Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline

Computational comparison of bone cement and poly aryl-ether-ether-ketone spacer in single-segment posterior lumbar interbody fusion: a pilot study

Posterior lumbar interbody fusion (PLIF) with a spacer and posterior instrument (PI) via minimally invasive surgery (MIS) restores intervertebral height in degenerated disks. To align with MIS, the spacer has to be shaped with a slim geometry. However, the thin spacer increases the subsidence and migration after PLIF. This study aimed to propose a new lumbar fusion approach using bone cement to achieve a larger supporting area than that achieved by the currently used poly aryl-ether-ether-ketone (PEEK) spacer and assess the feasibility of this approach using a sawbone model. Furthermore, the mechanical responses, including the range of motion (ROM) and bone stress with the bone cement spacer were compared to those noted with the PEEK spacer by finite element (FE) simulation. An FE lumbar L3-L4 model with PEEK and bone cement spacers and PI was developed. Four fixing conditions were considered: intact lumbar L3-L4 segment, lumbar L3-L4 segment with PI, PEEK spacer plus PI, and bone cement spacer plus PI. Four kinds of 10-NM moments (flexion, extension, lateral bending, and rotation) and two different bone qualities (normal and osteoporotic) were considered. The bone cement spacer yielded smaller ROMs in extension and rotation than the PEEK spacer, while the ROMs of the bone cement spacer in flexion and lateral bending were slightly greater than with the PEEK spacer. Compared with the PEEK spacer, peak contact pressure on the superior surface of L4 with the bone cement spacer in rotation decreased by 74% (from 8.68 to 2.25 MPa) and 69.1% (from 9.1 to 2.82 MPa), respectively, in the normal and osteoporotic bone. Use of bone cement as a spacer with PI is a potential approach to decrease the bone stress in lumbar fusion and warrants further research.

Selective local anesthesia versus corticosteroid infiltration on low back pain: a randomized clinical trial

ANTECEDENTS AND OBJECTIVE

Local infiltrations are second line therapy in the treatment of chronic low back pain, although their use is controversial in the literature. Our objective was to compare the effectiveness of 2 types of infiltration at the paravertebral lumbar level in two groups of patients diagnosed with low back pain: corticosteroids, and selective local anaesthetic administered using segmental neural therapy (SNT).

MATERIAL AND METHODS

Double-blind clinical trial in 55 patients diagnosed with low back pain in the neurosurgery department of the Hospital Central de la Defensa Gómez Ulla. Patients were randomised to 2 treatment groups to receive either paravertebral injections of corticosteroids or SNT. Outcomes were measured using a visual analogue scale, the Oswestry Disability Index, the Short Form-36, and patient satisfaction at the start of treatment (baseline) and at 3 and 12 months post intervention.

RESULTS

The combined treatment group showed a statistically significant improvement in Oswestry Disability Index at 3 months. The SNT group showed a statistically significant improvement in baseline visual analogue scale vs. visual analogue scale at 3 (1.398cm, p=0.001) and 12 months (0.791cm, p=0.007). No differences were observed in the remaining variables measured. The percentage of patients that would repeat the treatment was 81% and 83%, respectively.

CONCLUSIONS

Significant pain relief was achieved with SNT, and disability improved with the combined treatment. Although clinical improvement was limited, patients were satisfied. Local infiltrations should be considered as an alternative treatment for chronic low back pain.

CLINICAL TRIAL REGISTRATION

This clinical trial was registered at the European Union Clinical Trials Register with EUDRA-CT number 2015-001146-29.

Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results From a Markov Model

STUDY DESIGN

Markov model.

OBJECTIVE

Examine the 1-year effectiveness and cost-effectiveness (societal and payer perspectives) of adding nonpharmacologic interventions for chronic low back pain (CLBP) to usual care using a decision analytic model-based approach.

SUMMARY OF BACKGROUND DATA

Treatment guidelines now recommend many safe and effective nonpharmacologic interventions for CLBP. However, little is known regarding their effectiveness in subpopulations (e.g., high-impact chronic pain patients), nor about their cost-effectiveness.

METHODS

The model included four health states: high-impact chronic pain (substantial activity limitations); no pain; and two others without activity limitations, but with higher (moderate-impact) or lower (low-impact) pain. We estimated intervention-specific transition probabilities for these health states using individual patient-level data from 10 large randomized trials covering 17 nonpharmacologic therapies. The model was run for nine 6-week cycles to approximate a 1-year time horizon. Quality-adjusted life-year weights were based on six-dimensional health state short form scores; healthcare costs were based on 2003 to 2015 Medical Expenditure Panel Survey data; and lost productivity costs used in the societal perspective were based on reported absenteeism. Results were generated for two target populations: (1) a typical baseline mix of patients with CLBP (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain) and (2) high-impact chronic pain patients.

RESULTS

From the societal perspective, all but two of the therapies were cost effective (<$50,000/quality-adjusted life-year) for a typical patient mix and most were cost saving. From the payer perspective fewer were cost saving, but the same number was cost-effective. Assuming all patients in the model have high-impact chronic pain increases the effectiveness and cost-effectiveness of most, but not all, therapies indicating that substantial benefits are possible in this subpopulation.

CONCLUSION

Modeling leverages the evidence produced from clinical trials to provide more information than is available in the published studies. We recommend modeling for all existing studies of nonpharmacologic interventions for CLBP.

LEVEL OF EVIDENCE

4.

Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis

BACKGROUND

Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP).

METHODS

PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values.

RESULTS

58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias.

CONCLUSION

No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.

Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Proposal of a Standardized Multidisciplinary Team Care Pathway

Failed back surgery syndrome (FBSS) is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain (CBLP) Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.

Safety of intradiscal delivery of triamcinolone acetonide by a poly(esteramide) microsphere platform in a large animal model of intervertebral disc degeneration

BACKGROUND CONTEXT

Local corticosteroids have been used to relieve symptoms of chronic low back pain, although treatment effects have been shown to wear off relatively fast. Prolonging corticosteroid presence by controlled release from biomaterials may allow for longer pain relief while circumventing adverse effects such as high bolus dosages.

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of intradiscal controlled release of triamcinolone acetonide (TAA) by poly(esteramide) microspheres in a canine degenerated intervertebral disc (IVD) model.

STUDY DESIGN

In a preclinical experimental large animal model, the effect of prolonged glucocorticoid exposure on disc degeneration was evaluated.

METHODS

Degeneration was accelerated by nucleotomy of lumbar IVDs of Beagle dogs. After 4 weeks, microspheres loaded with 8.4 µg TAA, and 0.84mg TAA were administered to the degenerated IVDs by intradiscal injection (n=6 per group). Empty microspheres (n=6) and all adjacent non-nucleotomized noninjected IVDs were included as controls (n=24). Immediately prior to TAA administration and after 12 weeks, magnetic resonance imaging was performed. Degenerative changes were evaluated by disc height index, Pfirrmann grading, T1ρ and T2 mapping values, postmortem CT scans, macroscopic and microscopic grading, and biochemical/immunohistochemical analysis of inflammation and extracellular matrix content. In addition, nerve growth factor (NGF) protein expression, a biomarker for pain, was scored in nucleus pulposus (NP) tissues. The study was funded by a research grant from Health Holland (1.3million euros = 1.5million US dollars).

RESULTS

Macroscopic evaluation and CT images postmortem were consistent with mild disc degeneration. Other abnormalities were not observed. Nucleotomy-induced degeneration and inflammation was mild, reflected by moderate Pfirrmann grades and PGE₂ levels. Regardless of TAA dosage, local sustained delivery did not affect disc height index nor Pfirrmann grading, T1ρ and T2 mapping values, PGE₂ tissue levels, collagen, GAG, and DNA content. However, the low dosage of TAA microspheres significantly reduced NGF immunopositivity in degenerated NP tissue.

CONCLUSIONS

This is the first in vivo application in a preclinical large animal model of a controlled release formulation of corticosteroids in mild IVD degeneration. Sustained release of TAA locally in the IVD appeared safe and reduced NGF expression, suggesting its potential applicability for pain relief, although beneficial effects were absent on tissue degeneration.

CLINICAL SIGNIFICANCE

The present platform seems to be promising in extending the local controlled delivery of TAA with the potency to provide long-standing analgesia in the subset of LBP patients suffering from discogenic pain.

Cryopreserved amniotic membrane and umbilical cord particulate for managing pain caused by facet joint syndrome: A case series

Treatment of back pain due to facet joint syndrome has been a challenge for physicians since its recognition ∼80 years ago. Intra-articular injections of steroids, local anesthetics, and phenol have been widely adopted despite their known shortcomings. Recently, intra-articular injection of amniotic membrane-umbilical cord (AMUC) has been utilized in various orthopedic indications, including those involving synovial joints, due to its reported anti-inflammatory properties. Herein, use of AMUC for facet joint syndrome was evaluated.A single-center case series was conducted on patients presenting with pain caused by facet joint syndrome, confirmed by single blocking anesthetic injection and treated using a single intra-articular injection of 50 mg particulate AMUC (CLARIX FLO) suspended in preservative-free saline. Patient reported back pain severity (numerical scale 0-10) and opioid use were compared between baseline and 6 months following treatment.A total of 9 patients (7 males, 2 females), average age 52.1 ± 15.9 years, were included. Five patients with cervical pain had a history of trauma, 1 patient had suffered lumbar facet injury and 3 had degenerative lumbar facet osteoarthritis. All patients had severe pain prior to injection (8.2 ± 0.8) and 4 (44%) were taking opioids (>100 morphine milligram equivalents). Six-month post-treatment, average pain had decreased to 0.4 ± 0.7 (P <.05). All patients had ceased use of prescription pain medications, including opioids. No adverse events, repeat procedures, or complications were reported.Intra-articular injection of AMUC appears to be promising for managing facet pain and mitigating opioid use. Further investigation with larger sample size is warranted.

Patients' perceived needs for medical services for non-specific low back pain: A systematic scoping review

BACKGROUND

An improved understanding of patients' perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients' perceived needs for medical services for LBP.

METHODS

A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs for medical services for LBP were categorised.

RESULTS

50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients' preferences for medications. (3) Of the few studies which examined the patients' perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms.

CONCLUSIONS

Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.

The response to radiofrequency neurotomy of medial branches including a bipolar system for thoracic facet joints

Background and aims The evidence for interventional treatment of thoracic facet joint pain remains limited. This is partly due to inconsistency of the path of thoracic medial branches and a lower incidence of thoracic facet pain among spine pain patients. The purpose of this study is to evaluate the efficacy of bipolar radiofrequency (RF) neurotomy of medial branches for treating chronic thoracic facet joint pain. Methods This is a retrospective record review of all patients diagnosed to have thoracic facet pain with diagnostic block and subsequently treated with bipolar RF neurotomy of medial branch between January 2012 and December 2015. The outcome measures were mean changes in Numeral Rating Scale (NRS) and Pain Disability Index (PDI). Results There were 71 patients with complete data available for analysis. The mean age of the patients was 57.9±11.2 years. The mean duration of pain was 23±10.5 months. The majority of patients (82%) had pain reduction of more than 50% at 12 months after bipolar RF neurotomy. The NRS decreased significantly from baseline of 7.75±1.25 to 2.86±1.53 at 3 months and 2.82±1.29 at 12 months post-procedure (p<0.001. p<0.001, respectively). The PDI improved significantly from 40.92±12.22 to 24.15±9.79, p<0.05). There were no serious adverse effects or complications of the procedure reported in this study. Conclusions Bipolar RF neurotomy of thoracic medial branch is associated with a significant reduction in thoracic facet joint pain. The promising findings from this case series merit further assessment with prospective, randomized controlled trial which will produce a more reliable and accurate finding for its clinical applications.

Unique aspects of clinical trials of invasive therapies for chronic pain

Nearly all who review the literature conclude that the role of invasive procedures to treat chronic pain is poorly characterized because of the lack of “definitive” studies. The overt nature of invasive treatments, along with the risks, technical skills, and costs involved create challenges to study them. However, these challenges do not completely preclude evaluating invasive procedure effectiveness and safety using well-designed methods. This article reviews the challenges of studying outcomes of invasive therapies to treat pain and discuss possible solutions. Although the following discussion can apply to most invasive therapies to treat chronic pain, it is beyond the scope of the article to individually cover every invasive therapy used. Therefore, most of the examples focus on injection therapies to treat spine pain, spinal cord stimulation, and intrathecal drug therapies.

Facet-joint injections for non-specific low back pain: a feasibility RCT

BACKGROUND

Pain of lumbar facet-joint origin is a common cause of low back pain in adults and may lead to chronic pain and disability, with associated health and socioeconomic implications. The socioeconomic burden includes an inability to return to work resulting in loss of productivity in addition to direct and indirect health-care utilisation costs. Lumbar facet-joints are paired synovial joints between the superior and inferior articular processes of consecutive lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Facet-joint pain is defined as pain that arises from any structure that is part of the facet-joints, including the fibrous capsule, synovial membrane, hyaline cartilage and bone. This pain may be treated by intra-articular injections with local anaesthetic and steroid, although this treatment is not standardised. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. Because of the lack of high-quality, robust clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines on the management of chronic low back pain [NICE. Low Back Pain in Adults: Early Management. Clinical guideline (CG88). London: NICE; 2009] did not recommend the use of spinal injections despite their perceived potential to reduce pain intensity and improve rehabilitation, with NICE calling for further research to be undertaken. The updated guidelines [NICE. Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE guideline (NG59). London: NICE; 2016] again do not recommend the use of spinal injections.

OBJECTIVES

To assess the feasibility of carrying out a definitive study to evaluate the clinical effectiveness and cost-effectiveness of lumbar facet-joint injections compared with a sham procedure in patients with non-specific low back pain of > 3 months' duration.

DESIGN

Blinded parallel two-arm pilot randomised controlled trial.

SETTING

Initially planned as a multicentre study involving three NHS trusts in the UK, recruitment took place in the pain and spinal orthopaedic clinics at Barts Health NHS Trust only.

PARTICIPANTS

Adult patients referred by their GP to the specialist clinics with non-specific low back pain of at least 3 months' duration despite NICE-recommended best non-invasive care (education and one of a physical exercise programme, acupuncture or manual therapy). Patients who had already received lumbar facet-joint injections or who had had previous back surgery were excluded.

INTERVENTIONS

Participants who had a positive result following a diagnostic test (single medial branch nerve blocks) were randomised and blinded to receive either intra-articular lumbar facet-joint injections with steroids (intervention group) or a sham procedure (control group). All participants were invited to attend a group-based combined physical and psychological (CPP) programme.

MAIN OUTCOME MEASURES

In addition to the primary outcome of feasibility, questionnaires were used to assess a range of pain-related (including the Brief Pain Inventory and Short-Form McGill Pain Questionnaire version 2) and disability-related (including the EuroQol-5 Dimensions five-level version and Oswestry Low Back Pain Questionnaire) issues. Health-care utilisation and cost data were also assessed. The questionnaire visits took place at baseline and at 6 weeks, 3 months and 6 months post randomisation. The outcome assessors were blinded to the allocation groups.

RESULTS

Of 628 participants screened for eligibility, nine were randomised to receive the study intervention (intervention group, n = 5; sham group, n = 4), six completed the CPP programme and eight completed the study.

LIMITATIONS

Failure to achieve our expected recruitment targets led to early closure of the study by the funder.

CONCLUSIONS

Because of the small number of participants recruited to the study, we were unable to draw any conclusions about the clinical effectiveness or cost-effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. Although we did not achieve the target recruitment rate from the pain clinics, we demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely to all nine randomised participants, thus addressing many of the feasibility objectives.

FUTURE WORK

Stronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory who are suitable for inclusion in a future trial.

TRIAL REGISTRATION

EudraCT 2014-003187-20 and Current Controlled Trials ISRCTN12191542.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 74. See the NIHR Journals Library website for further project information.

Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes

BACKGROUND

Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids.

OBJECTIVE

To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol.

RESULTS

Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes.

CONCLUSION

This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.

Comparison of Lumbar Total Disc Replacement With Surgical Spinal Fusion for the Treatment of Single-Level Degenerative Disc Disease: A Meta-Analysis of 5-Year Outcomes From Randomized Controlled Trials

STUDY DESIGN

Meta-analysis.

OBJECTIVES

To evaluate the long-term efficacy and safety of total disc replacement (TDR) compared with fusion in patients with functionally disabling chronic low back pain due to single-level lumbar degenerative disc disease (DDD) at 5 years.

METHODS

PubMed and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials reporting outcomes at 5 years for TDR compared with fusion in patients with single-level lumbar DDD. Outcomes included Oswestry Disability Index (ODI) success, back pain scores, reoperations, and patient satisfaction. All analyses were conducted using a random-effects model; analyses were reported as relative risk (RR) ratios and mean differences (MDs). Sensitivity analyses were conducted for different outcome definitions, high loss to follow-up, and high heterogeneity.

RESULTS

The meta-analysis included 4 studies. TDR patients had a significantly greater likelihood of ODI success (RR 1.0912; 95% CI 1.0004, 1.1903) and patient satisfaction (RR 1.13; 95% CI 1.03, 1.24) and a significantly lower risk of reoperation (RR 0.52; 95% CI 0.35, 0.77) than fusion patients. There was no association with improvement in back pain scores whether patients received TDR or fusion (MD -2.79; 95% CI -8.09, 2.51). Most results were robust to sensitivity analyses. Results for ODI success and patient satisfaction were sensitive to different outcome definitions but remained in favor of TDR.

CONCLUSIONS

TDR is an effective alternative to fusion for lumbar DDD. It offers several clinical advantages over the longer term that can benefit the patient and reduce health care burden, without additional safety consequences.

First-in-human randomized clinical trials of the safety and efficacy of tanezumab for treatment of chronic knee osteoarthritis pain or acute bunionectomy pain

Supplemental Digital Content is Available in the Text.

Introduction:

The neurotrophin nerve growth factor has a demonstrated role in pain transduction and pathophysiology.

Objectives:

Two randomized, double-blind, placebo-controlled, phase 1 studies were conducted to evaluate safety, tolerability, and analgesic efficacy of single doses of tanezumab, a humanized anti–nerve growth factor monoclonal antibody, in chronic or acute pain.

Methods:

In the first study (CL001), patients with moderate to severe pain from osteoarthritis (OA) of the knee received a single intravenous infusion of tanezumab (3–1000 μg/kg) or placebo in a dose-escalation (part 1; N = 42) or parallel-arm (part 2; N = 79) study design. The second study (CL002) was a placebo-controlled dose-escalation (tanezumab 10–1000 μg/kg; N = 50) study in patients undergoing bunionectomy surgery.

Results:

Adverse event rates were generally similar across treatments. Most adverse events were generally mild to moderate in severity and no patients discontinued as a result of adverse events. Adverse events of abnormal peripheral sensation were more common with higher doses of tanezumab (≥100 μg/kg) than with placebo. These were generally mild to moderate in severity. Tanezumab provided up to 12 weeks of effective analgesia for OA knee pain, with statistically significant improvements at doses ≥100 μg/kg (P < 0.05). By contrast, no trend for analgesic activity was found when tanezumab was administered 8 to 16 hours before bunionectomy.

Conclusions:

The demonstration of a favorable safety profile and clinical efficacy in OA pain supports clinical development of tanezumab as a potential treatment for chronic pain conditions.

Patients' perceived needs of health care providers for low back pain management: a systematic scoping review

BACKGROUND CONTEXT

Optimal management of low back pain (LBP) involves patients' active participation in care, facilitated by positive interactions with their health care provider(s) (HCP). An understanding of patients' perceived needs regarding their HCP is, therefore, necessary to achieve such outcomes. Therefore, the aim of the present study is to review the existing literature regarding patients' perceived needs of HCP managing LBP.

METHODS

A systematic scoping review of publications in MEDLINE, EMBASE, CINAHL, and PsycINFO (1990-2016) was performed. Descriptive data regarding study design and methodology were extracted, and risk of bias was assessed. Aggregates of patients' perceived needs of HCP for LBP were categorized.

RESULTS

Forty-three studies (30 qualitative, 12 quantitative, and 1 mixed methods) from 1,829 were relevant. Four areas of perceived need emerged: (1) there are several characteristics of HCP that patients desire, such as good communication and shared decision-making; (2) patients wanted HCP to provide information, including a cause of their LBP and legitimization of their symptoms; (3) patients' valued holistic, individualized care, and continuity of care; and (4) patients perceived long waiting times, difficulties with access to treatment, cost, and personal effort to be obstacles to care.

CONCLUSIONS

Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.

Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries

This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial

BACKGROUND

The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care.

OBJECTIVES

To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective.

DESIGN

The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation.

SETTING

Five NHS acute trusts in England.

PARTICIPANTS

Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone.

INTERVENTIONS

All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session.

MAIN OUTCOME MEASURES

Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months.

RESULTS

Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84.

LIMITATIONS

Poor recruitment was a limiting factor.

CONCLUSIONS

This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain.

FUTURE WORK

Further work is needed to test recruitment from alternative clinical situations.

TRIAL REGISTRATION

EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Low Back Pain: What Have Clinical Guidelines Ever Done for Us?

The burden that low back pain (LBP) presents to sufferers and society is well established. This ubiquitous condition is served by a complex global clinical marketplace offering a wide range of assessment alternatives and accompanying interventions. Yet, while the costs of care are rising, the global burden does not appear to be diminishing. Considerable effort internationally has gone into developing CPGs for LBP. The authors highlight the similarities and differences between existing CPGs for LBP, as well as strengths, weaknesses, and opportunities for improvement in the implementation of guidelines generally. J Orthop Sports Phys Ther 2018;48(2):54-57. doi:10.2519/jospt.2018.0602.

Two-year Outcomes from a Single Surgeon's Learning Curve Experience of Oblique Lateral Interbody Fusion without Intraoperative Neuromonitoring

Introduction

Oblique lumbar interbody fusion (OLIF) is a newer procedure that avoids the psoas and lumbosacral plexus due to its oblique trajectory into the retroperitoneal space. While early experience with OLIF is reassuring, the longer-term clinical efficacy has not been well established. The purpose of this study was to describe two-year clinical outcomes with OLIF performed by a single surgeon during the learning curve without the aid of the neuromonitoring.

Materials and methods

Chart review was performed for the consecutive patients who underwent OLIF by a single surgeon. Back pain severity on a visual analog scale (VAS) and Oswestry Disability Index (ODI) were collected preoperatively and postoperatively at six weeks, three months, six months, one year and two years.

Results

A total of 21 patients (38 levels) were included in this study. The indications for surgery were degenerative disc disease (n=10, 47.6%), spondylolisthesis (n=9, 42.9%) and spinal stenosis (n=6, 28.6%). The median operating room time was 351 minutes (interquartile range (IQR): 279-406 minutes), blood loss was 40 ml (IQR: 30-150 ml), and hospital stay was 2.0 days (IQR: 1.0-3.5 days). The complication rate was 9.5%, both venous injuries. There were no other perioperative complications. Back pain severity decreased by 70%, on average, over two years (p <0.001). A total of 17 (81%) patients reported at least a two-point decrease from the baseline. The ODI scores decreased by 55%, on average, over two years (p <0.001), with 16 (76%) patients reporting at least a 15-point decrease from the baseline. Over two years, no symptomatic pseudarthrosis, hardware failure, reoperations, or additional complications were reported.

Conclusions

The oblique lateral interbody fusion performed without the intraoperative neuromonitoring was safe and clinically efficacious for up to two years. The complication rate in this cohort is similar to other published OLIF series and appears acceptable when compared to the lateral lumbar interbody fusion (LLIF) and the anterior lumbar interbody fusion (ALIF). No motor or sensory deficits were observed in this study, supporting the premise that the neuromonitoring is unnecessary in OLIF.

Factors affecting lumbar surgery outcome: A nation-wide, population-based retrospective study

BACKGROUND

Lower back pain is a very common symptom and treatment strategies vary according the severity and duration of illness. Surgical approaches are becoming increasingly popular with the advent of new and less invasive technologies; however, treatment outcomes are not yet well established on a population-based level. Taiwan's National Health Insurance Research Database (NHIRD) is longitudinal and includes 98% of the population since its inception in 1995. The database includes the ICD 9.0 codes (International Classification of Diseases) of all patients with lower back pain and lumbar surgery; furthermore, all the prescriptions.

METHODS

As part of a population-based cohort study of one million participants randomly selected from the NHIRD, we analyzed changes in prescription of analgesics 1 year before and 1 year after lumbar surgery; comorbidities, such as diabetes, asthma, osteoporosis, arthritis, depression and anxiety were also analyzed as covariates. A total of 3916 cases were enrolled in final analysis.

RESULTS

Post-operatively, the defined daily dosage (DDD) of analgesics decreased from a median DDD of 50.0 to a median of 14.2. In a multivariate model analysis, female, older age, anxiety and asthma were the significant factors for unfavorable outcome (defined by dosage of analgesics decreased less than 50% after surgery).

CONCLUSIONS

The analgesics significantly decreased for patients received lumbar surgeries, implying the decreased of pain. In addition, co-morbidity factors were identified by the failure for analgesics reduction, such as female, older age, anxiety and asthma. For patients with lower back pain, these factors should be considered before receiving lumbar surgeries.

Interventional Pain Management in Multidisciplinary Chronic Pain Clinics: A Prospective Multicenter Cohort Study with One-Year Follow-Up

Background

Interventional Pain Management (IPM) is performed in multidisciplinary chronic pain clinics (MCPC), including a range of invasive techniques to diagnose and treat chronic pain (CP) conditions. Current patterns of use of those techniques in MCPC have not yet been reported.

Objective

We aimed to describe quantitatively and qualitatively the use of IPM and other therapeutic procedures performed on-site at four Portuguese MCPC.

Methods

A prospective cohort study with one-year follow-up was performed in adult patients. A structured case report form was systematically completed at baseline and six and 12 months.

Results

Among 808 patients referred to the MCPC, 17.2% had been prescribed IPM. Patients with IPM were on average younger and had longer CP duration and lower levels of maximum pain and pain interference/disability. The three main diagnoses were low back pain (n = 28), postoperative CP, and knee pain (n = 16 each). From 195 IPM prescribed, nerve blocks (n = 108), radiofrequency (n = 31), and viscosupplementation (n = 22) were the most prevalent. Some IPM techniques were only available in few MCPC. One MCPC did not provide IPM.

Conclusions

IPM are seldom prescribed in Portuguese MCPC. Further studies on IPM safety and effectiveness are necessary for clear understanding the role of these techniques in CP management.

Does Pain Reduction with Oral Steroids Predict Pain Reduction after a First-Time Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain? A Pilot Study

Objective

Oral and injected steroids are used commonly in the treatment of cervical radicular pain despite a paucity of data demonstrating their efficacy. The purpose of this study is to assess whether the response to orally administered steroids among patients with acute cervical radicular pain who develop recurrent pain is associated with their subsequent response to cervical epidural steroid injections.

Methods

Patients referred to our center were evaluated and then referred for cervical epidural steroid injections at the clinical discretion of the provider; those who met inclusion criteria were offered participation in the study. After the injection was administered, patients were contacted by telephone and asked to complete the Brief Pain Inventory Short Form at one week, one month, three months, and six months postinjection.

Results

Pain reduction after cervical steroid injection was not significantly different between 49 patients who reported pain reduction with a prior course of oral steroids and 22 patients who reported no pain reduction. Average pain scores decreased over six months (P < 0.001) among 72 patients treated with epidural steroid injection for cervical radicular pain. Of the 55 who provided baseline and six-month data, 14 (25.5%) reported complete relief at six months and 20 (36.4%) reported decreased pain.

Conclusions

Patients can be reassured that they may experience pain reduction after a cervical epidural steroid injection even if oral steroid therapy was not effective. The majority of patients treated for cervical radicular pain with epidural steroid injection have reduced or absent pain for at least six months after treatment.

Characteristics of Paraspinal Muscle Spindle Response to Mechanically Assisted Spinal Manipulation: A Preliminary Report

OBJECTIVES

The purpose of this preliminary study is to determine muscle spindle response characteristics related to the use of 2 solenoid powered clinical mechanically assisted manipulation (MAM) devices.

METHODS

L6 muscle spindle afferents with receptive fields in paraspinal muscles were isolated in 6 cats. Neural recordings were made during L7 MAM thrusts using the Activator V (Activator Methods Int. Ltd., Phoenix, AZ) and/or Pulstar (Sense Technology Inc., Pittsburgh, PA) devices at their 3 lowest force settings. Mechanically assisted manipulation response measures included (a) the time required post-thrust until the first action potential, (b) differences in mean frequency (MF) and mean instantaneous frequency (MIF) 2 seconds before and after MAM, and (c) the time required for muscle spindle discharge (MF and MIF) to return to 95% of baseline after MAM.

RESULTS

Depending on device setting, between 44% to 80% (Pulstar) and 11% to 63% (Activator V) of spindle afferents required >6 seconds to return to within 95% of baseline MF values; whereas 66% to 89% (Pulstar) and 75% to 100% (Activator V) of spindle responses returned to within 95% of baseline MIF in <6 seconds after MAM. Nonparametric comparisons between the 22 N and 44 N settings of the Pulstar yielded significant differences for the time required to return to baseline MF and MIF.

CONCLUSION

Short duration (<10 ms) MAM thrusts decrease muscle spindle discharge with a majority of afferents requiring prolonged periods (>6 seconds) to return to baseline MF activity. Physiological consequences and clinical relevance of described MAM mechanoreceptor responses will require additional investigation.

Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines

Given the scale and cost of the low back pain problem, it is imperative that healthcare professionals involved in the care of people with low back pain have access to up-to-date, evidence-based information to assist them in treatment decision-making. Clinical guidelines exist to promote the consistent best practice, to reduce unwarranted variation and to reduce the use of low-value interventions in patient care. Recent decades have witnessed the publication of a number of such guidelines. In this narrative review, we consider three selected international interdisciplinary guidelines for the management of low back pain. Guideline development methods, consistent recommendations and inconsistencies between these guidelines are critically discussed.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

IMPORTANCE

Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

OBJECTIVE

To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

DATA SOURCES

Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.

DATA EXTRACTION AND SYNTHESIS

Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

MAIN OUTCOMES AND MEASURES

Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.

FINDINGS

Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

CONCLUSIONS AND RELEVANCE

Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data

Objective

To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections.

Design

Systematic review of the literature with comprehensive analysis of the published data.

Interventions

Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented.

Outcome Measures

The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence.

Results

The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies.

Conclusions

The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.

Patient Priority Weighting of the Roland Morris Disability Questionnaire Does Not Change Results of the Lumbar Epidural Steroid Injections for Spinal Stenosis Trial

STUDY DESIGN

Secondary analysis of lumbar epidural steroid injections for spinal stenosis randomized controlled trial data.

OBJECTIVE

To reevaluate whether outcomes for older adults receiving epidural steroid injections with or without corticosteroid improve after using patient-prioritized Roland-Morris Disability Questionnaire (RDQ) items.

SUMMARY OF BACKGROUND DATA

Epidural corticosteroid injections are commonly used to treat lumbar spinal stenosis symptoms, despite limited evidence for their effectiveness in clinical trials. It is unclear whether evaluating patient-prioritized outcomes would alter results of a large clinical trial.

METHODS

Outcomes from the trial of lumbar epidural corticosteroid injections for spinal stenosis (LESS) trial were reanalyzed using RDQ, Sickness Impact Profile (SIP) weights assigned to the RDQ items, and patient-prioritized RDQ items. Differences between corticosteroid + lidocaine versus lidocaine-alone groups and 95% confidence intervals (CI) were calculated using analysis of covariance with adjustment for baseline values of the RDQ and recruitment site.

RESULTS

At 6 weeks, both the corticosteroid + lidocaine group and the lidocaine-alone group had improvement in the RDQ scores (RDQ, RDQ using SIP weights, patient-prioritized RDQ) as compared with baseline scores (corticosteroid + lidocaine: -4.2 points, -4.1 points, -4.2; lidocaine-alone: -3.1 points, -2.9 points, and -3.1 points, respectively). However, there was no significant between-group difference in the RDQ or patient-prioritized RDQ (average treatment effect -1.0 points, 95% CI -2.1 to 0.1, P = 0.07; -1.0 points, 95% CI -2.0 to 0.1, P = 0.08, respectively). Although the between-group difference of RDQ using SIP weights was statistically significant (average treatment effect -1.1, 95% CI -2.2 to -0.1, P = 0.04), this was not clinically important.

CONCLUSION

Results of the LESS trial did not substantively differ based on reanalysis of data using RDQ with SIP weights or patient-prioritized RDQ outcomes. This provides additional evidence that epidural injection of corticosteroid + lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone for older adults with lumbar spinal stenosis.

LEVEL OF EVIDENCE

2.

Safety of Epidural Corticosteroid Injections

BACKGROUND AND OBJECTIVE

Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports.

METHODS

Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis.

RESULTS

Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating.

CONCLUSIONS

The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.

Multiexpandable cage for minimally invasive posterior lumbar interbody fusion

The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results.

Comparative effectiveness of percutaneous epidural adhesiolysis for different sacrum types in patients with chronic pain due to lumbar disc herniation: A propensity score matching analysis

For percutaneous epidural adhesiolysis (PEA) in patients with chronic low back and/or leg pain, comparative efficacy of lumbar PEA between the sacral types has not yet been investigated. This study aimed to determine the comparative efficacy of lumbar PEA between the sacral types in chronic pain with lumbosacral herniated intervertebral disc (L-HIVD).A total of 1158 chronic low back and/or leg pain patients who diagnosed with L-HIVD and underwent PEA between February 2011 and March 2015 were retrospectively examined. All enrolled patients were divided into 2 types: dome-sacral type and flat type. To avoid confounding bias, propensity score analysis was used. Numeric rating scales (NRS) and Patients' Global Impression of Change (PGIC) were compared between the 2 types at baseline and at 3 months post-PEA.After conducting a propensity score matching analysis, 114 patients were included in each type. The mean sacral angle significantly differed between the flat-sacral and dome-sacral types (P < 0.001). A linear mixed effect model analysis showed that the adjusted NRS score at baseline was 7.58 [95% confidence interval (CI): 7.40-7.76] for the flat-sacral type and 7.47 (95% CI: 7.29-7.64) for the dome-sacral type. The adjusted NRS score after 3 months post-PEA was 4.27 (95% CI: 3.77-4.77) for the flat-sacral type and 3.71 (95% CI: 3.21-4.21) for the dome-sacral type. We detected no significant differences in NRS at baseline (P = 0.371) and after 3 months (P = 0.121) between the 2 groups. No significant differences were observed in terms of the NRS score between the 2 groups during the 3 months follow-up (omnibus P = 0.223). There were no significant differences in PGIC between flat-sacral and dome-sacral types at 3 months after the follow-up period (4.40 ± 2.17 and 4.67 ± 1.88, respectively, P = 0.431).PEA provides sufficient pain relief for chronic pain due to L-HIVD at 3 months postprocedure. The sacral type might not affect the outcome of lumbar PEA in chronic pain associated lumbar HIVD.

Overview of Pain Management in Older Adults

Epidemiological data suggests that the prevalence of musculoskeletal and neuropathic pain increases with age until at least late mid-life, though the pattern is somewhat unclear beyond this point. And though the prevalence of some types of pain may peak in late midlife, pain is still a substantial and common complaint even in the oldest age groups. This article provides an overview of later-life pain and includes a brief review of its epidemiology, describes commonly encountered barriers to its management, and discusses guidelines and recommended approaches to its assessment and management.

Treatment of Lower Back Pain-The Gap between Guideline-Based Treatment and Medical Care Reality

Despite the fact that unspecific low back pain is of important impact in general health care, this pain condition is often treated insufficiently. Poor efficiency has led to the necessity of guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). We present some statements of the German medical care reality. Self-responsible action of the patient should be supported while invasive methods in particular should be avoided due to lacking evidence in outcome efficiency. However, it has to be stated that no effective implementation strategy has been established yet. Especially, studies on the economic impact of different implementation strategies are lacking. A lack of awareness of common available guidelines and an uneven distribution of existing knowledge throughout the population can be stated: persons with higher risk suffering from LBP by higher professional demands and lower educational level are not skilled in advised management of LBP. Both diagnostic imaging and invasive treatment methods increased dramatically leading to increased costs and doctor workload without being associated with improved patient functioning, severity of pain or overall health status due to the absence of a functioning primary care gate keeping system for patient selection. Opioids are prescribed on a grand scale and over a long period. Moreover, opioid prescription is not indicated properly, when predominantly persons with psychological distress like somatoform disorders are treated with opioids.

Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes

INTRODUCTION

Epidural steroid is an important modality in the conservative management of prolapsed lumbar disc and is being used for over 50 years. However, controversy still persists regarding their effectiveness in reducing the pain and improving the function with literature both supporting and opposing them are available.

AIM

To study the efficacy of epidural steroid injection in the management of pain due to prolapsed lumbar intervertebral disc and to compare the effectiveness between caudal, transforaminal and interlaminar routes of injection.

MATERIALS AND METHODS

A total of 152 patients with back pain with or without radiculopathy with a lumbar disc prolapse confirmed on MRI, were included in the study and their pre injection Japanese Orthopaedic Association (JOA) Score was calculated. By simple randomization method (picking a card), patients were enrolled into one of the three groups and then injected methyl prednisone in the epidural space by one of the techniques of injection i.e. caudal, transforaminal and interlaminar. Twelve patients didn't turn up for the treatment and hence were excluded from the study. Remaining 140 patients were treated and were included for the analysis of the results. Eighty two patients received injection by caudal route, 40 by transforaminal route and 18 by interlaminar route. Post injection JOA Score was calculated at six month and one year and effectiveness of the medication was calculated for each route. The data was compared by LSD and ANOVA method to prove the significance. Average follow-up was one year.

RESULTS

At one year after injecting the steroid, all three routes were found to be effective in improving the JOA Score (Caudal route in 74.3%, transforaminal in 90% and interlaminar in 77.7%). Transforaminal route was significantly more effective than caudal (p=0.00) and interlaminar route (p=0.03) at both 6 months and one year after injection. No significant difference was seen between the caudal and interlaminar route (p=0.36).

CONCLUSION

The management of low back pain and radicular pain due to a prolapsed lumbar intervertebral disc by injecting methyl prednisone in epidural space is satisfactory in the current study. All three injection techniques are effective with the best result obtained by transforaminal route.

CT-guided injection of a TRPV1 agonist around dorsal root ganglia decreases pain transmission in swine

One approach to analgesia is to block pain at the site of origin or along the peripheral pathway by selectively ablating pain-transmitting neurons or nerve terminals directly. The heat/capsaicin receptor (TRPV1) expressed by nociceptive neurons is a compelling target for selective interventional analgesia because it leaves somatosensory and proprioceptive neurons intact. Resiniferatoxin (RTX), like capsaicin, is a TRPV1 agonist but has greater potency. We combine RTX-mediated inactivation with the precision of computed tomography (CT)-guided delivery to ablate peripheral pain fibers in swine. Under CT guidance, RTX was delivered unilaterally around the lumbar dorsal root ganglia (DRG), and vehicle only was administered to the contralateral side. During a 4-week observation period, animals demonstrated delayed or absent withdrawal responses to infrared laser heat stimuli delivered to sensory dermatomes corresponding to DRG receiving RTX treatment. Motor function was unimpaired as assessed by disability scoring and gait analysis. In treated DRG, TRPV1 mRNA expression was reduced, as were nociceptive neuronal perikarya in ganglia and their nerve terminals in the ipsilateral dorsal horn. CT guidance to precisely deliver RTX to sites of peripheral pain transmission in swine may be an approach that could be tailored to block an array of clinical pain conditions in patients.

Targeted Therapy for Low Back Pain in Elderly Degenerative Lumbar Scoliosis: A Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To compare the novel treatment procedure with nonoperative treatment for low back pain (LBP) in elderly patients with degenerative lumbar scoliosis (DLS).

SUMMARY OF BACKGROUND DATA

Treatment of LBP associated with elderly DLS is controversial. We developed a novel treatment procedure, termed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI).

METHODS

We included patients with de novo DLS aged ≥65 years who had LBP with a visual analogue scale (VAS) score of >50 for ≥6 months with intervertebral vacuum and vertebral bone marrow edema (BME) defined on fat-saturated T2-weighted or gadolinium-enhanced T1-weighted magnetic resonance imaging. The primary outcomes were evaluated using the VAS score and modified Oswestry Disability Index (ODI). As an objective measurement, we scored BME on magnetic resonance imaging.

RESULTS

Between August 2004 and July 2011, 109 patients underwent PIPI and 53 received nonoperative treatment. At 1 month, mean improvements in VAS scores were -55.3 (95% CI, -60.5 to -50.1) and -1.9 (CI, -7.7 to 3.8) and mean improvements in ODI were -22.7 (CI, -27.3 to -18.2) and -0.6 (CI, -6.6 to 5.4) for the PIPI and nonoperative groups, respectively. At 2 years, mean improvements in VAS scores were -52.2 (CI, -59.9 to -44.4) and -4.0 (CI, -10.9 to 3.0) and mean improvements in ODI were -20.7 (CI, -27.3 to -14.5) and -1.0 (CI, -7.7 to 5.7) for the PIPI and nonoperative groups, respectively. BME substantially decreased in the PIPI group compared with the nonoperative group (P <0.001) and correlated with VAS score and ODI improvements (VAS score: r = 0.502, P <0.001; ODI: r = 0.372, P <0.001).

CONCLUSION

PIPI improved treatment for LBP, with a sustained clinical benefit for at least 2 years.

LEVEL OF EVIDENCE

3.

Long term follow-up of cervical intervertebral disc herniation inpatients treated with integrated complementary and alternative medicine: a prospective case series observational study

Background

Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.

Methods

A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.

Results

Of 165 patients who received inpatient treatment 20.8 ± 11.2 days, 117 completed the long term follow-up up at 625.36 ± 196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (n = 117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI 14.6 (95 % CI, 11.89, 17.32), and corresponding scores in the non-long term follow-up group (n = 48) were 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 (95 % CI, 1.84, 3.12) for arm pain, and that of NDI was 14.86 (95 % CI, 10.41, 19.3). Difference in long term NRS of neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64), and 2.64 (95 % CI, 1.99, 3.29), respectively. PGIC was reported to be “satisfactory” or higher in 79.5 % of patients at long term follow-up.

Conclusions

Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.

Trial registration

ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.

The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain

Invasive analgesic therapies provide an alternative to medical management of chronic pain. With the increasing incidence of chronic pain not only in the United States but worldwide, more therapies have evolved to address the growing need for pain relief options. These therapies include spinal injections, nerve blocks, radiofrequency ablation, neurostimulation, and intrathecal drug delivery.

COMPARISON OF THE EFFECTIVENESS OF RADICULAR BLOCKING TECHNIQUES IN THE TREATMENT OF LUMBAR DISK HERNIA

Objective : Compare the interlaminar blocking technique with the transforaminal blocking, with regard to pain and the presence or absence of complications. Methods : Prospective, descriptive and comparative, double-blind, randomized study, with 40 patients of both sex suffering from sciatic pain due to central-lateral or foraminal disc herniation, who did not respond to 20 physiotherapy sessions and had no instability diagnosed on examination of dynamic radiography. The type of blocking, transforaminal or interlaminar, to be performed was determined by draw. Results : We evaluated 40 patients, 17 males, mean age 49 years, average VAS pre-blocking of 8.85, average values in transforaminal technique in 24 hours, 7, 21, and 90 days of 0.71, 1.04, 2.33 and 3.84, respectively; the average VAS post-blocking for interlaminar technique was 0.89, 1.52, 3.63 and 4.88. The techniques differ only in the post-blocking period of 21 days and overall post-blocking, with significance of p=0.022 and p=0.027, respectively. Conclusion : Both techniques are effective in relieving pain and present low complication rate, and the transforaminal technique proved to be the most effective.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect the RTF recommendations will become a dynamic document, and undergo continual improvement.

PERSPECTIVE

A Task Force was convened by the NIH Pain Consortium, with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimal dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis

BACKGROUND

Use of epidural corticosteroid injections is increasing.

PURPOSE

To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration.

DATA SOURCES

Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists.

STUDY SELECTION

Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses.

DATA EXTRACTION

Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE).

DATA SYNTHESIS

30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low).

LIMITATIONS

The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings.

CONCLUSION

Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.