1. 2009;12;E123-E198Comprehensive Review of Therapeutic Interventions in Managing Chronic Spinal Pain
   EBM - Guidelines
   Laxmaiah Manchikanti, MD, Mark V. Boswell, MD, PhD, Sukdeb Datta, MD, Bert Fellows, MA, Salahadin Abdi, MD, PhD, Vijay Singh, MD, Ramsin M. Benyamin, MD, Frank J.E. Falco, MD, Standiford Helm II, MD, Salim M. Hayek, MD, PhD, and Howard S. Smith, MD.

BACKGROUND: Available evidence documents a wide degree of variance in the definition and practice of interventional pain management.

OBJECTIVE: To provide evidence-based clinical practice guidelines for interventional techniques in the treatment of chronic spinal pain.

DESIGN: Best evidence synthesis.

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 6 months or less and long-term relief as longer than 6 months, except ≤ one year and > one year for intradiscal therapies, mechanical disc decompression, spinal cord stimulation, and intrathecal infusion systems.

RESULTS: 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 to 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.

LIMITATIONS: The limitations of this guideline preparation included a paucity of literature, lack of updates, and lack of conflicts in preparation of systematic reviews and guidelines by various organizations.

CONCLUSION: The indicated evidence for therapeutic interventions is variable from Level I to III. This comprehensive review includes the evaluation of evidence for therapeutic procedures in managing chronic spinal pain and recommendations. However, this review and recommendations do not constitute inflexible treatment recommendations or “standard of care.”