Back Pain: Boswell MV

Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L, Anonymous00089. · American Society of Interventional Pain Physicians, Paducah, KY 42001, USA. · Pain Physician. · Pubmed #17256025 links to  free full text

Abstract: 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, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited.The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. 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."

Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. · Texas Tech University Health Science Center, Lubbock, TX, USA. · Pain Physician. · Pubmed #17256032 links to  free full text

Abstract: BACKGROUND: Facet joints are considered to be a common source of chronic spinal pain. Facet joint interventions, including intraarticular injections, medial branch nerve blocks, and neurotomy (radiofrequency and cryoneurolysis) are used to manage chronic facet-mediated spinal pain. A systematic review of therapeutic facet interventions published in January 2005, concluded that facet interventions were variably effective for short-term and long-term relief of facet joint pain. OBJECTIVE: To provide an updated evaluation of the effectiveness of 3 types of facet joint interventions in managing chronic spinal pain. STUDY DESIGN: A systematic review utilizing criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and the Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (November 2004 to December 2006) and manual searches of bibliographies of known primary and review articles within the last 2 years. Results of the analyses were performed for the different modes of facet joint interventions for the cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with these procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For intraarticular facet joint injections and medial branch blocks, short-term pain relief was defined as relief lasting less than 6 weeks and long-term relief as 6 weeks or longer. For medial branch blocks, repeated injections at defined intervals provided long-term pain relief. For medial branch radiofrequency neurotomy, short-term pain relief was defined as relief lasting less than 3 months and long-term relief as lasting 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For cervical intraarticular facet joint injections, the evidence is limited for short- and long-term pain relief. For lumbar intraarticular facet joint injections, the evidence is moderate for short- and long-term pain relief. For cervical, thoracic, and lumbar medial branch nerve blocks with local anesthetics (with or without steroids), the evidence is moderate for short- and long-term pain relief with repeat interventions. The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. CONCLUSION: With intraarticular facet joint injections, the evidence for short- and long-term pain relief is limited for cervical pain and moderate for lumbar pain. For medial branch blocks, the evidence is moderate for short- and long-term pain relief. For medial branch neurotomy, the evidence is moderate for short- and long-term pain relief.

Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. · Pain Management Center of Paducah, Paducah, KY 42003, USA. · Pain Physician. · Pubmed #19057627 links to  free full text

Abstract: BACKGROUND: The pathophysiology of lumbar radicular pain is a subject of ongoing research. The prevalence of sciatica or radiculitis ranges from 1.2% to 43%. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain secondary to disc herniation and radiculitis. There is a paucity of evidence with contemporary methodology used in performing epidural injections under fluoroscopy and based on pain relief and functional status improvement. STUDY DESIGN: A randomized, double-blind, equivalence trial. SETTING: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. OBJECTIVE: To evaluate the effectiveness of caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to disc herniation or radiculitis in providing effective and long-lasting pain relief and evaluate the differences between local anesthetic with or without steroids. METHODS: Patients were assigned to one of 2 groups; Group I patients received caudal epidural injections with an injection of local anesthetic (lidocaine 0.5%), whereas, Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization was performed by computer-generated random allocations sequence by simple randomization. OUTCOMES ASSESSMENT: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as a reduction of 40% or more. RESULTS: The percentage of patients with significant pain relief of 50% or greater at 12 months was 79% in Group I and 81% in Group II. Reduction of Oswestry scores of at least 40% was seen in 83% of the patients in Group I and 91% in Group II. The overall average procedures per year were 3.9 +/- 1.26 in Group I and 3.6 +/- 1.08 in Group II with an average total relief per year of 35.2 +/- 17.18 weeks in Group I and 35.9 +/- 15.34 weeks in Group II over a period of 52 weeks. LIMITATIONS: The results of this study are limited by lack of a placebo group and a preliminary report of 42 patients in each group. CONCLUSION: Caudal epidural injections with or without steroids may be effective in patients with disc herniation or radiculitis with between 79% to 91% of patients showing significant pain relief and improvement in functional status.

Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. · Anesthesia Pain Service, Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, OH 44106, USA. · Pain Physician. · Pubmed #16902652 links to  free full text

Abstract: Transforaminal epidural steroid injections under fluoroscopy are an alternative treatment for lower back pain with radiculopathy. We followed 82 patients with a standardized telephone questionnaire at 2, 6, and 12 months after the first injection, in order to assess their effectiveness. Ninety-two patients with radiculopathic back pain due to spinal stenosis, herniated discs, spondylolisthesis, and degenerated discs, underwent transforaminal epidural steroid injections under fluoroscopy. Eighty-two patients were followed with a standardized telephone questionnaire. The population was divided into four groups: Group I, previous back surgery (16%); Group II, discogenic abnormalities: herniations, bulges, or degeneration, (42%); Group III, spinal stenosis (32%); Group IV, those without MRI (11%). Age ranged between 24 to 99 years, mean 64.5. Forty-seven were female, 35 male. Thirteen patients (16%) underwent one procedure, 27 patients (33%) two, 37 patients (45%) three, and five patients (6%) four, an average 2.4 procedures per patient. The pain scores for all patients improved significantly at all three time points (2, 6 and 12 months) compared to the initial mean pain score of 7.3 to mean pain scores of 3.4, 4.5 and 3.9 respectively. After one year, 36 patients did not take any pain medications. Greater than 50% improvement after one year was seen in 23% of Group I; 59% in Group II; 35% in Group III and 67% in Group IV. Transforaminal epidural steroid injections can offer significant pain reduction up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.

Boswell MV, Hansen HC, Trescot AM, Hirsch JA. · Department of Anesthesiology, Case Western Reserve University, School of Medicine and University, Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio, 44106, USA. · Pain Physician. · Pubmed #16880879 links to  free full text

Abstract: Epidural injections with or without steroids are used extensively in the management of chronic spinal pain. However, evidence is contradictory with continuing debate about the value of epidural steroid injections in chronic spinal syndromes. The objective of this systematic review is to determine the effectiveness of epidural injections in the treatment of chronic spinal pain. Data sources include relevant literature identified through searches of MEDLINE, EMBASE (Jan 1966- Mar 2003), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings. Both randomized and non-randomized studies were included in the review based on the criteria established by the Agency for Healthcare Research and Quality (AHRQ). Studies were excluded from the analysis if they were simply review or descriptive and failed to meet minimum criteria. The results showed that there was strong evidence to indicate effectiveness of transforaminal epidural injections in managing lumbar nerve root pain. Further, evidence was moderate for caudal epidural injections in managing lumbar radicular pain. The evidence in management of chronic neck pain, chronic low back pain, cervical radiculopathy, spinal stenosis, and post laminectomy syndrome was limited or inconclusive. In conclusion, the evidence of effectiveness of transforaminal epidural injections in managing lumbar nerve root pain was strong, whereas, effectiveness of caudal epidural injections in managing lumbar radiculopathy was moderate, while there was limited or inconclusive evidence of effectiveness of epidural injections in managing chronic spinal pain without radiculopathy, spinal stenosis, post lumbar laminectomy syndrome, and cervical radiculopathy.

Manchikanti L, Boswell MV, Raj PP, Racz GB. · Medical Director, Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky 42003, USA. · Pain Physician. · Pubmed #16871301 links to  free full text

Abstract: Interventional pain management dates back to the origins of neural blockade and regional analgesia. Over the years, it evolved into a distinct specialty with the application of interventional techniques beyond those of simple neural blockade. The first therapeutic nerve block in pain management was described in 1899 by Tuffer. Subsequently, numerous techniques of interventional pain management with neural blockade were described. Diagnostic blockade in pain management was pioneered by von Gaza with the use of procaine for determining the pathways of obscure pain. Interventional pain management has entered into the modern era in the twenty-first century, driven by contributions from pioneers including Bonica, Winnie, Raj, Racz, Bogduk, and others. This historical review examines the origins of interventional pain management, its pathophysiologic basis, the role of precision diagnostic interventional techniques, therapeutic interventional techniques, and the future of interventional pain management.

Boswell MV, Wolfe JR. · Pain Medicine Fellowship, Department of Anesthesiology, Case School of Medicine and University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106, USA. · Pain Physician. · Pubmed #16868620 links to  free full text

Abstract: This report describes a 39 year-old woman who underwent attempted discography and intradiscal electrothermal therapy (IDET) of the L5/S1 intervertebral disc. The procedure was abandoned after multiple unsuccessful attempts to cannulate the disc. The case was complicated by at least two lumbar dural punctures, confirmed by injection of nonionic contrast that contained 12.5 mg/mL of cefazolin, included for prophylaxis of discitis. About 45 minutes later the patient developed severe back pain. Shortly thereafter she became progressively agitated and confused, and developed intractable seizures and coma. Despite aggressive treatment the patient could not be resuscitated and expired several hours later. Convulsions were initially attributed to an adverse reaction to meperidine and promethazine, given for the back pain, however this explanation proved to be untenable. In addition, the accidental administration of an ionic contrast agent, such as Hypaque(R), was excluded. Based on a detailed review of the case and the literature, it was concluded that the patient succumbed from an unintentional dose of intrathecal cefazolin, which had been diluted in the nonionic contrast agent that was used to confirm needle placement. Available evidence indicates that cefazolin is a potent epileptogenic agent when given intrathecally. The facts of the case and the evidence supporting the conclusion are presented. It is recommended that cefazolin not be mixed with the contrast agent used to document initial needle placement during discography.

Boswell MV, Shah RV, Everett CR, Sehgal N, McKenzie Brown AM, Abdi S, Bowman RC, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS, Wasserman RA, Manchikanti L. · Department of Anesthesiology, University Hospitals of Cleveland Case School of Medicine, Cleveland, Ohio 44106, USA. · Pain Physician. · Pubmed #16850041 links to  free full text

Abstract: BACKGROUND: The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. DESIGN: A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. 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, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Methodologic quality evaluation criteria utilized included AHRQ criteria, 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: The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thoracic facet joint pain. The evidence was strong for lumbar discography, whereas, the evidence was limited for cervical and thoracic discography. The evidence was moderate for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anesthetics and steroids was moderate for short-term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural steroid injections was 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 was strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis was strong. For spinal endoscopic adhesiolysis, the evidence was strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain was indeterminate. The evidence for intradiscal electrothermal therapy was strong for short-term relief and moderate for long-term relief in managing chronic discogenic low back pain, whereas, for nucleoplasty, the evidence was limited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems was moderate to strong. CONCLUSION: These guidelines included 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 do not represent "a standard of care".

Manchikanti L, Boswell MV, Rivera JJ, Pampati VS, Damron KS, McManus CD, Brandon DE, Wilson SR. · Pain Management Center of Paducah, Paducah, Kentucky 42003, USA. · BMC Anesthesiol. · Pubmed #16000173 links to  free full text

Abstract: BACKGROUND: Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic adhesiolysis in recent years in the management of chronic refractory low back and lower extremity pain has been described. METHODS: A prospective, randomized, double-blind trial was conducted to determine the outcome of spinal endoscopic adhesiolysis to reduce pain and improve function and psychological status in patients with chronic refractory low back and lower extremity pain. A total of 83 patients were evaluated, with 33 patients in Group I and 50 patients in Group II. Group I served as the control, with endoscopy into the sacral level without adhesiolysis, followed by injection of local anesthetic and steroid. Group II received spinal endoscopic adhesiolysis, followed by injection of local anesthetic and steroid. RESULTS: Among the 50 patients in the treatment group receiving spinal endoscopic adhesiolysis, significant improvement without adverse effects was shown in 80% at 3 months, 56% at 6 months, and 48% at 12 months. The control group showed improvement in 33% of the patients at one month and none thereafter. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain, functional status, and psychological status. CONCLUSION: Spinal endoscopic adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.

Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. · Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky, USA. · BMC Musculoskelet Disord. · Pubmed #15169547 links to  free full text

Abstract: BACKGROUND: Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice. METHODS: Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting. RESULTS: The prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49%-61%), with thoracic spine pain was 42% (95% CI, 30%-53%), and in with lumbar spine pain was 31% (95% CI, 27%-36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54%-72%) in the cervical spine, 55% (95% CI, 39%-78%) in the thoracic spine, and 27% (95% CI, 22%-32%) in the lumbar spine. CONCLUSION: This study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.

Manchikanti L, Boswell MV, Giordano J, Kaplan E. · No affiliation provided · Neurology. · Pubmed #17846419 No free full text.

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Manchikanti L, Boswell MV, Singh V. · No affiliation provided · Clin J Pain. · Pubmed #16093752 No free full text.

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Manchikanti L, Boswell MV, Singh V, Hansen HC. · No affiliation provided · Reg Anesth Pain Med. · Pubmed #14556149 No free full text.

This publication has no abstract.