Background Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians. Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Design Systematic assessment of the literature. Methods Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Outcomes Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term. Results The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2. Limitations The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations. Conclusion The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. 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. Further, these guidelines also do not represent "standard of care."

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Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain

Introduction: The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. Methods: The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. Results: Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated. Conclusions: Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.

The Appropriate Use of Neurostimulation of the Spinal Cord and Peripheral Nervous System for the Treatment of Chronic Pain and Ischemic Diseases: The Neuromodulation Appropriateness Consensus Committee

Study design Consecutive case series cohort. Objective To determine the relative frequencies of the spine, the sacroiliac (SI) joint, and the hip joint being the primary pain generator among patients presenting at a spine surgery clinic for low back pain (LBP). Summary of background data Identification of the primary pain generator in a patient with LBP is difficult. Possible pain sources include the lumbar spine, the SI joint, and the hip joint. Their relative frequencies among patients presenting at a spine surgeon's clinic have not been well established. Methods Three hundred sixty-eight new patients were seen at a single spine surgeon's clinic during a 10-month period. Of these, 289 (78.5%) complained primarily of LBP with or without leg pain. Seventy-seven had previous surgery. The remaining 200 cases were reviewed for all diagnostic tests performed, as well as the final diagnosis. Results One hundred sixty-four (82%) had spine pathology, but only 130 (65%) had spine-only pathology, whereas 35 (17.5%) had a combination of spine plus hip and/or SI joint pathology. An additional 16 (8%) had hip and/or SI joint pathology without spine pathology. Twenty (10%) had an undefined pain source. Overall, 25 (12.5%) had hip pathology, and 29 (14.5%) had SI joint pathology. Conclusion For patients presenting to a spine surgeon's clinic for LBP, up to 25% of patients may have significant pain contribution from the hip or SI joints, and an additional 10% will still have an undefined pain source even after diagnostic workup. This underscores the need for clinicians to be aware of nonspinal pain generators and to appropriately pursue alternative diagnoses.

http://www.ossano.se/Bibliotek/iFuse/Sembrano%202008%20-%20How%20Often%20Is%20Low%20Back%20Pain%20Not%20Coming%20From%20the%20Back.pdf

How often is low back pain not coming from the back

Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes.1 Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint2,3 and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration.2 Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis.4–8 Studies have shown that 22% of athletes with groin pain9 and 55% of patients with mechanical hip pain of unknown etiology2 were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.

The acetabular labrum is a ring consisting of both fibrocartilage and dense connective tissue10 attached to the bony rim of the acetabulum (Fig. 1). This ring is normally triangular in cross …

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Acetabular Labral Tears

Objective . Spinal cord and peripheral neurostimulation techniques have been practiced since 1967 for the relief of pain, and some techniques are also used for improvement in organ function. Neuromodulation has recognized complications, although very rarely do these cause long-term morbidity. The aim of this article is to present a review of complications observed in patients treated with neurostimulation techniques.

Methods . A review of the major recent publications in the literature on the subjects of spinal cord, occipital, sacral, and peripheral nerve field stimulation was conducted.

Results . The incidence of complications reported varies from 30% to 40% of patients affected by one or more complications. Adverse events can be subdivided into hardware-related complications and biological complications. The commonest hardware-related complication is lead migration. Other lead related complications such as failure or fracture have also been reported. Common biological complications include infection and pain over the implant. Serious biological complications such as dural puncture headache and neurological damage are rarely observed.

Conclusions . Spinal cord and peripheral neurostimulation techniques are safe and reversible therapies. Hardware-related complications are more commonly observed than biological complications. Serious adverse events such as neurological damage are rare.

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Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature.

Objective. To evaluate the clinical outcomes of 100 consecutive patients receiving peripheral nerve field stimulation (PNFS) for the treatment of chronic intractable pain.

Design.  Prospective, observational study.

Setting.  A private interventional pain specialty referral practice.

Patients.  One hundred consecutive private practice patients receiving PNFS for the treatment of chronic craniofacial, thorax, lumbosacral, abdominal, pelvic, and groin pain conditions.

Outcome Measures.  Pain (11-point numerical rating scale), complications, changes to analgesic use and employment status, disability (Oswestry or Neck Disability Indexes), depression (Zung Depression Index), and patient satisfaction.

Results.  We demonstrate an average pain reduction of 4.2 ± 2.5 pain scale points on an 11-point scale following PNFS (preimplant pain score of 7.4 ± 1.7 to a follow-up average of 3.2 ± 2.3 pain scale points) (P ≤ 0.00). At a follow-up period of 8.1 ± 4.7 months (range 1–23 months), an overall 72% of patients reduced their analgesic use following PNFS. Patients receiving a lumbosacral PNFS for chronic low back pain reported a significant reduction in disability following treatment, as determined by the Oswestry Disability Index. Of the 100 cases, no long-term complications were reported.

Conclusions.  This prospective 100 consecutive PNFS patient outcome study demonstrates that PNFS can be a safe and effective treatment option for, otherwise, intractable chronic pain conditions. PNFS has the potential to fundamentally change the way we think about pain management.

Peripheral nerve field stimulation for chronic pain: 100 cases and review of the literature.

Background: The hip joint is becoming increasingly recognized as a source of groin pain and, in the authors' experience, buttock and low back pain. Objectives: To determine the range of pathologic diagnoses, clinical presentation, and the correlation between magnetic resonance arthrographic, ultrasonographic, and arthroscopic findings in the hip joint. Methods: We prospectively studied 25 consecutive hip arthroscopies to determine the range of pathologic diagnoses, clinical presentation, and the correlation between magnetic resonance arthrographic, ultrasonographic, and arthroscopic findings. Results: All of the hips arthroscoped had pathology. Back pain and hip pain were the 2 most common presentations. The only consistently positive clinical test result was a restricted and painful hip quadrant compared with the contralateral hip. Of the 17 patients whose flexion, abduction, external rotation (FABER) test results were reported at the time of examination, 15 (88%) were positive, and 2 (12%) negative. Plain radiographs were normal in all patients. All but 1 patient underwent magnetic resonance arthrography. Although specificity of 100% was achieved in our study, the sensitivity was significantly lower, with a relatively high number of false negatives. Hip arthroscopy proved the definitive diagnostic procedure for intraarticular pathology. Conclusions: Hip pathology, particularly labral pathology, may be more common than has been previously recognized. In those patients with chronic groin and low back pain, a high index of suspicion should be maintained. Clinical signs of a painful, restricted hip quadrant and a positive FABER test result should suggest magnetic resonance arthrography in the first instance, but a negative magnetic resonance image should not preclude hip arthroscopy if there is high clinical suspicion of hip joint pathology.

Hip joint pathology: clinical presentation and correlation between magnetic resonance arthrography, ultrasound, and arthroscopic findings in 25 consecutive cases.

Objective. This study aims to evaluate the usefulness of peripheral nerve stimulation as a treatment option for patients with chronic low back pain.



Materials and Methods.  More than 12 months, we collected data on consecutive patients who had successful trials and were subsequently implanted with octrode percutaneous leads placed subcutaneously within the major area of pain. Eleven patients met diagnostic criteria for failed back surgery syndrome. A questionnaire assessed outcomes including: pain, analgesic use, and patient satisfaction. The response rate was 93% (13/14): average follow-up time was seven months.



Results.  There was a significant decrease in pain levels: an average reduction of 3.77 visual analog scale points. Eleven patients (85%) reported successful outcomes and an average pain reduction of 4.18 points but two reported a poor response. Pain relief was highly correlated with reduced analgesia and patient satisfaction. No complications were reported.



Conclusion.  This study demonstrates a treatment option that is safe, nonpharmacologic, reversible, and effective for patients with chronic low back pain that have exhausted other treatment options.

Peripheral nerve stimulation: a treatment for chronic low back pain and failed back surgery syndrome?

STUDY DESIGN Clinical observational study. OBJECTIVE To quantify the incidence of inadvertent intravascular injections in spinal medial branch blocks in a clinical setting. SUMMARY OF BACKGROUND DATA Previous research established the rate of inadvertent intravascular injection in lumbar medial branch blocks at 8%. The incidence of intravascular injection in cervical and thoracic medial branch blocks has not been reported previously. This study establishes the rate of inadvertent intravascular injection in patients receiving medial branch blocks of the cervical and thoracic spines. Further, this study reports a significantly lower rate of inadvertent intravascular injection for lumbar medial branch blocks than previously reported. METHODS Patients were originally referred to the clinic, for diagnosis and treatment of chronic spinal origin somatic pain. Medial branch blocks were then performed as diagnostic procedures to confirm the zygapophysial joint(s) as the suspected source of pain. Blocks were performed by experienced practitioners on nonidentified patients over a 3-year period. Clinical observations were recorded for 14,312 separate medial branch block levels. The level of the spine and the incidence of inadvertent intravascular injections were recorded. RESULTS This study demonstrates that the overall incidence of intravascular penetration in medial branch blocks is rare, with an overall rate of 3.5%. This study also establishes the rate of intravascular injection for levels within the spine: the cervical spine is likely to be intravascular 3.9% of the time and the lumbar spine 3.7%, whereas the thoracic spine is significantly lower, with just 0.7% injections reported as intravascular. Significant differences were also observed between individual vertebral levels. CONCLUSION The false-negative rate for medial branch blocks is likely to be lower than previously reported. The rate of inadvertent intravascular injection for thoracic medial branch blocks is 0.7%. Cervical and lumbar medial branch blocks are associated with an overall rate of 3.9% and 3.7%, respectively. Although these rates are lower than previously reported, the incidence of false-negative blocks still justifies the use of contrast to confirm nonvascular injection.

The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines.

Objective

The objective of this study is to evaluate the efficacy of peripheral nerve field stimulation (PNFS) for the treatment of chronic headache conditions.



Materials and Methods

For more than a four-year period, 83 patients underwent a trial of a PNFS system targeting the nerve regions including occipital and supraorbital and infraorbital nerves, which best corresponded with their area of head pain. Sixty patients reported a successful trial and underwent a subsequent implant of the PNFS system. Questionnaires, along with patients' charts, were used to assess outcomes as follows: pain (11-point numerical pain rating scale), analgesic use, depression (Zung Depression Scale), disability (Neck Disability Index), patient satisfaction, and surgical complications. Patients were followed up for an average of 12.9 ± 9.4 months (range 3–42 months).



Results

An average pain reduction of 4.8 ± 2.3 pain scale points was observed (preimplant 7.4 ± 1.6; follow-up 2.6 ± 2.1 [p ≤ 0.001]). Of the 60 patients implanted, 41 reported >50% pain relief. Medication use was reduced in 83% of patients who were previously taking analgesics or prophylactic medications. Similarly, reductions in degree of disability and depression also were observed. Of the 60 cases, ten surgical revisions were required; however, no long-term complications were reported.



Conclusions

PNFS for chronic headache is an evolving therapy. This study demonstrates that this reversible and effective treatment can be a promising pain relief strategy for this often intractable condition.

Bruce Mitchell

Papers

Peripheral nerve field stimulation for chronic pain: 100 cases and review of the literature.

Hip joint pathology: clinical presentation and correlation between magnetic resonance arthrography, ultrasound, and arthroscopic findings in 25 consecutive cases.

Peripheral nerve stimulation: a treatment for chronic low back pain and failed back surgery syndrome?

The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines.

Peripheral Nerve Field Stimulation for Chronic Headache: 60 Cases and Long-Term Follow-Up