoon MA, 1081. Bollow M, Braun J, Taupitz M, Haberle J, copy potentially alleviate low back and Horlocker TT. A retained Racz catheter Reibhauer BH, Paris S, Mutze S, Seyrek- leg pain in elderly patients with lum- fragment after epidural neurolysis: im- basan F, Wolf KJ, Hamm B. CT-guided bar spine stenosis. Br J Anaesth 2004; plications during magnetic resonance intraarticular corticosteroid injection 93:181-187. imaging. Anesth Analg 2003; 96:1717- into the sacroiliac joints in patients with 1719. 1056. Richardson J, McGurgan P, Chee- spondyloarthropathy: indication and ma S, Prasad R, Gupta S. Spinal en- 1071. Richter HP. Is the so-called epidural follow-up with contrast-enhanced MRI. doscopy in chronic low back pain with neuroplasty (Racz catheter) a harmless J Comput Assist Tomogr 1996; 20:512- radiculopathy: A prospective case se- procedure? Meeting abstract. Deutsche 521. ries. Anaesthesia 2001; 56:454-460. Gesellschaft für Neurochirurgie, Stras- 1082. Braun J, Bollow M, Seyrekbasan F, bourg, Germany May 2005. 1057. Manchikanti L, Pakanati RR, Pampati Haberle HJ, Eggens U, Mertz A, Dis- V. The value and safety of epidural en- 1072. Wagner KJ, Sprenger T, Pecho C, Kochs tler A, Sieper J. Computed tomography doscopic adhesiolysis. Am J Anesthesi- EF, Tölle TR, Berthele A, Gerdesmeyer guided corticosteroid injection of the ol 2000; 27:275-279. L. Risks and complications of epidural sacroiliac joint in patients with spon- neurolysis – a review with case report. dyloarthropathy with sacroiliitis: clini- 1058. Saberski L. A retrospective analysis of Anasthesiol Intensmed Notfallmed cal outcome and follow-up by dynam- spinal canal endoscopy and laminec- Schmerzther 2006; 41:213-222. ic magnetic resonance imaging. J Rheu- tomy outcomes data. Pain Physician 1073. Akbas M, Karsli B. Caudal epidural matol 1996; 23:659-664. 2000; 3:193-196.

104 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

1083. Gunaydin I, Pereira PL, Daikeler T, faction. Reg Anesth Pain Med 2007; trothermy (IDET) for chronic low back Mohren M, Trubenbach J, Schick F, Kanz 32:12-19. pain. Pain Physician 2002; 5:360-364. L, Kotter I. Magnetic resonance imaging 1095. Crock HV. Abnormal disc disruption. 1108. Saal JA, Saal JS. Intradiscal electro- guided corticosteroid injection of the A challenge to disc prolapse fifty years thermal treatment for chronic discogen- sacroiliac joints in patients with therapy on. Spine 1986; 11:650-653. ic low back pain: prospective outcome resistant spondyloarthropathy: A pilot 1096. Kapural L, Hayek S, Malak O, Arrigain study with a minimum 2-year follow-up. study. J Rheumatol 2000; 27:424-428. S, Mekhail N. Intradiscal thermal an- Spine 2002; 27:966-973. 1084. Pereira PL, Gunaydin I, Duda SH, Tr- nuloplasty versus intradiscal radiofre- 1109. Spruit M, Jacobs WC. Pain and func- ubenbach J, Remy CT, Kotter I, Kastler quency ablation for the treatment of tion after intradiscal electrothermal B, Claussen CD. Corticosteroid injec- discogenic pain: a prospective matched treatment (IDET) for symptomatic lum- tions of the sacroiliac joint during mag- control trial. Pain Med 2005; 6:425- bar disc degeneration. Eur Spine J 2002; netic resonance: preliminary results [in 431. 11:589-593. French]. J Radiol 2000; 81:223-226. 1097. Saal JA, Saal JS. Intradiscal electro- 1110. Lutz C, Lutz GE, Cooke PM. Treatment 1085. Pereira PL, Gunaydin I, Trubenbach thermal treatment for chronic discogen- of chronic lumbar diskogenic pain with J,Dammann F, Remy CT, Kotter I, Schick ic low back pain: a prospective outcome intradiscal electrothermal therapy: A F, Koenig CW, Claussen CD. Interven- study with minimum 1-year follow-up. prospective outcome study. Arch Phys tional MR imaging for injection of sac- Spine 2000; 25:2622-2627. Med Rehabil 2003; 84:23-28. roiliac joints in patients with sacroiliitis. 1098. Bogduk N, Lau P, Govind J, Karasek M. 1111. Kapural L, Mekhail N, Korunda Z, Basali AJR Am J Roentgenol 2000; 175:265- Intradiscal electrothermal therapy. Tech A. Intradiscal thermal annuloplasty for 266. Reg Anesth Pain Manag 2005; 9: 25- the treatment of lumbar discogenic pain 1086. Ojala R, Klemola R, Karppinen J, Se- 34. in patients with multilevel degenera- queiros RB, Tervonen O. Sacro-iliac joint 1099. Pauza KJ, Howell S, Dreyfuss P. A ran- tive disc disease. Anesth Analg 2004; arthrography in low back pain: feasibil- domized, placebo-controlled trial of in- 99:472-476. ity of MRI guidance. Eur J Radiol 2001; tradiscal electrothermal therapy for the 1112. Mekhail N, Kapural L. Intradiscal ther- 40:236-239. treatment of discogenic low back pain. mal annuloplasty for discogenic pain: 1087. Dussault RG, Kaplan PA, Anderson MW. Spine J 2004; 4:27-35. An outcome study. Pain Practice 2004; Fluoroscopy-guided sacroiliac joint in- 1100. Freeman BJ, Fraser RD, Cain CM, Hall 4:84-90. jections. Radiology 2000;214:273-277. DJ, Chapple DC. A randomized, double- 1113. Bryce DA, Nelson J, Glurich I, Berq RL. 1088. Slipman CW, Lipetz JS, Plastaras CT, blind, controlled trial: intradiscal elec- Intradiscal electrothermal annuloplasty Jackson HB, Vresilovic EJ, Lenrow DA, trothermal therapy versus placebo for therapy: A case series study leading to Braverman DL. Fluoroscopically guided the treatment of chronic discogenic low new considerations. WMJ 2005; 104:39- therapeutic sacroiliac joint injections back pain. Spine 2005; 30:2369-2377. 46. for sacroiliac joint syndrome. Am J Phys 1101. Karasek M, Bogduk N. Twelve-month fol- 1114. Endres SM, Fiedler GA, Larson KL. Effec- Med Rehabil 2001; 80:425-432. low-up of a controlled trial of intradiscal tiveness of intradiscal electrothermal 1089. Chakraverty R, Dias R. Audit of conser- thermal annuloplasty for back pain due therapy in increasing function and re- vative management of chronic low back to internal disc disruption. Spine 2000; ducing chronic low back pain in select- pain in a secondary care setting–part I: 25:2601-2607. ed patients. WMJ 2002; 101:31-34. facet joint and sacroiliac joint interven- 1102. Bogduk N, Karasek M. Two-year follow- 1115. Cohen SP, Larkin T, Abdi S, Chang A, tions. Acupunct Med 2004; 22:207-213. up of a controlled trial of intradiscal Stojanovic M. Risk factors for failure 1090. Ferrante FM, King LF, Roche EA, Kim electrothermal anuloplasty for chron- and complications of intradiscal elec- PS, Aranda M, Delaney LR, Mardini IA, ic low back pain resulting from internal trothermal therapy: A pilot study. Spine Mannes AJ. Radiofrequency sacroili- disc disruption. Spine J 2002; 2:343- 2003; 28:1142-1147. ac joint denervation for sacroiliac syn- 350. 1116. Freedman BA, Cohen SP, Kuklo TR, drome. Reg Anesth Pain Med 2001; 1103. Derby R, Eek B, Chen Y, O’Neill C, Ryan Lehman RA, Larkin P, Giuliani JR. Intra- 26:137–142. D. Intradiscal electrothermal annu- discal electrothermal therapy (IDET) for 1091. Gevargez A, Groenemeyer D, Schirp S, loplasty (IDET): A novel approach for chronic low back pain in active duty sol- Braun M. CT-guided percutaneous ra- treating chronic discogenic back pain. diers: 2-year follow-up. Spine J 2003; diofrequency denervation of the sac- Neuromodulation 2000; 3:82-88. 3:502-509. roiliac joint. Eur Radiol 2002; 12:1360– 1104. Saal JS, Saal JA. Management of chron- 1117. Lee MS, Cooper G, Lutz GE, Lutz C, Hong 1365. ic discogenic low back pain with a ther- HM. Intradiscal electrothermal thera- 1092. Cohen SP, Abdi S. Lateral branch blocks mal intradiscal catheter. A preliminary py (IDET) for treatment of chronic lum- as a treatment for sacroiliac joint pain: a report. Spine 2000; 25:382-388. bar discogenic pain: A minimum 2-year pilot study. Reg Anesth Pain Med 2003; 1105. Welch WC, Gerszten PC, McGrath P. In- clinical outcome study. Pain Physician 28:113–119. tradiscal electrothermy: Indications, 2003; 6:443–448. 1093. Buijs EJ, Kamphuis ET, Groen GJ. Radio- techniques, and clinical results. Clin 1118. Webster BS, Verma S, Pranksy GS. Out- frequency treatment of sacroiliac joint- Neurosurg 2001; 48:219-225. comes of workers’ compensation claim- related pain aimed at the first three 1106. Singh V. Intradiscal electrothermal ther- ants with low back pain undergoing in- sacral dorsal rami: a minimal approach. apy: A preliminary report. Pain Physi- tradiscal electrothermal therapy. Spine Pain Clinic 2004; 16:139–146. cian 2000; 3:367-373. 2004; 29:435–441. 1094. Burnham RS, Yasui Y. An alternate 1107. Gerszten PC, Welch WC, McGrath PM, 1119. Davis TT, Delamarter RB, Sra P, Gold- method of radiofrequency neurotomy Willis SL. A prospective outcome study stein TB. The IDET procedure for chronic of the sacroiliac joint: A pilot study of of patients undergoing intradiscal elec- discogenic low back pain. Spine 2004; the effect of pain, function, and satis- www.painphysicianjournal.com 105 Pain Physician: January 2007:10:7-111

29:752–756. kectomy for lumbar disk herniation. A 83:31-33. 1120. Derby R, Seo KS, Kazala K, Chen YC, Lee preliminary report. Clin Orthop Relat 1146. Grevitt MP, McLaren A, Shackleford SH, Kim BJ. A factor analysis of lumbar Res 1993; 286:174-179. IM, Mulholland RC. Automated percu- intradiscal electrothermal annuloplasty 1135. Waddell G, Gibson A, Grant I. Surgical taneous lumbar discectomy. An out- outcomes. Spine J 2005; 5:256-261. treatment of lumbar disc prolapse and come study. J Bone Joint Surg Br 1995; 1121. Hsia AW, Isaac K, Katz JS. Cauda equina degenerative lumbar disc disease. In 77:626-629. syndrome from intradiscal electrother- Nachemson AL, Jonsson E (eds). Neck 1147. Fiume D, Parziale G, Rinaldi A, Sher- and Back Pain: The Scientific Evidence mal therapy. Neurology 2000; 55:320. kat S. Automated percutaneous discec- of Causes, Diagnosis and Treatment, 1122. Saal JA. Complications related to intra- tomy in herniated lumbar discs treat- Lippincott Williams & Wilkins, 2000; pp discal electrothermal therapy: Technical ment: experience after the first 200 cas- 305-326. considerations and prevention. Semin es. J Neurosurg Sci 1994; 38:235-237. 1136. Krugluger J, Knahr K. Chemonucleolysis Spine Surg 2002; 14:163-165. 1148. Choy DS. Percutaneous laser disc de- and automated percutaneous discecto- 1123. Lee J, Lutz GE, Campbell D, Rodeo SA, compression (PLDD) update: Focus on my–a prospective randomized compari- Wright T. Stability of the lumbar spine device and procedure advances. J Clin son. Int Orthop 2000; 24:167-169. after intradiscal electrothermal therapy. Laser Med Surg 1993; 11:181-183. 1137. Chatterjee S, Foy PM, Findlay GF. Report Arch Phys Med Rehabil 2001; 82:120- 1149. Dullerud R, Amundsen T, Lie H, Juel NG, of a controlled clinical trial comparing 122. Abdelnoor M, Magnaes B. Clinical re- automated percutaneous lumbar dis- 1124. Ackerman WE. Cauda equina syndrome sults after percutaneous automated cectomy and microdiscectomy in the after intradiscal electrothermal therapy. lumbar nucleotomy. A follow-up study. treatment of contained lumbar disc her- Reg Anaesth Pain Med 2002; 27:622. Acta Radiol 1995; 36:418-424. niation. Spine 1995; 20:734-738. 1125. Eckel TS, Ortiz AO. Intradiscal electro- 1150. Gill K. New-onset sciatica after auto- 1138. Haines SJ, Jordan N, Boen JR, Nyman thermal therapy in the treatment of dis- mated percutaneous discectomy. Spine JA, Oldridge NB, Lindgren BR; LAPDOG/ cogenic low back pain. Tech Vasc Interv 1994; 19:466-467. Radiol 2002; 5:217-222. LEAPDOG Investigators. Discectomy strategies for lumbar disc herniation: 1151. Schaffer JL, Kambin P. A multicenter 1126. Djurasovic M, Glassman SD, Dimar JR results of the LAPDOG trial. J Clin Neu- analysis of percutaneous discectomy. 2nd, Johnson JR. Vertebral osteonecro- rosci 2002; 9:411-417. Spine 1991; 16:854-855. sis associated with the use of intradis- 1139. Haines SJ, Jordan N, Boen JR, Nyman 1152. Stevenson RC, McCabe CJ, Findlay AM. cal electrothermal therapy. A case re- An economic evaluation of a clinical tri- port. Spine 2002; 27:E325–E328 JA, Oldridge NB, Lindgren BR; LAP- DOG/LEAPDOG Investigators. Discec- al to compare automated percutaneous 1127. Scholl BM, Theiss SM, Lopez-Ben R, tomy strategies for lumbar disc hernia- lumbar discectomy with microdiscecto- Kraft M. Vertebral osteonecrosis related tion: study design and implications for my in the treatment of contained lum- to intradiscal electrothermal therapy: A clinical research. J Clin Neurosci 2002; bar disc herniation. Spine 1995; 20:739- case report. Spine 2003; 28:E161–E164. 9:440-446. 742. 1128. Wetzel FT. Cauda equina syndrome from 1140. Teng GJ, Jeffery RF, Guo JH, He SC, Zhu 1153. Casper GD, Hartman VL, Mullins LL. Per- intradiscal electrothermal therapy. Neu- HZ, Wang XH, Wu YZ, Lu JM, Ling XL, cutaneous laser disc decompression rology 2001; 56:1607. Qian Y, Zhang YM, Zhu MJ, Guan L, He with the holmium: YAG laser. J Clin La- 1129. Orr RD, Thomas S. Intradural migra- XM. Automated percutaneous lumbar ser Med Surg 1995; 13:195-203. tion of broken IDET catheter causing discectomy: a prospective multi-institu- 1154. Bosacco SJ, Bosacco DN, Berman AT, a radiculopathy. J Spinal Disord Tech tional study. J Vasc Interv Radiol 1997; Cordover A, Levenberg RJ, Stellabotte J. 2005; 18:185-187. 8:457-463. Functional results of percutaneous laser 1130. Cohen SP, Larkin T, Polly DW Jr. A gi- 1141. Onik G, Mooney V, Maroon JC, Wiltse L, discectomy. Am J Orthop 1996; 25:825- ant herniated disc following intradiscal Helms C, Schweigel J, Watkins R, Kah- 828. electrothermal therapy. J Spinal Disord anovitz N, Day A, Morris J. Automated 1155. Choy DS. Percutaneous laser disc de- Tech 2002; 15:537-541. percutaneous discectomy: A prospec- compression (PLDD): Twelve years’ ex- 1131. Finch PM, Price LM, Drummond PD. Ra- tive multi-institutional study. Neurosur- perience with 752 procedures in 518 diofrequency heating of painful annular gery 1990; 26:228-232. patients. J Clin Laser Med Surg 1998; disruptions: one-year outcomes. J Spi- 1142. Bernd L, Schiltenwolf M, Mau H, Schin- 16:325-331. nal Disord Tech 2005; 18:6-13. dele S. No indications for percutaneous 1156. Siebert WE, Berendsen BT, Tollgaard J. 1132. Delamarter RB, Howard MW, Goldstein lumbar discectomy? Int Orthop 1997; Percutaneous laser disk decompres- T, Deutsch AL, Mink JH, Dawson EG. Per- 21:164-168. sion. Experience since 1989. Orthopade cutaneous lumbar discectomy. Preoper- 1143. Sortland O, Kleppe H, Aandahl M, Bli- 1996; 25:42-48. ative and postoperative magnetic res- kra G. Percutaneous lumbar discecto- 1157. Ohnmeiss DD, Guyer RD, Hochschuler onance imaging. J Bone Joint Surg Am my. Technique and clinical result. Acta SH. Laser disc decompression. The im- 1995; 77:578-584. Radiol 1996; 37:85-90. portance of proper patient selection. 1133. Revel M, Payan C, Vallee C, Laredo JD, 1144. Negri V, Belledi G. Percutaneous nucle- Spine 1994; 19:2054-2058. Lassale B, Roux C, Carter H, Salomon C, otomy according to Onik: indications 1158. Liebler WA. Percutaneous laser disc nu- Delmas E, Roucoules J. Automated per- and results in 76 cases. Chir Organi Mov cleotomy. Clin Orthop Relat Res 1995; cutaneous lumbar discectomy versus 1996; 81:49-54. 310:58-66. chemonucleolysis in the treatment of 1145. Shapiro S. Long-term follow up of 57 1159. Botsford JA. Radiological consider- sciatica. A randomized multicenter trial. patients undergoing automated percu- ations: patient selection for percutane- Spine 1993; 18:1-7 taneous discectomy. J Neurosurg 1995; ous laser disc decompression. J Clin La- 1134. Sakou T, Masuda A. Percutaneous dis-

106 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

ser Med Surg 1994; 12:255-259. performed by an internist resulting in Hovorka I, Roux C, Chevallier P, Brune- 1160. Senel A, Gokyar A, Iyigun O, Cokluk C, cauda equina syndrome. J Spinal Disord ton JN. Clinical follow-up of 50 patients Rakunt, C; Celik, F. Percutaneous lum- 1999; 12:77-79. treated by percutaneous lumbar discec- bar disc decompression with NdYAG la- 1172. Chen YC, Lee SH, Chen D. Intradiscal tomy. Clin Imaging 2006; 30:242-244. ser. Ondokuz Mayis Universitesi Tip er- pressure study of percutaneous disc 1185. Domsky R, Goldberg M, Hirsh RA, Scar- gisi 1998; 15:221-226. decompression with nucleoplasty in inge D, Torjman MC. Critical failure of a 1161. Knight M, Goswami A. Lumbar percu- human cadavers. Spine 2003; 28:661- percutaneous discectomy probe requir- taneous KTP532 wavelength laser disc 665. ing surgical removal during disc decom- decompression and disc ablation in the 1173. Chen YC, Lee SH, Saenz Y, Lehman NL. pression. Reg Anesth Pain Med 2006; management of discogenic pain. J Clin Histologic findings of disc, end plate 31:177-179. Laser Med Surg 2002; 20:9-13. and neural elements after coblation of 1186. Old J, Calvert M. Vertebral compression 1162. Groenmeyer DH, Buschkamp H, Braun nucleus pulposus: An experimental nu- fractures in the elderly. Am Fam Physi- M, Schirp S, Weinsheimer PA, Gevargez cleoplasty study. Spine J 2003; 3:466- cian 2004; 69:111-1116. A. Image-guided percutaneous laser 470. 1187. Hall SE, Criddle RA, Comito TL, Prince disk decompression for herniated lum- 1174. Singh V, Piryani C, Liao K, Nieschultz RL. A case-control study of quality of bar disks: a 4-year follow-up in 200 S. Percutaneous disc decompression life and functional impairment in wom- patients. J Clin Laser Med Surg 2003; using coblation (nucleoplasty) in the en with long-standing vertebral osteo- 21:131-138. treatment of chronic discogenic pain. porotic fractures. Osteoporos Int 1999; 1163. Tassi GP. Preliminary Italian experience Pain Physician 2002; 5:250-259. 9:508. of lumbar spine percutaneous laser disc 1175. Sharps LS, Isaac Z. Percutaneous disc 1188. Report on Osteoporosis in the Europe- decompression according to Choy’s decompression using Nucleoplasty. an Commission. European Commission, method. Photomed Laser Surg 2004; Pain Physician 2002; 5:121-126. DG Employment, Industrial Relations 22:439-441. 1176. Welch WC, Gerszten PC. Alternative and Social Affairs, 1998. 1164. Zhao D, Du F, Yang J, Zheng YB. Cohort- strategies for lumbar discectomy: intra- 1189. Silverman SL. The clinical consequenc- controlled study on percutaneous laser discal electrothermy and nucleoplasty. es of vertebral compression fracture. decompression in treating lumbar disc Neurosurg Focus 2002; 13:E7. Bone 1992; 13(suppl 2):S27-S31. herniation. Chin J Clin Rehabil 2005; 1177. Singh V, Piryani C, Liao K. Role of per- 1190. Rapado A. General management of ver- 9:202-203. cutaneous disc decompression using tebral fractures. Bone 1996; 18(suppl 1165. Lee SH, Chung SE, Ahn Y, Kim TH, Park coblation in managing chronic disco- 3):191-196. JY, Shin SW. Comparative radiologic genic low back pain: A prospective, ob- 1191. Reginster J, Minne HW, Sorensen OH, evaluation of percutaneous endoscopic servational study. Pain Physician 2004; Hooper M, Roux C, Brandi ML, Lund B, lumbar discectomy and open microdis- 7:419-425. Ethgen D, Pack S, Roumagnac I, Eastell cectomy: a matched cohort analysis. Mt 1178. Singh V, Piryani C, Liao K. Evaluation of R. Randomized controlled trial of rise- Sinai J Med 2006; 73:795-801. percutaneous disc decompression us- dronate on vertebral fractures in wom- 1166. Tonami H, Yokota H, Nakagawa T, Hi- ing coblation in chronic back pain with en with established postmenopaus- gashi K, Okimura T, Yamamoto I, Nishi- or without leg pain. Pain Physician al osteoporosis. Osteoporos Int 2000; jima Y. Percutaneous laser discectomy: 2003; 6:273-280. 11:83-91. MR findings within the first 24 hours 1179. Marin FZ. CAM versus nucleoplasty. 1192. Philips FM. Minimally invasive treat- after treatment and their relationship Acta Neurochir Suppl 2005; 92:111-114. ments of osteoporotic vertebral com- to clinical outcome. Clin Radiol 1997; pression fractures. Spine 2003; 28(sup- 52:938-944. 1180. Gerszten PC, Welch WC, King JT. Quality of life assessment in patients undergo- pl):45-52. 1167. Nerubay J, Caspi I, Levinkopf M. Percu- ing nucleoplasty-based percutaneous 1193. Hu SS. Internal fixation in osteoporotic taneous carbon dioxide laser nucleoly- discectomy. J Neurosurg Spine 2006; spine Spine 1997; 22(suppl):42-45. sis with 2- to 5-year followup. Clin Or- 4:36-42. thop Relat Res 1997; 337:45-48. 1194. Dickman C, Fessler RG, MacMillan M, 1181. Bhagia SM, Slipman CW, Nirschl M, Haid RW. Transpedicular screw-rod fix- 1168. Simons P, Lensker E, von Wild K. Per- Isaac Z, El-Abd O, Sharps LS, Garvin ation of the lumbar spine: operative cutaneous nucleus pulposus denatur- C. Side effects and complications af- technique and outcome in 104 cases. J ation in treatment of lumbar disc pro- ter percutaneous disc decompression Neurosurg 1992; 77:860-870. trusions–a prospective study of 50 neu- using coblation technology. Am J Phys 1195. Essens S, Sacs BL, Drezyin V. Compli- rosurgical patients. Eur Spine J 1994; Med Rehabil 2006; 85:6-13. 3:219-221. cations associated with the technique 1182. Alo KM, Wright RE, Sutcliffe J, Brandt of pedicle screw fixation: A selected 1169. Mayer HM, Brock M, Stern E. Percuta- SA. Percutaneous lumbar discectomy: survey of ABC members. Spine 1993; neous endoscopic laser discectomy: Clinical response in an initial cohort of 18:2231-2239. Experimental results. In Percutaneous fifty consecutive patients with chronic 1196. Galibert P, Deramond H, Rosat P, Le Lumbar Discectomy. Springer-Verlag, radicular pain. Pain Pract 2004; 4:19- Heidelberg, 1989. Gars D. Preliminary note on the treat- 29. ment of vertebral angioma by percuta- 1170. Epstein NE. Nerve root complications 1183. Alo KM, Wright RE, Sutcliffe J, Brandt SA. neous acrylic vertebroplasty [in French]. of percutaneous laser-assisted diskec- Percutaneous lumbar discectomy: one- Neurochirurgie 1987; 33:166-168. tomy performed at outside institutions: year follow-up in an initial cohort of fifty 1197. Coumans JV, Reinhardt MK, Lieberman A technical note. J Spinal Disord 1994; consecutive patients with chronic radic- 7:510-512. IH. Kyphoplasty for vertebral compres- ular pain. Pain Pract 2005; 5:116-124. sion fractures: 1-year clinical outcomes 1171. Epstein NE. Laser-assisted diskectomy 1184. Amoretti N, David P, Grimaud A, Flory P, from a prospective study. J Neurosurg www.painphysicianjournal.com 107 Pain Physician: January 2007:10:7-111

comparing percutaneous vertebroplas- Neuroradiol 2002; 23:1117-1120. 2003; 99:44-50. ty with conservative therapy. American 1198. Heini PF, Orler R. Kyphoplasty for treat- Journal Medicine 2003; 114:257-265. 1223. Kaufmann TJ, Jensen ME, Schweickert PA, Marx WF. Age of fracture and clini- ment of osteoporotic vertebral frac- 1213. Amar AP, Larsen DW, Esnaashari N, Al- tures. Eur Spine J 2004; 13:184-192. cal outcomes of percutaneous verte- buquerque FC, Lavine SD, Teitelbaum broplasty. AJNR Am J Neuroradiol 2001; 1199. McGraw JK, Lippert JA, Minkus KD, Rami GP. Percutaneous transpedicular poly- 22:1860-1863. PM, Davis TM, Budzik RF. Prospective methylmethacrylate vertebroplasty for 1224. O’Brien JP, Sims JT, Evans AJ. Verte- evaluation of pain relief in 100 patients the treatment of spinal compression broplasty in patients with severe ver- undergoing percutaneous vertebro- fractures. Neurosurgery 2001; 49:1105- tebral compression fractures: A techni- plasty: Results and follow-up. J Vasc In- 1114. terv Radiol 2002; 13:883-886. cal report. AJNR Am J Neuroradiol 2000; 1214. Brown DB, Glaiberman CB, Gilula LA, 21:1555-1558. 1200. Lieberman I, Reinhardt MK. Vertebro- Shimony JS. Correlation between pre- 1225. Brown DB, Gilula LA, Sehgal M, Shimo- plasty and kyphoplasty for osteolyt- procedural MRI findings and clinical ny JS. Treatment of chronic symptomatic vertebral collapse. Clin Orthop Relat outcomes in the treatment of chronic vertebral compression fractures with Res 2003; 415S:S176-S186. ic symptomatic vertebral compres- percutaneous vertebroplasty. AJR Am J sion fractures with percutaneous ver- 1201. Truumees E. The roles of vertebroplas- Roentgenol 2004; 182:319-322. ty and kyphoplasty as parts of a treat- tebroplasty. AJR Am J Roentgenol 2005; ment strategy. Curr Opin Orthop 2002; 184:1951-1955. 1226. Legroux-Gérot I, Lormeau C, Boutry N, Cotton A, Duquesnoy B, Cortet B. Long- 13:193-199. 1215. Gaughen JR Jr, Jensen ME, Schweickert term follow-up of vertebral osteoporot- - PA, Kaufmann TJ, Marx WF, Kallmes DF. 1202. Gross KA. Vertebroplasty: A new thera ic fractures treated by percutaneous Relevance of antecedent venography peutic option. Orthop Nurs 2002; 21:23- vertebroplasty. Clin Rheumatol 2004; in percutaneous vertebroplasty for the 29. 23:310-317. treatment of osteoporotic compression 1203. Levine SA, Perin LA, Hayes D, Hayes 1227. Cortet B, Cotten A, Boutry N, Flipo WS. An evidence-based evaluation of fractures. AJNR Am J Neuroradiol 2002; 23:594-600. RM, Duquesnoy B, Chastanet P, Del- percutaneous vertebroplasty. Manag cambre B. Percutaneous vertebroplas- 1216. Hodler J, Peck D, Gilula LA. Midterm Care 2000; 9:56-63. ty in the treatment of osteoporotic ver- outcome after vertebroplasty: Predic- 1204. Truumees E, Hilibrand A, Vaccaro AR. tebral compression fractures: An open tive value of technical and patient-relat- Percutaneous vertebral augmentation. prospective study. J Rheumatol 1999; ed factors. Radiology 2003; 227:662- Spine J 2004; 4:218-229. 26:2222-2228. 668. 1205. Gangi A, Guth S, Imbert JP, Marin H, 1228. Grohs JG, Matzner M, Trieb K, Krepler P. 1217. Lane JM, Johnson CE, Khan SN, Girar- Dietemann JL. Percutaneous vertebro- Minimal invasive stabilization of osteo- di FP, Cammisa FP Jr. Minimally invasive plasty: Indications, technique, and re- porotic vertebral fractures: A prospec- options for the treatment of osteoporot- sults. Radiographics 2003; 23:e10. tive nonrandomized comparison of ver- ic vertebral compression fractures. Or- 1206. Garfin SR, Yuan HA, Reiley MA. New tebroplasty and balloon kyphoplasty. J thop Clin North Am 2002; 33:431-438. technologies in spine: Kyphoplasty Spinal Disord Tech 2005; 18:238-242. 1218. McKiernan F, Jensen R, Faciszewski T. and vertebroplasty for the treatment of 1229. Yeom JS, Kim WJ, Choy W, Lee CK, The dynamic mobility of vertebral com- painful osteoporotic compression frac- Chang BS, Kang JW. Leakage of cement pression fractures. J Bone Miner Res tures. Spine 2001; 26:1511-1515. in percutaneous transpedicular veter- 2003; 18:24-29. 1207. Moreland DB, Landi MK, Grand W. Ver- broplasty for painful osteoporotic com- tebroplasty: Techniques to avoid com- 1219. Evans AJ, Jensen ME, Kip KE, DeNar- pression fractures. J Bone Joint Surg plications. Spine J 2001; 1:66-71. do AJ, Lawler GJ, Negin GA, Remley KB, 2003; 85:83-89. Boutin SM, Dunnagan SA. Vertebral 1208. Wong W, Riley MA, Garfin S. Vertebro- 1230. Cotten A, Deramond H, Cortet B, compression fractures: Pain reduction plasty/kyphoplasty. J Womens Imaging Lejeune JP, Leclerc X, Chastanet P, Cla- and improvement in functional mobili- 2000; 2:117-124. risse J. Preoperative percutaneous in- ty after percutaneous polymethylmeth- jection of methyl methcrylate and N- 1209. Watts NB, Harris ST, Genant HK. Treat- acrylate vertebroplasty retrospective butyl cyanoacrylate in vertebral hem- ment of painful osteoporotic vertebral report of 245 cases. Radiology 2003; angiomas. Am Soc Neuroradiology fractures with percutaneous vertebro- 226:366-72. plasty or kyphoplasty. Osteoporos Int 1996;17:137-142 1220. Gaughen JR Jr, Jensen ME, Schweickert 2001; 12:429-437. 1231. Alvarez L, Perez-Higueras A, Quinones PA, Kaufmann TJ, Marx WF, Kallmes DF. D, Quinones D, Calvo E, Rossi RE. Verte- 1210. Kallmes DF, Jensen ME. Percutane- Lack of preoperative spinous process broplasty in the treatment of vertebral ous vertebroplasty. Radiology 2003; tenderness does not affect clinical suc- tumors: postprocedural outcome and 229:27-36. cess of percutaneous vertebroplasty. J quality of life. Eur Spine J 2003; 12:356- 1211. Fourney DR, Schomer DF, Nader R, Ch- Vasc Interv Radiol 2002; 13:1135-1138. 360. lan-Fourney J, Suki D, Ahrar K, Rhines 1221. Gaughen JR Jr, Jensen ME, Schweickert 1232. Jang JS, Lee SH, Jung SK. Pulmonary LD, Gokaslan ZL. Percutaneous verte- PA, Marx WF, Kallmes DF. The therapeu- embolism of polymethylmethacrylate broplasty and kyphoplasty for pain- tic benefit of repeat percutaneous ver- after percutaneous vertebroplasty: A ful vertebral body fractures in cancer tebroplasty at previously treated verte- report of three cases. Spine 2002; 27: patients. J Neurosurg (Spine 1) 2003; bral levels. AJNR Am J Neuroradiol 2002; E416-E418. 98:21-30. 23:1657-1661. 1233. Tsou IY, Goh PYT, Peh WCG, Goh LA, 1212. Diamond TH, Champion B, Clark WA. 1222. Kallmes DF, Schweickert PA, Marx WF, Chee TS. Percutaneous vertebroplasty Management of acute osteoporotic ver- Jensen ME. Vertebroplasty in the mid- in the management of osteoporotic vertebral fractures: A nonrandomized trial and upper thoracic spine. AJNR Am J

108 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

tebral compression fractures: initial ex- 1244. Gaitanis IN, Hadjipavlou AG, Katonis syndrome: A prospective, randomized perience. Annals Acad Medicine, Singa- PG, Tzermiadianos MN, Pasku DS, Pat- study design. Stereotact Funct Neuro- pore 2002;31:15-20. wardhan AG. Balloon kyphoplasty for surg 1994; 62:267-272. 1234. Kasperk C, Hillmeier J, Noldge G, Grafe the treatment of pathological verte- 1256. Raphael JH, Southall JL, Gnanadurai IA, Dafonseca K, Raupp D, Bardenheuer bral compressive fractures. Eur Spine J TV, Treharne GJ, Kitas GD. Multiple lead H, Libicher M, Liegibel UM, Sommer U, 2005; 14:250-260. spinal cord stimulation for chronic me- Hilscher U, Pyerin W, Vetter M, Meinzer 1245. Barr JD, Barr MS, Lemley TJ, McCann chanical low back pain: a comparative HP, Meeder PJ, Taylor RS, Nawroth P. RM. Percutaneous vertebroplasty for study with intrathecal opioid drug de- Treatment of painful osteoporotic ver- pain relief and spinal stabilization. livery. Neuromodulation 2004; 7:260- tebral fractures by kyphoplasty in pa- Spine 2000; 25:923-928. 266. tients with primary osteoporosis. J Bone 1246. Yu SW, Lee PC, Ma CH, Chuang TY, 1257. Kemler MA, Barendse GA, van Kleef & Mineral Res 2004 [in press]. Chen YG. Vertebroplasty for the treat- M, de Vet HC, Rijks CP, Furnee CA, van 1235. Komp M, Ruetten S, Godolias G. Min- ment of osteoporotic compression spi- den Wildenberg FA. Spinal cord stimula- imally invasive therapy for functional- nal fracture: Comparison of remedi- tion in patients with chronic reflex sym- ly unstable osteoporotic vertebral frac- al action at different stages of injury. J pathetic dystrophy. N Engl J Med 2000; ture by means of kyphoplasty: prospec- Trauma 2004; 56:629-632. 343:618-624. tive comparative study of 19 surgically 1247. Jensen ME, Evans AJ, Mathis JM, Kallm- 1258. Kemler M, Furnee C. Economic evalua- and 17 conservatively treated patients. es DF, Cloft HJ, Dion JE. Percutaneous tion of spinal cord stimulation for chron- J Miner Stoffwechs 2004:11(suppl 1):13- polymethylmethacrylate vertebroplasty ic reflex sympathetic dystrophy.Neurol - 15 in the treatment of osteoporotic verte- ogy 2002; 59:1203-1209. 1236. Darius T, Vanderschot P, Broos P. Bal- bral body compression fractures: Tech- 1259. North RB, Kidd DH, Farrokhi F, Pianta- loon kyphoplasty: A new treatment op- nical aspects. AJNR Am J Neuroradiol dosi SA. Spinal cord stimulation versus tion for painful osteoporotic vertebral 1997; 18:1897-1904. repeated lumbosacral spine surgery for body compression fractures. Tijdschrift 1248. Martin JB, Jean B, Sugiu K, San Millan chronic pain: A randomized, controlled voor Geneekuunde 2003; 59:1141-1152. Ruiz D, Piotin M, Murphy K, Rufenacht trial. Neurosurgery 2005; 56:98-107. 1237. Dudeney S, Lieberman IH, Reinhardt B, Muster M, Rufenacht DA. Vertebro- 1260. Burchiel KJ, Anderson VC, Brown FD, MK, Hussein M. Kyphoplasty in the plasty: Clinical experience and follow- Fessler RG, Friedman WA, Pelofsky treatment of osteolytic vertebral com- up results. Bone 1999; 25:11S-15S. S, Weiner RL, Oakley J, Shatin D. Pro- pression fractures as a result of multiple 1249. Oakley J, Prager J. Spinal cord stimula- spective: Multicenter study of spinal myeloma. J Clin Oncol 2002; 20:2382- tion: Mechanism of action. Spine 2002; cord stimulation for relief of chronic 2387. 22:2574-2583. back and extremity pain. Spine 1996; 21:2786-2794. 1238. Garfin SR. A Multi-center Post-Mar- 1250. Turner JA, Loeser JD, Bell KG. Spinal keting Registry To Assess Outcomes of cord stimulation for chronic low back 1261. Barolat G, Oakley JC, Law JD, North Treatment of Vertebral Body Compres- pain. A systematic literature synthesis. RB, Ketcik B, Sharan A. Epidural spinal sion Fractures with an Inflatable Bone Neurosurgery 1995; 37:1088-1096. cord stimulation with a multiple electrode paddle lead is effective in treating Tamp. Final Report 2003 [Kyphon Reg- 1251. Taylor RS. Spinal cord stimulation in istry Report – unpublished]. low back pain. Neuromodulation 2001; complex regional pain syndrome and re- 4:59-66. 1239. Hillmeier J, Meeder PJ, Noldge G. Min- fractory neuropathic back and leg pain/ imal invasive reduction and internal failed back surgery syndrome: results 1262. Oakley JC, Espinoso F, Bothe H, McK- stabilisation of osteoporotic vertebral of a systematic review and meta-analy- ean J, Allen P, Burchiel K, Quartery G, body fracture. Operat Orthop und Trau- sis. J Pain Symptom Manage 2006; 31: Spincemaille G, Nuttin B, Gielen F, King matologie 2003, 4:343-362. S13-S19. G, Holsheimer J. Transvere tripolar spinal cord stimulation: Results of an inter- 1240. Kasperk C. Kyphoplastie Konzept zur 1252. Taylor RS, Van Buyten JP, Buchser E. behandlung schmerzhafter wirbelkor- national multi-center study. Neuromod- Spinal cord stimulation for complex re- ulation 2006; 9:192-203. perbruch. Deutsches Afzteblatt 2003; gional pain syndrome: a systematic re- 100:1748-1753. view of the clinical and cost-effective- 1263. Harke H, Gretenkort P, Ladleif HU, Rah- 1241. Kumar S, Ferrari R, Narayan Y, Jones T. ness literature and assessment of prog- man S. Spinal cord stimulation in sym- The effect of a 3-point harness restraint nostic factors. Eur J Pain 2006; 10:91- pathetically maintained complex re- and car seat in whiplash-type lateral im- 101. gional pain syndrome type I with severe pacts. Spine 2006; 31:E11-18. disability. A prospective clinical study. 1253. Cameron T. Safety and efficacy of spi- Eur J Pain 2005; 9:363-373. 1242. Phillips FM, Wetzel TF, Lieberman I, nal cord stimulation for the treatment Campbell-Hupp M. An in vivo compar- of chronic pain: A 20-year literature re- 1264. Harke H, Gretenkort P, Ladleif HU, ison of the potential for extraverte- view. J Neurosurg 2004; 100:S254-S67. Koester P, Rahman S. Spinal cord stimulation in postherpetic neuralgia and in bral cement leak after vertebroplasty 1254. Taylor RS, Taylor RJ, Van Buyten JP, Bu- and kyphoplasty. Spine 2002; 27:2173- acute herpes zoster pain. Anesth Analg chser E, North R, Bayliss S. The cost ef- 2002; 94:694-700. 2178. fectiveness of spinal cord stimulation in 1243. Phillips FM, Ho E, Campbell-Hupp M, the treatment of pain: a systematic re- 1265. Comiter CV. Sacral neuromodulation McNally T, Todd Wetzel F, Gupta P. Ear- view of the literature. J Pain Symptom for the symptomatic treatment of re- ly radiographic and clinical results of Manage 2004; 27:370-378. fractory interstitial cystitis: A prospective study. J Urol 2003; 169:1369-1373. balloon kyphoplasty for the treatment 1255. North RB, Kidd DH, Lee MS, Pianta- of osteoporotic vertebral compression dosi S. Spinal cord stimulation versus 1266. Kemler MA, Barendse GA, Van Kleef fractures. Spine 2003; 28:2260-2265. reoperation for the failed back surgery M, Van Den Wildenberg FA, Weber WE. www.painphysicianjournal.com 109 Pain Physician: January 2007:10:7-111

Electrical spinal cord stimulation in re- lines for intraspinal infusion: Report of 1289. Smith TJ, Staats PS, Deer T, Stearns flex sympathetic dystrophy: retrospec- an expert panel. J Pain Symptom Man- LJ, Rauck RL, Boortz-Marx RL, Buchs- tive analysis of 23 patients. J Neurosurg age 2000; 20:S37-S43. er E, Catala E, Bryce DA, Coyne PJ, Pool GE; Implantable Drug Delivery Systems 1999; 90(1 Suppl):79-83. 1279. Walker SM, Goudas LC, Cousins MJ, Study Group. Randomized clinical trial 1267. Bennett DS, Alo KM, Oakley J, Feler CA. Carr DB. Combination spinal analge- of an implantable drug delivery system Spinal cord stimulation for complex re- sic chemotherapy: A systematic review. compared with comprehensive medi- gional pain syndrome I (RSD): A retro- Anesth Analg 2002; 95:674-715. cal management for refractory cancer spective multi-center experience from 1280. Anderson VC, Burchiel KJ. A prospec- pain: impact on pain, drug-related tox- 1995-1998 of 101 patients. Neuromodu- tive study of long-term intrathecal mor- icity, and survival. J Clin Oncol 2002; lation 1999; 2:202-210. phine in the management of chronic 20:4040-4049. 1268. Calvillo O, Racz G, Didie J, Smith K. nonmalignant pain. Neurosurgery 1999; 1290. Staats PS, Yearwood T, Charapata SG, Neuroaugmentation in the treatment of 44:289-301. Presley RW, Wallace MS, Byas-Smith M, complex regional pain syndrome of the 1281. Kumar K, Kelly M, Pirlot T. Continu- Fisher R, Bryce DA, Mangieri EA, Luther upper extremity. Acta Orthop Belg 1998; ous intrathecal morphine treatment for RR, Mayo M, McGuire D, Ellis D. Intra- 64:57-63. chronic pain of nonmalignant etiology: thecal ziconotide in the treatment of 1269. Dario A, Fortini G, Bertoloo D, Bacuzzi Long-term benefits and efficacy. Surg refractory pain in patients with cancer A, Girzzetti C, Cuffari S. Treatment of Neurol 2001; 55:79-88. or AIDS: A randomized controlled trial. failed back surgery syndrome. Neuro- 1282. Rainov NG, Heidecke V, Burkert W. JAMA 2004; 291:63-70. modulation 2001; 4:105-110. Long-term intrathecal infusion of drug 1291. Hassenbusch SJ, Stanton-Hicks M, Cov- 1270. North RB, Ewend MG, Lawton MT, Kidd combinations for chronic back and leg ington EC, Walsh JG, Guthrey DS. Long- DH, Piantadosi S. Failed back surgery pain. J Pain Symptom Manage 2001; term intraspinal infusions in the treat- syndrome: 5-year follow-up after spinal 22:862-871. ment of neuropathic pain. J Pain Symp- cord stimulator implantation. Neurosur- 1283. Kumar K, Hunter G, Demeria DD. Treat- tom Manage 1995; 10:527-543. gery 1991; 28:692-699. ment of chronic pain by using intrathe- 1292. Angel IF, Gould HJ Jr., Carey ME. Intra- 1271. Villavicencio AT, Leveque JC, Rubin L, cal drug therapy compared with con- thecal morphine pump as a treatment Bulsara K, Gorecki JP. Laminectomy ver- ventional pain therapies: A cost effec- option in chronic pain of nonmalignant sus percutaneous electrode placement tiveness analysis. J Neurosurg 2002; origin. Surg Neurol 1998; 49:92-99. for spinal cord stimulation. Neurosur- 97:803-810. 1293. Corrado P, Gottlieb H, Varga CA. The ef- gery 2000; 46:399-405. 1284. Anderson VC, Burchiel KJ, Cooke B. A fect of intrathecal morphine infusion on 1272. Quigley DG, Arnold J, Eldridge PR. Long- prospective, randomized trial of intra- pain level and disability in pain patients term outcome of spinal cord stimulation thecal injection vs. epidural infusion in with chronic intractable low back pain. and hardware complications. Stereotact the selection of patients for continuous AJPM 2000; 10:160-166. Funct Neurosurg 2003; 81:50-56. intrathecal opioid therapy. Neuromodu- 1294. Onofrio BM, Yaksh TL. Long-term pain lation 2003; 6:142-152. 1273. Chandler GS III, Nixon B, Stewart LT, relief produced by intrathecal infu- Love J. Dorsal column stimulation for 1285. Deer T, Chapple I, Classen A, Javery K, sion in 53 patients. J Neurosurg 1990; lumbar spinal stenosis. Pain Physician Stoker V, Tonder L, Burchiel K. Intrathe- 72:200-209. 2003; 6:113-118. cal drug delivery for treatment of chron- 1295. Paice JA, Penn RD, Shott S. Intraspinal ic low back pain: Report from the Na- 1274. Alo KM, Redko V, Charnov J. Four year morphine for chronic pain: A retrospec- tional Outcomes Registry for Low Back follow up of dual electrode spinal cord tive, multicenter study. J Pain Symptom Pain. Pain Med 2004; 5:6-13. stimulation for chronic pain. Neuro- Manage 1996; 11:71-80. modulation 2002; 5:79-88. 1286. Hassenbusch SJ, Portenoy RK, Cous- 1296. Winkelmüller M, Winkelmüller W. ins M, Buchser E, Deer TR, Du Pen SL, 1275. North RB, Kidd DH, Zahurak M, James Long-term effects of continuous intra- Eisenach J, Follett KA, Hildebrand KR, CS, Long DM. Spinal cord stimulation thecal opioid treatment in chronic pain Krames ES, Levy RM, Palmer PP, Rath- for chronic, intractable pain: experience of nonmalignant etiology. J Neurosurg mell JP, Rauck RL, Staats PS, Stearns L, over two decades. Neurosurgery 1993; 1996; 85:458-467. 32:384-394. Willis KD. Polyanalgesic consensus con- ference 2003: an update on the man- 1297. Roberts LJ, Finch PM, Goucke CR, Price 1276. Kumar K, Hunter G, Demeria D. Spinal LM. Outcome of intrathecal opioids cord stimulation in treatment of chron- agement of pain by intraspinal drug delivery— report of an expert panel. J Pain in chronic non-cancer pain. Eur J Pain ic benign pain: challenges in treatment 2001; 5:353-361. planning and present status, a 22- Symptom Manage 2004; 27:540-563. 1298. Burton AW, Rajagopal A, Shah HN, year experience. Neurosurgery 2006; 1287. Siddall PJ, Molloy AR, Walker S, Mather Mendoza T, Cleeland C, Hassenbusch 58:481-496. LE, Rutkowski SB, Cousins MJ The efficacy of intrathecal morphine and cloni- SJ 3rd, Arens JF. Epidural and intrathecal 1277. Heidecke V, Rainov NG, Burkert W. analgesia is effective in treating refrac- Hardware failures in spinal cord stimu- dine in the treatment of pain after spinal cord injury. Anesth Analg 2000; tory cancer pain. Pain Med 2004; 5:239- lation for failed back surgery syndrome. 247. Neuromodulation 2000; 3:27-30. 91:1493-1498. 1299. Mueller-Schwefe G, Hassenbusch SJ, 1278. Bennett G, Burchiel K, Buchser E, Clas- 1288. van Hilten BJ, van de Beek WJ, Hoff JI, Voormolen JH, Delhaas EM. Intrathecal Reig E. Cost-effectiveness of intrathe- sen A, Deer T, Du Pen S, Ferrante FM, baclofen for the treatment of dystonia cal therapy for pain. Neuromodulation Hassenbusch SJ, Lou L, Maeyaert J, 1999; 2:77-84. Penn R, Portenoy RK, Rauck R, Serafi- in patients with reflex sympathetic dys- 1300. Tutak U, Doleys DM. Intrathecal infu- ni M, Willis KD, Yaksh T. Clinical guide- trophy. N Engl J Med 2000; 343:654- 656.

110 www.painphysicianjournal.com Interventional Techniques: Evidence-based Guidelines

impulses. Anesth Analg 1987; 66:553- sion systems for treatment of chronic 1311. Schimmer BP, Parker KL. Adrenocortico- 559. low back and leg pain of noncancer ori- tropic hormone; adrenocortical steroids gin. South Med J 1996; 89: 295-300. and their synthetic analogs; inhibitors 1323. Abram SE, Marsala M, Yaksh TL. Anal- of the synthesis and actions of adreno- gesic and neurotoxic effects of intrathe- 1301. Willis KD, Doleys DM. The effects of cortical hormones. In Harman JG, Mo- cal corticosteroids in rats. Anesthesiol- long-term intraspinal infusion thera- linoff PB, Ruddon RW (eds). Goodman’s ogy 1994; 81:1198-1205. py with noncancer pain patients: Eval- & Gilman’s, The Pharmacological Basis uation of patient, significant-other, and 1324. Latham JM, Fraser RD, Moore RJ, Blum- of Therapeutics, Ninth Edition, McGraw- bergs PC, Bogduk N. The pathologic ef- clinic staff appraisals. Neuromodula- Hill, New York, 1996; pp 1459-1485. tion 1999; 2: 241-253. fects of intrathecal betamethasone. 1312. McEvoy GK, Litvak K, Welsh OH. Adre- Spine 1997; 22:1558-1562. 1302. Manchikanti L. Documentation for nals. AHFS 99 drug information. Amer- evaluation and management services. 1325. Robustelli della Cuna FS, Mella M, Ma- ican Society of Health-System Pharma- Principles of Documentation, Billing, gistrali G, Ricci M, Losurdo A, Goglio cists, Bethesda, 1999; pp 2636-2662. Coding & Practice Management for the AM. Stability and compatibility of meth- Interventional Pain Professional. ASIPP 1313. Boonen S, Van Distel G, Westhovens R, ylprednisolone acetate and ropivacaine Publishing, Paducah KY 2004; pp 31- Dequeker J. Steroid myopathy induced hydrochloride in polypropylene syring- 46. by epidural triamcinolone injection. Brit es for epidural administration. Am J J Rheumatol 1995; 34:385-386. 1303. 1995 Documentation Guidelines for Health Syst Pharm 2001; 58:1753-1756. Evaluation and Management Services. 1314. Maillefert JF, Aho S, Huguenin MC, Cha- 1326. Swai EA, Rosen M. An attempt to de- Centers for Medicare & Medicaid Ser- tard C, Peere T, Marquignon MF, Lucas velop a model to study the effects of in- vices. http://www.cms.hhs.gov/MLN- B, Tavernier C. Systemic effects of epi- trathecal steroids. Eur J Anaesthesiol Products/Downloads/1995dg.pdf dural dexamethasone injections. Revue 1986; 3:127-136. du Rhumatisme 1995; 62:429-432. 1304. 1997 Documentation Guidelines for 1327. Dunbar SA, Manikantan P, Philip J. Epi- Evaluation and Management Services. 1315. Ward A, Watson J, Wood P, Dunne C, dural infusion pressure in degenerative Centers for Medicare & Medicaid Ser- Kerr D. Glucocorticoid epidural for sci- spinal disease before and after epidur- vices. http://www.cms.hhs.gov/MLN- atica: Metabolic and endocrine sequel- al steroid therapy. Anesth Analg 2002; Products/Downloads/MASTER1.pdf ae. Rheumatology 2002; 41:68-71. 94:417-420. 1305. Evaluation & Management Services 1316. Shishido H, Kikuchi S, Heckman H, My- 1328. Slucky AV, Sacks MS, Pallares VS, Ma- Guide, Revised July 2006. Centers for ers RR. Dexamethasone decreases linin TI, Eismont FJ. Effects of epidural Medicare & Medicaid Services. http:// blood flow in normal nerves and dorsal steroids on lumbar dura material prop- www.cms.hhs.gov/MLNProducts/ root ganglia. Spine 2002; 27:581-586. erties. J Spin Disord 1999; 12:331-340. downloads/eval_mgmt_serv_guide.pdf 1317. Mace S, Vadas P, Pruzanski W. Anaphy- 1329. Stanczak J, Blankenbaker DG, De Smet 1306. Consultations in Medicare: Coding lactic shock induced by intraarticular in- AA, Fine J. Efficacy of epidural injec- and Reimbursement . March 2006. Cen- jection of methylprednisolone acetate. J tions of Kenalog and Celestone in the ters for Medicare & Medicaid Services. Rheumatol 1997; 24:1191-1194. treatment of lower back pain. AJR Am J http://www.oig.hhs.gov/oei/reports/ 1318. Weissman DE, Dufer D, Vogel V, Abel- Roentgenol 2003; 181:1255-1258. oei-09-02-00030.pdf off MD. Corticosteroid toxicity in neuro- 1330. Noe CE, Haynsworth RF Jr. Comparison 1307. Current Procedural Terminology. CPT oncology patients. J Neurooncol 1987; of epidural depo-medrol vs. aqueous 2007, American Medical Association, 5:125-128. betamethasone in patients with low Chicago, 2006. 1319. Delaney TJ, Rowlingson JC, Carron H, back pain. Pain Pract 2003; 3:222-225. 1308. Mikhail GR, Sweet LC, Mellinger RC. Butler A. Epidural steroid effects on 1331. Adminastar Federal Paravertebral Facet Parenteral long-acting corticosteroid nerves and meninges. Anesth Analg Joint Nerve Block (Diagnostic or Thera- effect on hypothalamic pituitary adre- 1980; 58:610-614. peutic) Policy. LCD Database ID Number nal function. Ann Allergy 1973; 31:337- 1320. Mackinnon SE, Hudson AR, Gentili F, L7848. Effective Date 09/20/2005. 343. Kline DG, Hunter D. Peripheral nerve in- 1332. Adminastar Federal Paravertebral Fac- 1309. Mikhail GR, Livingood CS, Mellinger jection injury with steroid agents. Plast et Nerve Denervation Policy. LCD Data- RC, Paige TN, Salyer HL. Effect of long- Reconstr Surg 1982; 69:482-489. base ID Number L8527. Effective Date acting parenteral corticosteroids on 1321. Chino N, Awad EA, Kottke FJ. Pathol- 09/20/2005. adrenal function. Arch Dermatol 1969; ogy of propylene glycol administered 1333. Adminastar Federal Epidural Injec- 100:263-268. by perineural and intramuscular injections: Transforaminal Policy. LCD Data- 1310. Melby JC. Drug spotlight program: Sys- tion in rats. Arch Phys Med Rehab 1974; base ID Number L17911. temic corticosteroid therapy; pharma- 55:33-38. 1334. Adminastar Federal Epidural and Intra- cologic and endocrinologic consider- 1322. Benzon HT, Gissen AJ, Strichartz GR, thecal Injections: Interlaminar or Cau- ations. Ann Intern Med 1974; 81:505- Avram MJ, Covino BG. The effect of poly- dal Policy. LCD Database ID Number 512. ethylene glycol on mammalian nerve L17912. Effective Date 09/20/2004.