1. 2013;16;S49-S283An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations
   Guidelines
   Bradley W. Wargo, DO, Stephen P. Ward, MD, Ricardo Vallejo, MD, PhD, John R Swicegood, MD, Lee T Snook, MD, Howard S. Smith, MD, Vijay Singh, MD, Thomas T. Simopoulos, MD, Manohar Lal Sharma, MD, Nalini Sehgal, MD, Gabor B. Racz, MD, Allan T. Parr, MD, Vikram B. Patel, MD, Carla D. McManus, RN, BSN, Obi Onyewu, MD, Kavita N. Manchikanti, MD, Marion Lee, MD, Alan D Kaye, MD, PhD, Rafael Justiz, MD, Jeffrey W Janata, PhD, Standiford Helm II, MD, Hans Hansen, MD, Mariam Hameed, MD, Haroon Hameed, MD, Sanjeeva Gupta, MD, Jay S. Grider, DO, PhD, Stephanie Geffert, MLIS, Bert Fellows, MA, Frank J.E. Falco, MD, Timothy R. Deer, MD, Sudhir Diwan, MD, Sukdeb Datta, MD, Sareta Coubarous, DO, Ann Conn, MD, Harold Cordner, MD, James Colson, MD, Steven P. Cohen, MD, David L. Caraway, MD, Aaron K. Calodney, MD, Kimberly A. Cash, RT, Paul J. Christo, MD, David A. Bryce, MD, Patricia A Burks, LPT, Ricardo M. Buenaventura, MD, Salahadin Abdi, MD, PhD, Sairam Atluri, MD, Ramsin M. Benyamin, MD, Mark V. Boswell, MD, PhD, Laxmaiah Manchikanti, MD, Jie Zhu, MD, and Joshua A. Hirsch, MD.

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

METHODOLOGY: Systematic assessment of the literature.

EVIDENCE:
I. LUMBAR SPINE
• The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair.
• The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks.
• The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and  transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections.
• The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections.
• For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy.
• For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis.
• For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE.
• For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision.

II. CERVICAL SPINE
• The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks.
• The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome.
• The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections.

III. THORACIC SPINE
• The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks.
• The evidence is fair for thoracic epidural injections in managing thoracic pain.
• The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections.

IV. IMPLANTABLES
• The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems.

V. ANTICOAGULATION
• There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques.
• There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox).
• There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities.
• There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events.

CONCLUSIONS: Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed.

DISCLAIMER:  The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent “standard of care.”