Injection therapy for subacute and chronic low back pain: an updated Cochrane review

Understanding the Landscape of Spinal Injections: Insights and Challenges from Latin America

BACKGROUND

Low back pain and neck pain are primary causes of disability, with low back pain being a frequent reason for medical consultations. After conservative and pharmacological treatments, spinal injections are considered the next option. Despite multiple guidelines, spinal blocks remain controversial in terms of indication, technique, and operator, leading to considerable interinstitutional variability. The absence of regional studies in Latin America on how spinal surgeons handle spinal injections prompts the objectives of this study: to evaluate spinal surgeons' knowledge and experience, analyze techniques, and identify barriers and challenges in implementing spinal injections, including resource limitations, technology access, and training.

METHODS

A cross-sectional survey was performed using a questionnaire specifically designed by the authors.

RESULTS

Two hundred sixty spinal surgeons from Latin America participated and answered a 17-question questionnaire; 75% performed their own spinal blocks and they are willing to keep on learning new techniques on the field. The most frequent block, was the lumbar facet injection (80%). And the great majority (76%) used fluoroscopy in their practice.

CONCLUSIONS

The study addresses a critical gap in the literature by focusing on spinal interventions in Latin America, where there is a notable lack of regional studies. The majority of the surgeons enrolled perform their own spinal injections, and they are interested in keep on learning. The findings not only contribute to the global discourse on spinal care but also offer a basis for the development of region-specific guidelines and educational initiatives.

Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

The MOTION study: Two-year results of a real-world randomized controlled trial of the mild® procedure for treatment of lumbar spinal stenosis

OBJECTIVE

The MOTION study is designed to measure the impact of percutaneous image-guided lumbar decompression as a first-line therapy on patients otherwise receiving real-world conventional medical management for lumbar spinal stenosis with neurogenic claudication secondary to hypertrophic ligamentum flavum. This prospective, multicenter randomized controlled trial uses objective and patient-reported outcome measures to compare the combination of the mild® percutaneous treatment and nonsurgical conventional medical management (CMM) to CMM-Alone.

METHODS

Test group patients received the mild procedure after study enrollment. Test and control groups were allowed conventional conservative therapies and low-risk interventional therapies as recommended by their physicians. Subjective outcomes included the Oswestry Disability Index, Numeric Pain Rating Scale, and Zurich Claudication Questionnaire. Objective outcomes included a validated Walking Tolerance Test, the rate of subsequent lumbar spine interventions, and safety data.

RESULTS

Two-year follow-up included 64 mild + CMM and 67 CMM-Alone patients. All outcome measures showed significant improvement from baseline for mild + CMM, whereas the majority of CMM-Alone patients had elected to receive mild treatment or other lumbar spine interventions by 2 years, precluding valid 2-year between-group comparisons. Neither group reported any device- or procedure-related adverse events.

CONCLUSIONS

The durability of mild + CMM for this patient population was demonstrated for all efficacy outcomes through 2 years. Improvements in walking time from baseline to 2 years for patients treated with mild + CMM were significant and substantial. The lack of reported device or procedure-related adverse events reinforces the strong safety profile of the mild procedure. These results provide support for early interventional treatment of symptomatic LSS with the mild procedure.

Epidural Steroid Injection Prior to Spinal Surgery: A Step-Wise and Wise Approach

BACKGROUND

An epidural steroid injection (ESI) is used to treat a number of morbid central nervous system pathologies and is considered a reasonably safe procedure. This study aimed to determine the relative infection risk after spinal surgery by comparing outcomes in spinal surgery patients who received an ESI shortly prior to the surgery against those who did not receive an ESI shortly prior to the surgery.

METHODS

The present study is a retrospective cohort study using a multi-institutional healthcare database, TriNetX, to collect data on patients who received spinal surgery with and without having had ESIs six months before surgery. Two cohorts were generated: Cohort 1 included patients who had received an ESI in the six months prior to spinal surgery, and cohort 2 included patients who did not have an ESI in the six months prior to spinal surgery. The patients in cohort 2 had propensity scores matched 1:1 to those in cohort 1 using common baseline demographics, comorbidities and spinal procedure indications. The spinal procedures and surgeries considered for the analysis included open procedures for any purpose, including exploration, decompression, resection, revision or biopsy. Multiple outcomes were compared across these two cohorts in the three months following the spinal procedure/surgery, including the occurrence of death, surgical site infection, epidural and/or spinal abscess, and dural tear.

RESULTS

An ESI in the six months prior to spinal surgery was associated with a significant decrease in the likelihood epidural/spinal abscess in the three months after surgery. There was no change in mortality, wound infection or identification of dural tear in the three months after spinal surgery for those who received an ESI six months before spinal surgery.

CONCLUSION

This data suggests that epidural steroid injections' anti-inflammatory effects provide benefits before surgery beyond symptomatic relief. Given that the degeneration of spinal pathologies is typically advanced rather than corrected by the body's inflammatory response, it is likely that preventing hyperactivation of the body's immune system in the months preceding surgical intervention, a traumatic insult, is protective compared to no intervention and, importantly, without major adverse effects.

Comparative Effectiveness of Epidural Steroid İnjections in Patients With Disc Bulging and Disc Protrusion

Purpose Discogenic low back pain is a widespread disorder in the world. Many methods have been developed and continue to be developed in the treatment of discogenic low back pain. We aimed to examine the effect of epidural steroid administration on disc bulging and disc protrusion in patients with discogenic low back pain. Design The clinical effects of interlaminar epidural steroids administered to 71 patients who were admitted to our clinic and whose treatment did not require surgery were radiologically divided into two groups disc bulging and disc protrusion. Patients were followed up for six months and clinical results were recorded. Methods The scores of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured before the procedure, one week after the procedure, one month after the procedure, and six months after the procedure. The normal distribution of continuous variables was evaluated using the Kolmogorov-Smirnov test. Continuous variables were compared with the Mann-Whitney U test and categorical variables were compared using the Chi-square test or Fisher's exact test. Results There was no significant difference in demographic data in patients with disc bulging and disc protrusion. In the disc protrusion group, the VAS scores in the first week after, the first month after and the sixth month after the procedure showed a significant decrease compared to the pre-procedure. There was no significant difference between the disc bulging and protrusion groups in the first week of post-procedure VAS score reduction. In the Disc Bulging group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. In the Disc Protrusion group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. Conclusion There was strong evidence that lumbar interlaminar steroid injection is an effective treatment for disc bulging and discogenic pain due to protrusion. When the ODI and VAS scores of patients with both disc bulging and disc protrusion were evaluated, it was seen that they benefited from epidural steroid injection. In the disc protrusion group, except for the first week of injection, relief due to the use of epidural steroids was observed to be greater compared to disc bulging.

Use of Steroids in Spine Surgery

Steroids are commonly used in spine pathologies. A broad range of providers from different specialties such as primary care, emergency medicine, and spine surgeons use steroids. The indications and controversies of steroid use are discussed in this article. A literature review was conducted on the use of steroids in spine pathologies. Steroids have been successfully used in anterior cervical discectomy and fusion (ACDF) to prevent dysphagia, in spinal cord injuries to improve neurological function, in acute back and neck pain for pain control, and in spinal metastasis. Steroid injections have been used for axial as well as radicular pain. Techniques and complications are further discussed. Local and systemic steroids have been successful in preventing dysphagia after anterior cervical diskectomy and fusion. Steroids failed to improve the neurologic outcomes after spinal cord injuries, and they were associated with multiple complications. Systemic steroids have not been proven to provide better clinical outcomes for acute low back pain. Steroid injections are more effective in radicular pain rather than axial pain. There are not enough high-quality studies on the use of steroids for metastatic spinal cord compression.

Use of injections for chronic pain from 2010 to 2019 in Ontario, Canada

PURPOSE

The management of chronic pain often involves interventional procedures such as injections. Nevertheless, there have been concerns raised regarding the frequency with which these injections are being performed. We conducted a descriptive study to examine trends in the use of pain injections over a ten-year time period in Ontario, Canada.

METHODS

We used provincial administrative data to conduct a retrospective observational study of the most common pain injections performed from 2010 to 2019 in Ontario. We determined the frequency of pain injections and their associated physician billings from physician billing data.

RESULTS

A total of 18,050,058 pain injections were included in this study with an associated total cost of CAD 865,431,605. There was a threefold increase in the number of blocks performed annually and associated costs, rising from 1,009,324 blocks (CAD 50,026,678) in 2010 to 3,198,679 blocks (CAD 156,809,081) in 2019. The majority of injections were performed by general practioners (70.8%), followed by anesthesiologists (8.3%).

CONCLUSION

This descriptive study revealed a rapid increase in the frequency of pain injections performed in Ontario from 2010 to 2019. Given the associated costs and potential risks, this warrants further investigation to ensure that these interventions are being administered appropriately.

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review

OBJECTIVE

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).

METHODS

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

RESULTS

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

CONCLUSIONS

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings.

IMPACT

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems.

LAY SUMMARY

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.

Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS).

METHODS

Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups.

RESULTS

The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS.

CONCLUSIONS

Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.

Effectiveness of subacromial injections in rotator cuff lesions: systematic review and meta-analysis protocol

INTRODUCTION

Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder.

METHODS AND ANALYSIS

Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software.

ETHICS AND DISSEMINATION

Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events.

PROSPERO REGISTRATION NUMBER

CRD42020199292.

The clinical impact of lumbar epidural steroid injections prior to spine surgery for lumbar spinal stenosis

Introduction

Lumbar spinal stenosis is a common finding in the adult population. Lumbar Epidural Steroid Injections (ESIs) are often used in management of this condition, with conflicting evidence regarding their efficacy. Previous research has suggested a negative impact of ESIs on the postoperative outcomes when ESIs are administered preoperatively prior to spine surgery in this population. Our retrospective study was performed to gain greater insight into the impact of preoperative ESIs on postoperative outcomes following spine surgery in management of lumbar stenosis.

Objective

Our objective is to determine how preoperative ESIs impact postoperative outcomes following spine surgery in management of lumbar stenosis.

Design

Retrospective cohort involving 95 patients (39 patients who received ESI in the preoperative timeframe and 56 patients who did not) who underwent surgical management of lumbar stenosis. Data for patients with preoperative ESI was compared to those without preoperative ESI administration.

Setting

Institutional.

Interventions

Not Applicable.

Main outcome measures

PROMIS (Patient-Reported Outcomes Measurement Information System) scores, VAS (Visual Analog Scale) pain scores, ODI (Oswestry Disability Index), NDI (Neck Disability Index).

Results

At baseline (time of surgery), the ESI group had significantly higher ODI, PROMIS pain, PROMIS pain interference, VAS leg and lower PROMIS physical function, but no significant difference in PROMIS satisfaction, VAS back and NDI, compared to the Non-ESI group. At 3 months after surgery, both the ESI and Non-ESI groups demonstrated a significant decrease in VAS back, VAS leg, PROMIS pain and ODI from baseline scores. The improvement in PROMIS pain at 3 months after surgery was larger in the ESI group than the Non-ESI group.

Conclusions

Preoperative ESI administration did not lead to worsening of disability, function, or pain symptoms in the short-term postoperative period following surgical management of lumbar stenosis. Patients had short term improvements in radicular pain following surgical management of lumbar stenosis, regardless of preoperative ESI administration.

Effect of platelet-rich plasma injections for chronic nonspecific low back pain: A randomized controlled study

BACKGROUND

Patient with chronic nonspecific low back pain is weakened ligament, and prolotherapy is the effective treatment but their use remains controversial. These ligaments can be strengthened by platelet-rich plasma injection. We hypothesized that the effectiveness of platelet-rich plasma injection and prolotherapy may decrease pain and improved disability of patient with chronic low back pain.

METHODS

This study was a prospective, double-blind, randomized controlled trial and was conducted for 3 years for patient enroll and follow-up. Thirty-four patients with chronic nonspecific low back pain (duration of at least 3 months) refectory to conventional management were randomized to platelet-rich plasma injection and lidocaine injection. Patients were treated with weekly platelet-rich plasma or lidocaine injections at the lumbopelvic ligaments for 2 weeks and then weekly prolotherapy with 15% glucose for 2 weeks and followed up 6 months. Visual analog scale, Oswestry Disability Index, and Roland-Morris Disability Questionnaire were evaluated at initial, 4 weeks, 3 months, and 6 months. Four patients did not complete this trial. Three were in the platelet-rich plasma injection and 1 was in the lidocaine injection.

RESULTS

The intensity of pain was significantly decreased in platelet-rich plasma injections at 6 months as compared lidocaine injections; between-group differences were 0.9 (95% confidence interval 0.10-1.75 [P = .027]). All participants were significantly decreased pain and disability index at 4 weeks, 3 months, and 6 months but there were no significant differences between groups except for visual analog scale at 6 months. The baseline parameters were no significant differences in both groups.

CONCLUSIONS

In chronic nonspecific low back pain, the platelet-rich plasma injection in combination with prolotherapy is an effective intervention and either lidocaine or platelet-rich plasma injection significantly reduced disability. And injection at the lumbopelvic ligaments using the platelet-rich plasma and prolotherapy is also an effective treatment for pain.

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

BACKGROUND

There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking.

AIM

To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial.

METHOD

The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention.

RESULTS

In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians' communication skills, during the consultation, in reference to listening skills, validation of patients' pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients' clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management.

CONCLUSION

The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients' perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.

Role of psychological distress screening in predicting the outcomes of epidural steroid injection in chronic low back pain

BACKGROUND

There is a paucity of studies investigating relationship between psychological distress and effectiveness of epidural steroid injection in patients with chronic lower back pain (CLBP).

AIMS

This prospective cohort study assessed whether the outcome can be predicted in CLBP patients undergoing epidural injection by pre-treatment psychological stress stratification using objective screening methods.

METHODS

96 patients with CLBP were recruited to this prospective cohort study. Preoperative level of psychological distress was measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ) and back pain related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal epidural steroid injection comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure.

RESULTS

There were 60 (62.5%) not-distressed patients, 3(3.1%) purely somatising, 15(15.6%) depressed and 18(18.8%) with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Average VAS and MPQ improved significantly at 6 and 26 weeks. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was negatively associated with VAS MCIC at 6 weeks and 6 months but it failed to predict the outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC at 6 months with 53%-sensitivity and 78%-specificity. None of psychological measures used showed a significant predictive value of ODI at any follow-up point.

CONCLUSIONS

Psychological distress may predict response only in certain outcome measures in patients suffering from nonspecific CLBP. If the interest lied primarily in pain and functional improvement, the psychological distress failed to discriminate the results at 6 months.

Outbreak of Pseudomonas aeruginosa infections after CT-guided spinal injections

BACKGROUND

Meningitis and spinal infections with Gram-negative bacteria after local injections for treatment of chronic back pain are rare. This study investigated an outbreak of Pseudomonas aeruginosa infections following computed tomography (CT)-guided spinal injections (SI).

METHODS

A case was defined as a spinal infection or meningitis with P. aeruginosa after SI between 10^th January and 1^st March 2019 in the same outpatient clinic. Patients without microbiological evidence of P. aeruginosa but with a favourable response to antimicrobial therapy active against P. aeruginosa were defined as probable cases.

FINDINGS

Twenty-eight of 297 patients receiving CT-guided SI during the study period developed meningitis or spinal infections. Medical records were available for 19 patients. In 15 patients, there was microbiological evidence of P. aeruginosa, and four patients were defined as probable cases. Two of 19 patients developed meningitis, while the remaining 17 patients developed spinal infections. The median time from SI to hospital admission was 8 days (interquartile range 2-23 days). Patients mainly presented with back pain (N=18; 95%), and rarely developed fever (N=3; 16%). Most patients required surgery (N=16; 84%). Seven patients (37%) relapsed and one patient died. Although the source of infection was not identified microbiologically, documented failures in asepsis when performing SI probably contributed to these infections.

CONCLUSIONS

SI is generally considered safe, but non-adherence to asepsis can lead to deleterious effects. Spinal infections caused by P. aeruginosa are difficult to treat and have a high relapse rate.

Optimal Cut-Off Points of Sagittal Spinopelvic Parameters as a Morphological Parameter to Predict Efficiency in Nerve Block and Pulsed Radiofrequency for Lumbar Facet Joint Pain: A Retrospective Study

Background

After proper patient selection, anatomically correct pulsed radiofrequency of the lumbar facet joints provide long-term pain relief in a routine clinical setting. In the study, we performed an analysis of clinical and radiological predictive factors and provide the scientific basis for this promising modality.

Methods

The study included 198 patients with lower back pain due to lumbar facet joint disease who underwent medial branch block and pulsed radiofrequency during the period 2015–2019. According to the improvement in pain score, the patients were divided into good and poor outcome groups. Clinical and radiological data were collected and analyzed.

Results

The multivariable analysis revealed the predictive factors, including lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and post lumbar fusion procedures.

Conclusion

With the results of this study, we demonstrated that the improved outcome after the surgery was related to lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and the lumbar fusion procedures. Old compression fractures and lumbar fusion would change the radiological factors and cause refractory lumbar facet joint pain.

Trigger point injections for axial back pain in adolescents

Adolescents who participate in athletics or have abnormal musculoskeletal anatomy have higher incidences of back pain than non-athletic peers with normal anatomy. Significant time and money spent in diagnostic evaluations for axial back pain can result in treatment delay causing a subsequent decrease in quality of life. Myofascial trigger points are a commonly overlooked reason for axial back pain. They develop due to an abnormal myoneural connection in the setting of muscle overuse. Trigger point injections are a technically simple intervention that is both diagnostic and therapeutic in alleviating trigger point-mediated back pain. There are few complications from these injections, and they should be considered prior to surgical referral or fluoroscopic-guided interventions.

Current patterns of practice in spinal fusion for chronic low back pain-results from a survey at the German Spine Societies' Annual Congress 2018

BACKGROUND

There is debate regarding criteria to select patients for lumbar fusion surgery who have chronic low back pain (CLBP) and corresponding degenerative changes, but without nerve root compression or neurogenic claudication. The aim of this study was to compare patterns in current practice.

METHOD

A total of 143 printed questionnaires containing 51 questions were distributed at the German Spine Societies' (DWG) annual congress, 6-8 December 2018.

RESULTS

We received 127 (89%) surveys (64 orthopedic surgeons and 63 neurosurgeons). Excluding the 22% who do not perform lumbar fusion for CLBP, 41.4% reported performing 1-10 lumbar fusion procedures for patients with CLBP per year, 20.2% reported 11-20, 10.1% reported 21-30 and 17.2% reported performing more than 50. A total of 44.9% of surgeons reported treating patients for at least 6-12 months conservatively before considering surgery; 65.6% considered postoperative pain reduction of 50-70% a treatment success; 32.6% of respondents believe that <50% of patients showed good outcomes after fusion in CLBP and only 15.5% believed that 70% or more showed good outcomes. Orthopedic surgeons perform more lumbar fusion surgeries than neurosurgeons (p = 0.05), fuse more lumbar segments than neurosurgeons (p = 0.02) and are more likely to suggest that their patients with CLBP cease smoking preoperatively (p = 0.02).

CONCLUSIONS

Despite discouraging evidence in the literature, the majority of respondents still perform fusion surgery in patients with CLBP. The use of preoperative diagnostics and tests vary widely among spine surgeons.

Does ultrasound-guided facet joint injection reduce pain and improve mobility in patients with failed back surgery syndrome?

OBJECTIVES

This study aims to evaluate whether ultrasound (US)-guided facet joint injection reduces pain and improves mobility in patients with failed back surgery syndrome (FBSS).

PATIENTS AND METHODS

This retrospective study included 27 patients (8 males, 19 females; mean age 43.6±11.5 years; range, 31 to 54 years) who underwent US-guided facet injections for FBSS between January 2017 and January 2019. Patients' medial records were assessed. Pain rating scores were evaluated with the Numeric Rating Scale (NRS). Functional status was assessed with Oswestry Disability Index (ODI) version 2.0. Lumbar flexion degree was noted. After injection (lidocaine-betamethasone mixture), patients were reevaluated at first and sixth months. The study data were analyzed with Wilcoxon signed-rank test.

RESULTS

Successful facet joint injections were achieved without any complications in all patients. The median duration of time after surgery was 7.8±1.3 months. Mean duration of pain was 6.7±5.7 months. There was a significant decrease in NRS values between baseline and sixth month comparison (7.0 at baseline and 6.0 at sixth month, p=0.006). Baseline-first month and first-sixth months comparisons were not significant (p=0.165 and p=0.106, respectively). For ODI, no significant change was observed between baseline-first month, first-sixth months, and baseline-sixth month comparisons (p=0.109, p=0.857, and p=0.095, respectively). For lumbar flexion, all comparisons resulted in significant increase (50.0° for baseline, 60.0° at first month, and 70.0° at sixth month; p<0.001 for baseline-first month comparison, p<0.001 for baseline-sixth month comparison, and p<0.001 for first-sixth months comparison).

CONCLUSION

Our results show that pain is reduced and mobility is improved with US-guided facet joint injections in patients with FBSS.

Retrospective Study on Ganglionic and Nerve Block Series as Therapeutic Option for Chronic Pain Patients with Refractory Neuropathic Pain

Objective

Current recommendations controversially discuss local infiltration techniques as specific treatment for refractory pain syndromes. Evidence of effectiveness remains inconclusive and local infiltration series are discussed as a therapeutic option in patients not responding to standard therapy. The aim of this study was to investigate the effectiveness of infiltration series with techniques such as sphenopalatine ganglion (SPG) block and ganglionic local opioid analgesia (GLOA) for the treatment of neuropathic pain in the head and neck area in a selected patient group.

Methods

In a retrospective clinical study, 4960 cases presenting to our university hospital outpatient pain clinic between 2009 and 2016 were screened. Altogether, 83 patients with neuropathic pain syndromes receiving local infiltration series were included. Numeric rating scale (NRS) scores before, during, and after infiltration series, comorbidity, and psychological assessment were evaluated.

Results

Maximum NRS before infiltration series was median 9 (IQR 8–10). During infiltration series, maximum NRS was reduced by mean 3.2 points (SD 3.3, p < 0.001) equaling a pain reduction of 41.0% (SD 40.4%). With infiltration series, mean pain reduction of at least 30% or 50% NRS was achieved in 54.2% or 44.6% of cases, respectively. In six percent of patients, increased pain intensity was noted. Initial improvement after the first infiltration was strongly associated with overall improvement throughout the series.

Conclusion

This study suggests a beneficial effect of local infiltration series as a treatment option for refractory neuropathic pain syndromes in the context of a multimodal approach. This effect is both significant and clinically relevant and therefore highlights the need for further randomized controlled trials.

Confluent abscesses in autochthonous back muscles after spinal injections : A case report and narrative review of the literature on low back pain and spinal injections

Injection therapy is a frequently used method for the treatment of subacute and chronic low back pain (LBP) despite scant evidence for its effectiveness. To date there are relatively few studies comparing this method with other treatments. Moreover, there are many possible side effects associated with injection therapies, some of which are potentially life threatening. We present the case of a 59-year-old woman admitted to the emergency department with confluent abscess formations of autochthonous back muscles and staphylococcal sepsis caused by injection therapy performed by a general practitioner for LBP. The findings of this case report emphasize a careful selection of patients for this type of treatment and a multidisciplinary approach to treatment of LBP.

Low Back Pain Induced by Posterior Longitudinal Ligament Incision in Percutaneous Transforaminal Endoscopic Lumbar Discectomy

OBJECTIVE

To illustrate the posterior longitudinal ligament is one of the tissue candidates who can contribute to low back pain (LBP).

METHODS

This is a retrospective study. A series of 72 patients who underwent single-level percutaneous endoscopic lumbar discectomy performed for lumbar disc herniation with LBP from June 2014 to June 2016 were examined. There are 42 males and 30 females. The ages of patients were 40 to 57 years, and the mean age was 49.8 years. The symptomatic disc level was at L_4-5 in 43 patients and L₅ S₁ in 29 patients. Thirty-two patients (19 patients in L_4-5 disc level, 13 patients in L₅ S₁ disc level) had LBP (which was limited to the lower back and buttock area) before the operation. All of the operative approaches were performed under local anesthesia. A posterior body diagram (15 cm × 10 cm) was made for this study to record the pain distribution. The centered foci of low back pain were subjectively recorded before, during, and after the operation. The transforaminal endoscopic spine system technology was used in this study. Radiological examinations (X-ray, computed tomography, and magnetic resonance imaging) were performed prior to and after surgery. The Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) scores were taken before and after the surgery to observe the degree of pain. The VSA and ODI score before and after operation were expressed as mean ± SD, and compared by t-test for statistical analysis.

RESULTS

When inciting the posterior longitudinal ligament during the operation, all 72 patients had provoked low back pain. Forty-three patients with symptomatic discs at L_4-5 had pain foci in the lower back and upper gluteal region under the L₄ spinous process. Twenty-nine patients with symptomatic discs at L₅ S₁ had pain foci in the gluteal region under the S₁ spinous process. The pain localizations of L_4-5 and L₅ S₁ were different. After the surgery, the provoked low back pain disappeared, and had not returned in any of the patients at the 6-month follow-up. After the operation, one patient suffered from lower limb pain that he did not have before the operation, and the lower limb pain abated a few days later. Three patients had cerebrospinal fluid leakage and were treated with higher pressure applied on the incision and bed rest for 10 days. During the 6-months follow-up period, the mean VAS decreased from 5.97 ± 1.10 to 2.13 ± 0.78. The mean ODI score decreased from 23.14 ± 3.28 to 7.92 ± 1.85.

CONCLUSIONS

The intervertebral posterior longitudinal ligament may be one of the tissues from which low back pain originates.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

BACKGROUND

Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS.

METHODS

To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements.

RESULTS

During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS.

CONCLUSIONS

A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Validity, Reliability, Feasibility, and Usefulness of Pain Monitor: A Multidimensional Smartphone App for Daily Monitoring of Adults With Heterogenous Chronic Pain

OBJECTIVES

Ecological momentary assessment has been recommended in the management of chronic pain. Smartphone apps might be a useful tool for that purpose. This goal of this study was to develop and test a multidimensional smartphone app for adults with chronic pain. A multidisciplinary team developed the app content after a series of meetings, considering clinical guidelines for pain measurement. The content included pain intensity and interference, fatigue, mood, perceived health status, activity level, side effects of the medication, use of rescue medication, and pain-related sychological constructs (catastrophizing, acceptance, fear, and coping).

METHODS

Thirty-eight participants (21 to 59 y) used the app, called Pain Monitor, twice a day during 30 consecutive days. Patients completed a set of well-established measures at the beginning and end of the study via paper-and-pencil. Weekly phone assessments were also made for pain intensity, pain interference, fatigue, and mood.

RESULTS

Construct validity was revealed by moderate-to-strong correlations between app content and traditional measures. Feasibility was supported by high compliance (between 70% and 82%) and high acceptability and ease of use. Both side effects of the medication and use of rescue medication were found to be useful tools to guide treatment.

DISCUSSION

The new assessment protocol in the app allows for an easy and rapid multidimensional assessment of chronic pain patients.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP.

METHODS AND ANALYSIS

Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L .

ETHICS AND DISSEMINATION

Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).

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.

Abandoned techniques in spine surgery

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.

Development of pain in older adults: a latent class analysis of biopsychosocial risk factors

Pain significantly restricts the quality of life and well-being of older adults. With our increasingly ageing population, it is important to examine whether differing classes of biopsychosocial risk factors can predict the development of pain in older adults. Latent class analysis provides a model-based approach to identifying underlying subgroups in a population, based on some measured characteristics. In this study, latent class analysis was used to identify biopsychosocial risk classes in people aged 50 years and older, from The Irish Longitudinal Study on Ageing, who reported not often being troubled by pain at wave 1 and completed the 2-year follow-up at wave 2 (n = 4458). Four classes were identified based on 11 potential risk factors at wave 1. These classes were characterised as "Low Risk," "Physical Health Risk," "Mental Health Risk," and "High Risk." The Low-Risk class accounted for over half the sample (51.2%), whereas the High-Risk class represented 7.8% of the sample. At follow-up (wave 2), 797 (17.9%) participants reported being troubled by pain. Associations between the biopsychosocial risk classes and developing pain were examined using logistic regression, adjusting for sociodemographic variables. The High-Risk class was more likely to develop pain compared with the Low-Risk class (adjusted OR = 3.16, 95% CI = 2.40-4.16). These results add to existing data in other populations supporting the role of a range of biopsychosocial risk factors that increase the risk of developing pain. These findings have important implications for the identification, and potential moderation, of these risk factors.

Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief

BACKGROUND AND PURPOSE

The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain.

MATERIALS AND METHODS

All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded.

RESULTS

Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level (P < .001) and patient age (P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) (P = .005).

CONCLUSIONS

Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection.

Injectable Corticosteroids in Sport

OBJECTIVE

To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes.

DATA SOURCES

An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles.

MAIN RESULTS

Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits.

CONCLUSIONS

Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

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.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

ROS-mediated lysosomal membrane permeabilization is involved in bupivacaine-induced death of rabbit intervertebral disc cells

Bupivacaine is frequently administered for diagnosing and controlling spine-related pain in interventional spine procedures. However, the potential cytotoxic effects of bupivacaine on intervertebral disc (IVD) cells and the underlying molecular mechanisms have not yet been fully established. Here, we showed that bupivacaine decreased the viability of rabbit IVD cells in a dose- and time-dependent manner. Moreover, the short-term cytotoxicity of bupivacaine in IVD cells was primarily due to cell necrosis, as assessed by Annexin V-propidium iodide staining and live/dead cell staining. Necrosis was verified by observations of swollen organelles, plasma membrane rupture, and cellular lysis under transmission electronic microscopy. Interestingly, our data indicated that bupivacaine-induced primary necrosis might involve the necroptosis pathway. The key finding of this study was that bupivacaine was able to induce lysosomal membrane permeabilization (LMP) with the release of cathepsins into the cytosol, as evidenced by LysoTracker Red staining, acridine orange staining, and cathepsin D immunofluorescence staining. Consistently, inhibitors of lysosomal cathepsins, CA074-Me and pepstatin A, significantly reduced bupivacaine-induced cell death. Finally, we found that bupivacaine resulted in an increase in intracellular reactive oxygen species (ROS) and that inhibition of ROS by N-acetyl-L-cysteine effectively blocked bupivacaine-induced LMP and cell death. In summary, the results of this in vitro study reveal a novel mechanism underlying bupivacaine-induced cell death involving ROS-mediated LMP. Our findings establish a basis for the further investigation of bupivacaine cytotoxicity in an in vivo system.

•

Bupivacaine decreases IVD cell viability in a dose- and time-dependent manner.

•

The short-term cytotoxicity of bupivacaine is primarily due to cell necrosis.

•

LMP is involved in bupivacaine-induced death of IVD cells.

•

ROS is an important mediator in bupivacaine-induced LMP and cell death.

Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration

The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.

Cost-effectiveness of Lumbar Epidural Steroid Injections

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

To determine the cost per quality-adjusted life-year for lumbar epidural steroid injections (LESI).

SUMMARY OF BACKGROUND DATA

Despite being a widely performed procedure, there are few studies evaluating the cost-effectiveness of LESIs.

METHODS

Patients who had received LESI between June 2012 and July 2013 with EuroQOL-5D (EQ-5D) scores available before and after LESIs but before any surgical intervention were identified. Costs were calculated on the basis of the Medicare Fee Schedule multiplied by the number of LESIs received between the 2 clinic visits. Quality-adjusted life-years (QALYs) were calculated using the EQ-5D.

RESULTS

Of 421 patients who had pre-LESI EQ-5D data, 323 (77%) had post-LESI data available; 200 females, 123 males, mean age: 59.2 ± 14.2 years. Cost per LESI was $608, with most patients receiving 3 LESIs for more than 1 year (range: 1-6 yr). Mean QALY gained was 0.005. One hundred forty-five patients (45%) had a QALY gain (mean = 0.117) at a cost of $62,175 per QALY gained; 127 patients (40%) had a loss in QALY (mean = -0.120) and 51 patients (15%) had no change in QALY. Fourteen of the 145 patients who improved, and 29 of the 178 patients who did not, have medical comorbidities that precluded surgery. Thirty-two (22%) of 131 patients without medical comorbidities who improved and 57 (32%) of 149 patients without medical comorbidities who did not improve subsequently had undergone surgery (P = 0.015).

CONCLUSION

LESI may not be cost-effective in patients with lumbar degenerative disorders. For the 145 patients who improved, cost per QALY gained was acceptable at $62,175. However, for the 178 patients with no gain or a loss in QALY, the economics are not reportable with a cost per QALY gained being theoretically infinite. Further studies are needed to identify specific patient populations who will benefit from LESI because the economic viability of LESI requires improved patient selection.

LEVEL OF EVIDENCE

2.

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.

[Conservative treatment of nonspecific, chronic low back pain : Evidence of the efficacy - a systematic literature review]

OBJECTIVES

Non-specific chronic low back pain (NSCLBP): Which conservative therapy shows an evident effectiveness - A review of the current literature.

MATERIALS AND METHODS

Our results are based on literature reviews of current randomised control studies, reviews and meta-analysis drawn from the Cochrane Library and Medline-Database between the years 2004 until 2015. German and English Studies were included. We focused on different conservative Treatments of NSCLBP, which are listed at, the NVL-Guidelines. Based on the given evidence we evaluated their effectiveness.

RESULTS

As part of the review we identified 4657 Publications, 85 were included in this study. Therapeutic options such as bed rest, TENS, Massage, Spine Supports, Back Schools and Antidepressants showed no evident effectiveness. Injections, NSAR analgesic therapy, Thermotherapy and Opioid analgesic therapy indicated a short-time effectiveness. A long term success (> 6 weeks) however, can not be shown. Only the Movement therapy can, in the summation of the included studies, postulate an evident (Evidence Level I) long-term effect treating NSCLBP. Only a few therapy options indicate a significant evident effectiveness for treating NSCLBP conservatively. At short notice methods such as injection therapy, thermo-therapy and analgesic therapies with NSAR and/or opioids help coping the acute phase. In the long term only movement therapy seems to provide an evident effectiveness. In the case of therapy-refractory NSCLBP a multimodal therapy should be considered.

Management of Lumbar Conditions in the Elite Athlete

Lumbar disk herniation, degenerative disk disease, and spondylolysis are the most prevalent lumbar conditions that result in missed playing time. Lumbar disk herniation has a good prognosis. After recovery from injury, professional athletes return to play 82% of the time. Surgical management of lumbar disk herniation has been shown to be a viable option in athletes in whom nonsurgical measures have failed. Degenerative disk disease is predominately genetic but may be accelerated in athletes secondary to increased physiologic loading. Nonsurgical management is the standard of care for lumbar degenerative disk disease in the elite athlete. Spondylolysis is more common in adolescent athletes with back pain than in adult athletes. Nonsurgical management of spondylolysis is typically successful. However, if surgery is required, fusion or direct pars repair can allow the patient to return to sports.

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

OBJECTIVE

Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.

METHODS

A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.

RESULTS

The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.

CONCLUSIONS

Lumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma

BACKGROUND

Over 100 million Americans are living with chronic pain, and pain is the most common reason that patients seek medical attention. Despite the prevalence of pain, the practice of pain management and the scientific discipline of pain research are relatively new fields compared to the rest of medicine - contributing to a twenty-first century dilemma for health care providers asked to relieve suffering in the "Fifth Vital Sign" era.

METHODS

This manuscript provides a narrative review of the basic mechanisms of chronic pain and history of chronic pain management in the United States - including the various regulatory, health system and provider factors that contributed to the decline of multidisciplinary pain treatment in favor of the predominant opioid treatment strategy seen today. Multiple non-opioid pain treatment strategies are then outlined. The manuscript concludes with three key questions to help guide future research at the intersection of pain and addiction.

CONCLUSIONS

The assessment and treatment of chronic pain will continue to be one of the most common functions of a health care provider. To move beyond an over reliance on opioid medications, the addiction and pain research communities must unite with chronic pain patients to increase the evidence base supporting non-opioid analgesic strategies.