Does the location of low back pain predict its source? PM R. 2011;3:33-39. [PMID: 21257131 DOI: 10.1016/j.pmrj.2010.09.006]

Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline

STUDY DESIGN

Systematic review of the literature and subsequent meta-analysis for the development of a new guideline.

OBJECTIVES

This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure.

METHODS

A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications.

CONCLUSION

Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management

There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.

Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review

Background

The accuracy of diagnostic tests available in primary care to identify the disc, sacroiliac joint, and facet joint as the source of low back pain is uncertain.

Methods

Systematic review of diagnostic tests available in primary care. MEDLINE, CINAHL, and EMBASE were searched between March 2006 and 25th January 2023. Pairs of reviewers independently screened all studies, extracted data, and assessed risk of bias using QUADAS-2. Pooling was performed for homogenous studies. Positive likelihood ratios (+LR) ≥2 and negative likelihood ratios (-LR) ≤0.5 were considered informative. This review is registered with PROSPERO (CRD42020169828).

Findings

We included 62 studies: 35 investigated the disc, 14 the facet joint, 11 the sacroiliac joint, and 2 investigated all three structures in patients with persistent low back pain. For risk of bias, the domain 'reference standard' scored worst, however approximately half the studies were of low risk of bias for every other domain. For the disc, pooling demonstrated MRI findings of disc degeneration and annular fissure resulted in informative +LRs: 2.53 (95% CI: 1.57-4.07) and 2.88 (95% CI: 2.02-4.10) and -LRs: 0.15 (95% CI: 0.09-0.24) and 0.24 (95% CI: 0.10-0.55) respectively. Pooled results for Modic type 1, Modic type 2, and HIZ on MRI, and centralisation phenomenon yielded informative +LRs: 10.00 (95% CI: 4.20-23.82), 8.03 (95% CI: 3.23-19.97), 3.10 (95% CI: 2.27-4.25), and 3.06 (95% CI: 1.44-6.50) respectively, but uninformative -LRs: 0.84 (95% CI: 0.74-0.96), 0.88 (95% CI: 0.80-0.96), 0.61 (95% CI: 0.48-0.77), and 0.66 (95% CI: 0.52-0.84) respectively. For the facet joint, pooling demonstrated facet joint uptake on SPECT resulted in informative +LRs: 2.80 (95% CI: 1.82-4.31) and -LRs: 0.44 (95% CI: 0.25-0.77). For the sacroiliac joint, a combination of pain provocation tests and absence of midline low back pain resulted in informative +LRs of 2.41 (95% CI: 1.89-3.07) and 2.44 (95% CI: 1.50-3.98) and -LRs of 0.35 (95% CI: 0.12-1.01) and 0.31 (95% CI: 0.21-0.47) respectively. Radionuclide imaging yielded an informative +LR 7.33 (95% CI: 1.42-37.80) but an uninformative -LR 0.74 (95% CI: 0.41-1.34).

Interpretation

There are informative diagnostic tests for the disc, sacroiliac joint, and facet joint (only one test). The evidence suggests a diagnosis may be possible for some patients with low back pain, potentially guiding targeted and specific treatment approaches.

Funding

There was no funding for this study.

Is a history of episodic low back pain an indicator of Modic changes?

Background

Prior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition.

Purpose

To determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain.

Study design

/setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center.

Patient sample

Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020.

Methods

A retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level).

Results

A total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa ​= ​0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa ​= ​0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values.

Conclusions

A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis

OBJECTIVE

To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP).

DESIGN

Systematic review with single-arm meta-analysis.

POPULATION

Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes.

INTERVENTION

Intraosseous BVN RFA.

COMPARISON

Sham, placebo procedure, active standard care treatment, or none.

OUTCOMES

The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score.

METHODS

Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence.

RESULTS

Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively.

CONCLUSION

According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.

The Symmetry of Lower Back Pain as a Potential Screening Factor for Serious Pathology: A Survey Study

Background: Pain maps provide reliable information on pain location in various conditions. This study explored the feasibility of pain maps as a screening tools for serious underlying conditions. The pain symmetry was evaluated as the possible distinguishing feature. Methods: A Web-based survey on the correlation of pain-related disability and pain pattern was developed. Respondents with lower back pain were asked to mark the exact location of their pain over the pain chart. The symmetry index was calculated and used to divide subjects into two groups that were then compared in terms of the prevalence of red flags for serious pathologies, as well as the pain-related disability measured with COMI and ODI instruments. Results: Of the 4213 respondents who completed the survey, 1018 were included in the study. The pain related disability was greater in respondents with asymmetrical pain patterns, as shown with all instruments. The distribution of red flags was also dependent on pain symmetry. The history of weight loss (6.70 vs. 1.76 p < 0.001) and fever (4.91 vs. 2.14 p < 0.001) were more prevalent with symmetrical pain patterns, and the history of trauma was more frequent with asymmetrical pain (21.41 vs. 10.71 p < 0.001). Conclusions: It was shown that the symmetry of pain is correlated to the prevalence of red flags and pain-related disability.

Association of NAT2 genetic polymorphism with the efficacy of Neurotropin® for the enhancement of aggrecan gene expression in nucleus pulposus cells: a pilot study

BACKGROUND

Intervertebral disc degeneration, one of the major causes of low-back pain, results from altered biosynthesis/turnover of extracellular matrix in the disc. Previously, we reported that the analgesic drug Neurotropin® (NTP) had an anabolic effect on glycosaminoglycan synthesis in cultured nucleus pulposus (NP) cells via the stimulation of chondroitin sulfate N-acetylgalactosaminyltransferase 1. However, its effect on the aggrecan core protein was not significantly detected, because of the data variance. A microarray analysis suggested that the effect of NTP on aggrecan was correlated with N-acetyltransferase 2 (NAT2), a drug-metabolizing enzyme. Specific NAT2 alleles are known to correlate with rapid, intermediate, and slow acetylation activities and side effects of various drugs. We investigated the association between the efficacy of NTP on aggrecan expression and the NAT2 genotype in cell donors.

METHODS

NP cells were isolated from intervertebral disc tissues donated by 31 Japanese patients (28-68 years) who underwent discectomy. NTP was added to the primary cell cultures and its effect on the aggrecan mRNA was analyzed using real-time quantitative PCR. To assess acetylator status, genotyping was performed based on the inferred NAT2 haplotypes of five common single-nucleotide polymorphisms using allele-specific PCR.

RESULTS

The phenotype frequencies of NAT2 in the patients were 0%, 42.0%, and 58.0% for slow, intermediate, and rapid acetylators, respectively. The proportions of responders to NTP treatment (aggrecan upregulation, ≥ 1.1-fold) in the intermediate and rapid acetylators were 76.9% and 38.9%, respectively. The odds ratio of the comparison of the intermediate acetylator status between responders and nonresponders was 5.2 (95% CI 1.06-26.0, P = 0.036), and regarding the 19 male patients, this was 14.0 (95% CI 1.54-127.2, P = 0.012). In the 12 females, the effect was not correlated with NAT2 phenotype but seemed to become weaker along with aging.

CONCLUSIONS

An intermediate acetylator status significantly favored the efficacy of NTP treatment to enhance aggrecan production in NP cells. In males, this tendency was detected with higher significance. This study provides suggestive data of the association between NAT2 variants and the efficacy of NTP treatment. Given the small sample size, results should be further confirmed.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

OBJECTIVE

The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.

METHODS

A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.

RESULTS

Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.

CONCLUSION

The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.

Prognostic factors in low back pain individuals undergoing steroid and anaesthetic intra-articular facet joint infiltration: a protocol for a prospective, longitudinal, cohort study

INTRODUCTION

Lumbar pain of facet origin is a common problem worldwide. For those patients not responding to traditional treatment, one approach may be intra-articular infiltration of corticoid and anaesthetic. However, despite the increasing demand for this procedure, no consensus exists regarding its therapeutic value. The selection of eligible participants may be a determining factor since only those with an inflammatory process will benefit from the use of corticosteroids. This study aims to identify differences in disability, pain and quality of life scores in individuals with and without facet joint inflammation who were diagnosed using MRI.

METHOD AND ANALYSIS

This prospective cohort will include individuals older than 18 years with a clinical diagnosis of facet syndrome who underwent intra-articular infiltration. Changes in scores of pain, disability and quality of life questionnaires at 1, 3, 6 and 12 months of follow-up compared with baseline will be analysed. An MRI examination performed before infiltration will help to distinguish between exposed (with inflammation) and non-exposed (non-inflammation) groups with facet syndrome. The primary outcome will be the disability questionnaire (Roland Morris), and the secondary outcomes will be the score questionnaires for pain (Visual Analogue Scale), quality of life (EuroQol Quality of Life Questionnaire) and disability (Oswestry).

ETHICS AND DISSEMINATION

The Internal Review Board approved this study, which started only after the approval number (5291417.0.0000.0071) was received. All recruited participants will receive a verbal explanation about the purpose of the study, and their decision to participate will be free and voluntary. All participants enrolled in the study will provide a signed informed consent form including confidentiality terms. The results obtained in this study will be presented at national and international conferences and published in peer-reviewed scientific journals to disseminate the knowledge.

TRIALS REGISTRATION NUMBER

NCT03304730; Pre-results.

Fluoroscopically Guided vs Landmark-Guided Sacroiliac Joint Injections: A Randomized Controlled Study

OBJECTIVES

To determine the prevalence of intra- and extra-articular sacroiliac joint (SIJ) pain, which injection is more beneficial, and whether fluoroscopy improves outcomes.

PATIENTS AND METHODS

This patient- and evaluator-blinded comparative effectiveness study randomized 125 participants with SIJ pain from April 30, 2014, through December 12, 2017, to receive fluoroscopically guided injections into the joint capsule (group 1) or "blind" injections to the point of maximum tenderness using sham radiographs (group 2). The primary outcome was average pain on a 0 to 10 scale 1 month after injection. A positive outcome was defined as at least a 2-point decrease in average pain score coupled with positive (>3) satisfaction on a Likert scale from 1 to 5.

RESULTS

For the primary outcome, no significant differences were observed between groups (mean ± SD change from baseline, -2.3±2.4 points in group 1 vs -1.7±2.3 points in group 2; 95% CI, -0.33 to 1.36 points for adjusted difference; P=.23), nor was there a difference in the proportions of positive blocks (61% vs 62%) or 1-month categorical outcome (48% vs 40% in groups 1 and 2, respectively; P=.33). At 3 months, the mean ± SD reductions in average pain (-1.8±2.1 vs -0.9 ± 2.0 points; 95% CI, 0.11 to 1.58 points for adjusted difference; P=.02) and worst pain (-2.2±2.5 vs -1.4±2.0 points; 95% CI, 0.01 to 1.66 points for adjusted difference; P=.049) were greater in group 1 than 2, with other outcome differences falling shy of statistical significance.

CONCLUSION

Although fluoroscopically guided injections provide greater intermediate-term benefit in some patients, these differences are modest and accompanied by large cost differences.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02096653.

Is a History of Severe Episodic Low Back Pain an Indicator of a Discogenic Etiology?

Objective

To determine if a history of severe episodic low back pain (LBP) correlates with positive discography.

Methods

A retrospective chart review identified patients undergoing discography from January 2012 through February 2016. The review determined if the patient's LBP began or continued with severe disabling episodes (lasting a minimum of two days). A gradual onset or initiating event with continuous symptoms was considered a nonepisodic history. Patients were excluded for unclear record, workers' compensation, litigation, prior lumbar surgery, radiologic instability, or indeterminate discography.

Results

Seventy-eight patients underwent discography. Thirty-nine patients were included, 31 of which had positive discograms. Eight had negative discograms. Nineteen patients had a history of episodic LBP, and 20 had no history of episodic LBP. Of those 19 with a history of episodic LBP, 18 had positive discography and one had negative discography. Of those with no history of episodic LBP, 13 had positive discography and seven had negative discography. Using the historical finding of severe episodic LBP as a test for discogenic source of LBP, the sensitivity is 58% (95% confidence interval [CI] = 41-75%) and the specificity is 88% (95% CI = 65-100%). The likelihood ratio is 4.7 (95% CI = 0.72-30). The positive predictive value (PPV) is 95% (95% CI = 72-100%). The PPV is based upon a prevalence of 79% (discogram positive) in our sample of patients considering fusion surgery. The diagnostic confidence odds are 18.2, with a diagnostic confidence of 95%.

Conclusions

A positive history of severe episodic LBP may be a strong indicator for a discogenic etiology.

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.

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

Low back pain remains one of the most common patient complaints. It can exist alone or with the presence of lower extremity symptoms. Review of evidence-based guidelines will assist primary care providers in the identification and treatment of various lumbar disorders in addition to ruling out specific lumbar spinal pathologies.

Management of lumbar zygapophysial (facet) joint pain

AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.

METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.

RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.

CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Cellular supplementation technologies for painful spine disorders

Low back pain affects more than 80% of adults. A proportion of these adults develops chronic low back pain (CLBP) and becomes disabled by their condition. CLBP is expensive to diagnose and treat and in terms of associated loss of productivity in the work place setting by affected individuals. Although challenging, the source of CLBP can be identified. Contemporary literature contains several studies that have established prevalence estimates for various structural sources of CLBP. In young adults, the intervertebral disk is a common source of CLBP, once it incurs annular injury that heals incompletely. Effective treatment for painful disks currently is an unmet clinical need. In older adults, the facet and sacroiliac joints are more commonly responsible for CLBP. Although certain minimally invasive techniques do exist for these painful joints, an effective restorative intervention has yet to be established. Annular injury precipitates a physiologic response that can lead to a catabolic state within the disk that impairs disk restoration. Cell loss is a feature of this process as well as the pathophysiology associated with painful facet and sacroiliac joints. Cellular supplementation is an attractive treatment strategy to initiate the repair of an injured lumbosacral structure. The introduction of exogenous cells may lead to increased extracelluar matrix production and reduced pain and disability in diskogenic CLBP. Compelling data in animal studies have been produced, stimulating Food and Drug Administration-regulated trials in humans. Numerous questions remain regarding cell viability and sufficient native nutrients to support these cells. Clinical research protocols have focused predominantly on diskogenic CLBP, and very few have addressed painful facet and/or sacroiliac joints.

Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists

Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.

The differential diagnosis of low back pain: a primer on the evolving paradigm

OBJECTIVES

The issue of low back pain (LBP) is as common as it is perplexing. LBP is thought to be a chronic issue in approximately 10% of the U.S. population. This condition has wide-reaching social and economical reverberations. Despite the availability of modern diagnostic tools, the cause of the pain generator is often unidentifiable. The authors were asked to create an overview of the etiology of LBP for physicians who implant neurostimulation devices for the treatment of chronic pain patients. Some prevalence data, based on the current available literature, have been provided for the more common structural conditions causing LBP. However, a comprehensive review of prevalence of various conditions and their respective manifestations as LBP is beyond the scope of this article.

MATERIALS AND METHODS

A review was performed of frequently cited articles with search terms for "low back pain" using PubMed, Medline, and Google Scholar. The authors also reviewed other literature from commonly utilized sources in the field of interventional pain medicine such as the journals of Neuromodulation, Pain Medicine, Spine, and Neurosurgery in the publication date range of 1975 to the present. Moreover, recent edition textbooks of other specialties such as obstetrics and gynecology, neurology, internal medicine, and surgery were referenced to develop a comprehensive list of the differential diagnoses. In order to capture the broad scope of information presented in this article, the criteria used to choose the references included published peer-reviewed articles that provided information on LBP as a symptom of a case report to common presentations of various conditions as described in a number of current, and commonly used, textbooks in their specialty.

RESULTS

The article serves as a reference for commonly cited causes of LBP as well as less common conditions presenting with LBP as a possible symptom, which may occur as a solitary pain generator or in combination with other etiologies. The information is structured in such a fashion to allow a comprehensive overview for every reader, including the most experienced implanting physicians. The article is designed to kindle critical thinking regarding the massive scope involved in the assessment of a patient with a complaint of LBP. The results of the comprehensive research to produce this article clearly indicate the broad scope of this list of differential diagnoses. The reader should be aware that the lists are by no means all-inclusive. Perhaps additional efforts will be necessary to build on the available information in this article in the future. Furthermore, although some prevalence data for LBP, as it is related to structural spine, is readily available based on the excellent work of our colleagues and presented throughout this paper, for other disease processes, the prevalence data are scarce to nonexistent. This underscores the need for further research to better understand this elusive condition. The size and breadth of the topic at hand in this article would arguably deserve its own comprehensive textbook. The complexity and discussion points of each identified pain generator could be given a chapter or section to reflect complex learning deserved by each topic. With these limitations, the authors recommend the reader to evaluate this article in the context of a broader topic of LBP and neurostimulation.

CONCLUSIONS

LBP is an extremely common condition associated, as a symptom, with various disease processes, regardless of their relationship with the lumbar spine or its innervation. This article underscores the broad nature of LBP as a symptom of many diagnoses. The primary conclusion reached by the authors is the most important recommendation by all mentors in medicine, which is to obtain a comprehensive history and perform a complete physical examination on each patient. Despite the fact that there is an emerging school of thought questioning the validity of the physical examination, this tool continues to be the current standard of care and used by a majority of clinicians around the world. The physician must analyze the information obtained from his/her history, physical examination, and diagnostic tools with the recognition of the broad nature of the differential diagnoses of LBP in order to be able to best treat the patient.

Sacroiliac joint syndrome 10 years after lumbar arthroplasty: the importance of spinopelvic alignment

INTRODUCTION

Sagittal balance is an independent predictor of outcomes in spinal care and several authors focused their attention on the lumbar lordosis restoration as the key point to prevent secondary sacroiliac joint dysfunction (SIJD) after fusion. On the other hand, lumbar disc arthroplasty allows preservation of motion avoiding increased stress on the spinopelvic junction and preventing iatrogenic sagittal imbalance.

METHODS

We analyze the incidence of a secondary SIJD and the spinopelvic alignment on a series of 31 consecutive lumbar disc prosthesis with a 10-year follow-up.

RESULTS

Sagittal balance assessment showed no significant variation of preoperative spinopelvic parameters. Four patients (12 %) presented a symptomatic SIJD. Only two of them required a percutaneous SIJ fixation. Both of them presented a fused L5-S1 prosthesis.

CONCLUSIONS

The low rate of SIJD 10 years after lumbar arthroplasty might be explained by the preservation of the spinopelvic balance.

Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment

Sacroiliac joint (SIJ) pain is an underappreciated source of mechanical low back pain, affecting between 15 and 30% of individuals with chronic, nonradicular pain. Predisposing factors for SIJ pain include true and apparent leg length discrepancy, older age, inflammatory arthritis, previous spine surgery, pregnancy and trauma. Compared with facet-mediated and discogenic low back pain, individuals with SIJ pain are more likely to report a specific inciting event, and experience unilateral pain below L5. Owing in part to its size and heterogeneity, the pain referral patterns of the SIJ are extremely variable. Although no single physical examination or historical feature can reliably identify a painful SIJ, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, with clinical studies demonstrating intermediate-term benefit for both intra- and extra-articular steroid injections. In those who fail to experience sustained relief from SIJ injections, radiofrequency denervation may provide significant relief lasting up to 1 year. This review covers all aspects of SIJ pain, with the treatment section being primarily focused on procedural interventions.

Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial

PURPOSE

The sacroiliac joint (SIJ) may be a cause of sciatica. The aim of this study was to assess which treatment is successful for SIJ-related back and leg pain.

METHODS

Using a single-blinded randomised trial, we assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks.

RESULTS

Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003).

CONCLUSION

In this small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection.

The young adult spine in sports

In summary, LBP is a common problem for the young adult athlete, with discogenic pain being the most common of all etiologies. Although rare, more serious etiologies such as tumor or infection should be included in the differential diagnosis until effectively ruled out. Regardless of the cause, nonoperative and conservative strategies should be the cornerstone of treatment, owing to the favorable natural history of most LBP etiologies. Short-term non-narcotic medications are helpful, and avoidance of bed rest is critical for the athletic population. Rehabilitation should focus on stabilization and strengthening of the core and pelvic muscle groups, and biomechanical imbalances should be addressed. Surgical intervention ought to be utilized as a last resort in this population. Return to play should be considered only when the athlete is pain free with full range of motion and daily medications have been discontinued. Careful monitoring of the training regimen should always be undertaken,especially with chronic pain or recurrent injuries.

Structural etiology of chronic low back pain due to motor vehicle collision

OBJECTIVE

To estimate prevalence rates of discogenic, facet, and sacroiliac joint pain, and describe clinical features of chronic low back pain patients whose symptoms were initiated by motor vehicle collisions.

DESIGN

Retrospective chart review.

SETTING

Academic spine center.

PATIENTS

Twenty-seven motor vehicle collision-induced chronic low back pain patients were included after undergoing diagnostic procedures.

INTERVENTIONS

Lumbar provocation discography, dual diagnostic facet joint blocks, and intra-articular sacroiliac joint injections.

METHODS

Enrolled patients underwent diagnostic procedures based on clinical presentation until the pain source was identified. The prevalence of each source of low back pain was estimated. Clinical, categorical, and continuous characteristics within the source groups were calculated with SAS v.9.2 (SAS Institute Inc., Cary, NC).

OUTCOME MEASURES

Etiology and prevalence were analyzed for each diagnosis group.

RESULTS

Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain. Seventy-eight percent were female. Mean age was 42.5 years (standard deviation = 10.4) with median duration of symptoms of 24 months (interquartile range = 6-48).

CONCLUSIONS

Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.