Back Pain: Dunbar EE

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."

Singh V, Manchikanti L, Shah RV, Dunbar EE, Glaser SE. · Pain Diagnostics Associates, Niagara, WI 54151, USA. · Pain Physician. · Pubmed #18850027 links to  free full text

Abstract: BACKGROUND: Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. OBJECTIVE: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography. STUDY DESIGN: A systematic review of provocation thoracic discography. METHODS: A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. Studies meeting the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher were included for the assessment of the level of evidence. Level of evidence was based on the United States Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. Based on the level of evidence, recommendations were made according to Guyatt et al's criteria. RESULTS: The clinical value of thoracic provocation discography is limited (Level II-3) with 2C/weak recommendation derived from low quality or very low quality evidence indicating that other alternatives may be equally reasonable. CONCLUSION: Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints.

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.

Sehgal N, Dunbar EE, Shah RV, Colson J. · University of Wisconsin School of Medicine and Public Health, Madison, WI 53595, USA. · Pain Physician. · Pubmed #17256031 links to  free full text

Abstract: BACKGROUND: A 2-year review of literature from October 2004 to December 2006 was completed to update current scientific evidence on diagnostic utility of facet joint injections. Diagnostic injections are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. There is no physical examination technique, laboratory test, or imaging modality that can precisely identify the spinal structure causing pain, distinguish the culprit from a variety of potential targets, and predict response to a therapeutic intervention. Zygapophysial joint injections, commonly called facet injections (intraarticular joint injections and medial branch blocks) are local anesthetic injections of the facet joint or its nerve supply. These are diagnostic procedures used to determine if pain is arising from facet joints, distinguish painful from nonpainful joints and prognosticate response to therapeutic facet joint interventions. Diagnostic injections must meet the cardinal features of a diagnostic test i.e., accuracy, safety, and reproducibility. Accuracy is based on comparison with a "gold standard" to confirm presence or absence of a disease. There is, however, no available gold standard to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. OBJECTIVES: Evaluate and update available evidence (2004 to 2006) relating to clinical utility of facet joint injections (intraarticular and medial branch blocks) in diagnosing chronic spinal pain of facet joint origin. STUDY DESIGN: Review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing facet joint pain according to Agency for Healthcare Research and Quality (AHRQ) and Quality Assessment Studies of Diagnostic Accuracy (QUADAS) criteria. The level of evidence was classified as conclusive (Level I), strong (Level II), moderate (Level III), or limited (Level IV). METHODS: Computerized database search (2004 to 2006) of PUBMED, EMBASE, CINAHL, and Web of Knowledge was conducted to identify studies on facet joint pain and diagnostic interventions. Abstracts, reviews, book chapters, case reports, studies based on single blocks or blocks without radiologic control, and studies describing techniques were excluded. Prospective studies were given priority over retrospective studies. RESULTS: There is no change in the strength of evidence for facet joint diagnostic injections. There is strong evidence for controlled comparative local anesthetic facet joint injections or medial branch blocks in the diagnosis of neck and low back pain and moderate evidence in the diagnosis of pain arising from thoracic facet joints. CONCLUSION: The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.