1. 2005;8;1-47Interventional Techniques in The Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines
   Practice Guidelines
   Mark V. Boswell, MD, PhD, Rinoo V. Shah, MD, Clifford R. Everett, MD, Nalini Sehgal, MD, Ann Marie McKenzie Brown, MD, Salahadin Abdi, MD, PhD, Richard C. Bowman II, MD, Timothy R. Deer, MD, Sukdeb Datta, MD, James D. Colson, MS, MD, William F. Spillane, MD, Howard S. Smith, MD, Linda F. Levin, MD, Allen W. Burton, MD, Pradeep Chopra, MD, Peter S. Staats, MD, Ronald A. Wasserman, MD, and Laxmaiah Manchikanti, MD.

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.”

Keywords: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions, epidural injections, epidural adhesiolysis, discography, radiofrequency, spinal cord stimulation, intrathecal implantable systems