Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain

Pain Physician. Jul-Aug 2009;12(4):699-802.

Abstract

Background: Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians.

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

Design: Systematic assessment of the literature.

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 at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term.

Results: The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. 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 or 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. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2.

Limitations: The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations.

Conclusion: The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. 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. Further, these guidelines also do not represent "standard of care."

Publication types

  • Practice Guideline

MeSH terms

  • Anesthetics, Local / administration & dosage
  • Anesthetics, Local / standards
  • Back Pain / etiology
  • Back Pain / physiopathology
  • Back Pain / therapy*
  • Chronic Disease / therapy
  • Clinical Protocols / standards*
  • Diskectomy, Percutaneous / methods
  • Diskectomy, Percutaneous / standards
  • Electric Stimulation Therapy / methods
  • Evidence-Based Medicine / methods*
  • Evidence-Based Medicine / standards
  • Humans
  • Injections, Intra-Articular / methods
  • Injections, Intra-Articular / standards
  • Pain, Intractable / etiology
  • Pain, Intractable / physiopathology
  • Pain, Intractable / therapy*
  • Spinal Diseases / complications*
  • Spinal Diseases / physiopathology

Substances

  • Anesthetics, Local