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

Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.

Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review

INTRODUCTION

Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations.

MATERIALS AND METHODS

MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines.

RESULTS

Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity.

CONCLUSIONS

Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.

Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study

PURPOSE

Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR.

MATERIALS AND METHODS

Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round.

RESULTS

Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice.

CONCLUSIONS

Experts agree effectiveness of interventions differs through the evolution of LR.IMPLICATIONS FOR REHABILITATIONTo date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition.Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication.Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered.Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity.

Critical Appraisal of Current Acute LBP Management and the Role of a Multimodal Analgesia: A Narrative Review

Acute low back pain (LBP) stands as a leading cause of activity limitation and work absenteeism, and its associated healthcare expenditures are expected to become substantial when acute LBP develops into a chronic and even refractory condition. Therefore, early intervention is crucial to prevent progression to chronic pain, for which the management is particularly challenging and the most effective pharmacological therapy is still controversial. Current guideline treatment recommendations vary and are mostly driven by expertise with opinion differing across different interventions. Thus, it is difficult to formulate evidence-based guidance when the relatively few randomized clinical trials have explored the diagnosis and management of LBP while employing different selection criteria, statistical analyses, and outcome measurements. This narrative review aims to provide a critical appraisal of current acute LBP management by discussing the unmet needs and areas of improvement from bench-to-bedside, and proposes multimodal analgesia as the way forward to attain an effective and prolonged pain relief and functional recovery in patients with acute LBP.

The Benefit of Early Epidural Corticosteroid Injections for Acute Sciatica-Associated Lower Back Pain: A Four-Year Case Series in Lebanon

Background Early epidural steroid injections are currently widely used for patients experiencing lumbago. However, there is uncertainty about their efficacy, such as the limitation of continuous drug infusion and the need for well-trained physicians on this technique. The main objective of this study was to evaluate the effectiveness of early epidural steroid injections in treating patients with acute sciatica in the lower back in terms of symptom relief and recurrence rate. Methods A case series was conducted in Lebanon from 2015 to 2019. We recruited 98 patients suffering from sciatica due to disc disease over three-time intervals: two weeks, one, and three months. The immediate results accounted for the intensity of various symptoms (numerical rating scale (NRS) for pain) and the assessment of patient satisfaction (Macnab criteria). Results The clinical results showed at least a three-point pain relief according to Numerical Rating Scale (NRS) and a good grade according to MacNab (P <0.001), with only 10.4% of the total population having a positive leg raise test post-injection. The maximum benefit was noted after two weeks from the injection with a 5.7 mean change in NRS (p<0.001) with a good/excellent response in MacNab and a 4.9 change with only a good response after one month. This study noticed a rebound phenomenon where around half of the patients needed two steroid injections after three months (39.6 % after three months and 17.9 % after six months). Conclusion Even though current guidelines worldwide may suggest the use of conservative treatment for low back pain with acute sciatica, our study has demonstrated the effectiveness of epidural steroid injections in the Lebanese population with a significant outcome.

Transforaminal injection of autologous platelet-rich plasma for lumbar disc herniation: A single-center prospective study in Vietnam

OBJECTIVE

Lumbar radiculopathy is a major health problem, which often treated by neurosurgery or guided lumbar epidural steroids for pain relief. We used autologous Platelet Rich Plasma (PRP) as a novel pharmaceutical agent that has strongly emerged in recent years to treat patients of lumbar disc herniation. From that, we evaluated the efficacy of PRP via transforaminal route in treatment of radicular pain in patients with lumbar disc herniation.

METHODS

Twenty-five patients were enrolled and injected with 4 ml of autologous platelet rich plasma under fluoroscopic guidance via transforaminal epidural injection into area of affected nerve root. They were followed using Visual Analogue Scale (VAS), Modified Oswestry Disability Index (ODI) and Straight Leg Raising Test (SLRT) for clinical assessment.

RESULTS

Patients who received transforaminal injections with autologous PRP showed statistically significant improvements on all three evaluation tools (VAS, ODI, SLRT). The improvements were sustained over twelve-month follow-up and there were no associated complications.

CONCLUSION

Transforaminal injection with autologous PRP helps patients relieve chronic pains and be able return to work. Besides, autologous PRP can be considered as a good alternative to epidural steroids in management of lumbar disc herniation.

Percutaneous Intervertebral-Vacuum Polymethylmethacrylate Injection for Foraminal Stenosis with Degenerative Lumbar Scoliosis

BACKGROUND

Percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) is a minimally invasive procedure for low back pain in elderly patients with degenerative lumbar scoliosis (DLS). Patients with DLS often have radiculopathy as a result of foraminal stenosis in addition to low back pain. The purpose of this study was to evaluate the clinical and radiologic results of PIPI for foraminal stenosis with radiculopathy in elderly patients with DLS.

METHODS

We included patients with de novo DLS aged 65 years or older who underwent PIPI. The presence of an intervertebral vacuum on computed tomography and bone marrow edema on magnetic resonance imaging was required for inclusion. The intersegmental radiologic parameters on plain radiographs and computed tomography and the extent of bone marrow edema on magnetic resonance imaging were measured. The clinical outcomes were evaluated using the visual analog scale (VAS) and Oswestry Disability Index (ODI).

RESULTS

We enrolled 40 patients with DLS who underwent PIPI. There were 16 men and 24 women, and the mean age was 79.0 ± 6.3 years. The mean foraminal height and extent of bone marrow edema showed a significant increase and reduction, respectively, after PIPI (P < 0.05). VAS score for radiculopathy and ODI significantly improved after PIPI (P < 0.01). The minimum clinically important differences in VAS score for radiculopathy and ODI at the final follow-up were 73.9% and 63.6%, respectively.

CONCLUSIONS

PIPI is a minimally invasive procedure not only for low back pain but also for radiculopathy in elderly patients with DLS. It leads to intervertebral stabilization and indirect decompression of the foramen.

Exercise-induced FNDC5/irisin protects nucleus pulposus cells against senescence and apoptosis by activating autophagy

Intervertebral disc degeneration (IVDD) is a major cause of low back pain (LBP), and excessive senescence and apoptosis of nucleus pulposus (NP) cells are major pathological changes in IVDD. Physical exercise could effectively delay the process of intervertebral disc degeneration; however, its mechanism is still largely unknown. Irisin is an exercise-induced myokine released upon cleavage of the membrane-bound precursor protein fibronectin type III domain-containing protein 5 (FNDC5), and its levels increase after physical exercise. Here, we show that after physical exercise, FNDC5/irisin levels increase in the circulation and NP, senescence and apoptosis are reduced, autophagy is activated in NP tissue, and the progression of IVDD is delayed. Conversely, after knocking out FNDC5, the benefits of physical exercise are compromised. Moreover, the overexpression of FNDC5 in NP tissue effectively alleviated the degeneration of the intervertebral disc (IVD) in rats. By showing that FNDC5/irisin is an important mediator of the beneficial effects of physical exercise in the IVDD model, the study proposes FNDC5/irisin as a novel agent capable of activating autophagy and protecting NP from senescence and apoptosis.

Suggestions in Hypnosis to Aid Pain Education (SHAPE) in People with Chronic Low-Back Pain: A Pilot Feasibility Randomized, Controlled Trial

Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community). Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

Low back pain: What is the role of YouTube content in patient education?

The aim of this study was to characterize the educational quality and reliability of YouTube videos related to low back pain (LBP) as well as to identify factors associated with the overall video quality. A review of YouTube was performed using two separate search strings. Video-specific characteristics were analyzed for the first 50 videos of each string. Seventy-seven eligible videos were identified as a result. The mean Journal of the American Medical Association score was 2.25 ± 1.09 (range: 0-4) out of 4. The mean Global Quality Score (GQS) score was 2.29 ± 1.37 (range: 1-4) out of 5. The mean LBP score (LPS) score was 3.83 ± 2.23 (range: 0-11) out of 15. Video power index was a predictor of GQS score (β = 55.78, p = 0.048), whereas the number of likes (β = -2.49, p = 0.047) and view ratio (β = -55.62, p = 0.049) were associated with lower quality scores. Days since initial upload (β = 0.32, p = 0.042) as well as like ratio (β = 0.37, p = 0.019) were independent predictors of higher LPS scores. The results of this study suggest that the overall reliability and educational quality of videos uploaded to YouTube concerning LBP are unsatisfactory. More popular videos demonstrated poorer educational quality than their less popular counterparts. As the prevalence of LBP rises, more accurate and thorough educational videos are necessary to ensure accurate information is available to patients.

Technical Report of Color Doppler Ultrasonography-Assisted Lumbar Spinal Interventions

ABSTRACT

Ultrasonography (US) has recently been used more frequently during interventions involving the lumbar spine. However, physicians who are more familiar with musculoskeletal US targeting muscles, tendons, and nerves may find it challenging to perform US-guided lumbar spine interventions using only bony landmarks. This study described the use of color Doppler US for the visualization of the lumbar spinal blood supply to identify vascular landmarks in addition to bony landmarks and thus more easily and accurately perform lumbar spine interventions.

Low-Dose Collagenase Chemonucleolysis Combined with Radiofrequency in the Treatment of Lumbar Disc Herniation: A 10-Year Retrospective Study

Objective

This study explored the 10-year efficacy, safety, and prognostic factors of low-dose collagenase chemonucleolysis (CCNL) combined with radiofrequency (RF) in the treatment of lumbar disc herniation (LDH).

Methods

The data of 167 LDH patients were collected. Modified MacNab criteria, Numerical Rating Scale (NRS), and Japanese Orthopedic Association (JOA) scores were, respectively, used to evaluate patients' excellent and good rates, pain degree, and nerve function. The preoperative and 10-year postoperative patients' pain, numbness, and muscle weakness were compared. Patients' complications in perioperative period, recurrent/reappeared LDH, and reoperations were recorded. Finally, the independent risk factors affecting the long-time efficacy were assessed.

Results

A total of 126 patients were included. The patients' excellent and good rates were 86.51%–92.86% with no significant difference (P > 0.05). Postoperative NRS and JOA scores significantly improved (P < 0.01), most obvious within 6 months postoperatively. At 10 years postoperatively, 65.08%, 83.95%, and 93.02% of patients' pain, numbness, and muscle weakness were completely relieved (P < 0.05). Perioperative complications occurred in three patients with the rate of 2.38%. Recurrent/reappeared LDH patients were 11 with the ratio of 8.73%; nine of them underwent reoperations with the rate of 7.14%. And patients' probability of fair and poor efficacy at 10 years postoperatively with the course of disease >12 months and the responsibility disc ≥2 were, respectively, 6.005 and 4.227 times that of patients with the course of disease ≤12 months and the responsibility disc = 1 (P < 0.05).

Conclusion

The combined treatment is effective and safe in the long term. A course of disease >12 months and responsibility disc ≥2 independently reduce efficacy, and a course of disease >12 months has a more significant impact.

Effect of Nonsurgical Spinal Decompression on Intensity of Pain and Herniated Disc Volume in Subacute Lumbar Herniated Disc

OBJECTIVE

Nonsurgical spinal decompression therapy (NSDT) is a conservative treatment for the lumbosacral herniated intervertebral disc (L-HIVD). This study aimed to evaluate the clinical effectiveness of the NSDT and change in disc volume through magnetic resonance imaging (MRI) in subacute L-HIVD.

METHODS

Sixty patients with subacute L-HIVD were randomized into either the decompression group (group D, n = 30) or the nondecompression group (group N, n = 30). In group D, NSDT was performed ten times in eight weeks. In group N, pseudodecompression therapy (no force) was performed with the same protocol. Lower back and lower leg pain intensities and functional improvements were measured by the visual analog scale and the Korean Oswestry Disability Index (K-ODI). The change in the lumbosacral disc herniation index (HI) was evaluated through a follow-up MRI three months after the therapy.

RESULTS

The lower leg pain intensity in group D was lower than that in group N at two months (p=0.028). Additionally, there were significantly lower K-ODI scores in group D at two and three months (p=0.023, 0.019) than in group N. The change in HI after the therapy was -27.6 ± 27.5 (%) in group D and -7.1 ± 24.9 (%) in group N, with a significant difference (p=0.017). Approximately 26.9% of patients in group D and no patients in group N showed over 50% reduction in HI (p=0.031).

CONCLUSION

NSDT may be a suitable treatment option for conservative treatment of subacute L-HIVD.

Team Approach: Management of an Acute L4-L5 Disc Herniation

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Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life.

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The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation.

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Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy.

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The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers.

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This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

Low Back Pain

Low back pain is a common problem that is the leading cause of disability and is associated with high costs. Evaluation focuses on identification of risk factors indicating a serious underlying condition and increased risk for persistent disabling symptoms in order to guide selective use of diagnostic testing (including imaging) and treatments. Nonpharmacologic therapies, including exercise and psychosocial management, are preferred for most patients with low back pain and may be supplemented with adjunctive drug therapies. Surgery and interventional procedures are options in a minority of patients who do not respond to standard treatments.

Efficacy of Single Level Versus Double Levels Surgery of Percutaneous Disc Nucleoplasty (PDN) Approach in Treating Lumbar Disc Herniation

Background

Although percutaneous disc nucleoplasty (PDN) has been widely applied in treating lumbar disc herniation (LDH) in recent years, the efficacy of surgical levels for PDN on LDH has been reported in limited studies. This study aimed to explore and compare the efficacy of surgical levels (single level vs double level) of PDN in treating LDH.

Material/Methods

All patients diagnosed with LDH from January 2012 to December 2014 in our hospital who underwent PDN were included in this study. Patients were divided into a single-level group and double-level group based on the number of discs/surgical treatment levels. The improvement of visual analog scale (VAS) score, patient satisfaction, and reoperation occurrence were compared between the 2 groups.

Results

Of 105 total patients, 75 patients were treated with single-level treatment and 30 patients with double-level treatment. VAS for leg pain and patient satisfaction scores in the double-level group were worse than those in the single-level group at 6 months after surgery (P<0.05). Among all 105 patients, the incidence of reoperation was 11.4%. Also, there was a marked difference in reoperation occurrence at 6 months after surgery between the single-level (6.7%) and double-level (23.3%) groups; however, the difference was not statistically significant (P=0.05).

Conclusions

PDN is a safe and minimal-invasive approach, which could effectively treat LDH. The number of surgical levels might be an important factor influencing the efficacy of PND. Caution should be exercised to strictly follow the clinical indications for nucleoplasty.

Artificial intelligence predicts disk re-herniation following lumbar microdiscectomy: development of the "RAD" risk profile

PURPOSE

Surgical treatment of herniated lumbar intervertebral disks is a common procedure worldwide. However, recurrent herniated nucleus pulposus (re-HNP) may develop, complicating outcomes and patient management. The purpose of this study was to utilize machine-learning (ML) analytics to predict lumbar re-HNP, whereby a personalized risk prediction can be developed as a clinical tool.

METHODS

A retrospective, single center study was conducted of 2630 consecutive patients that underwent lumbar microdiscectomy (mean follow-up: 22-months). Various preoperative patient pain/disability/functional profiles, imaging parameters, and anthropomorphic/demographic metrics were noted. An Extreme Gradient Boost (XGBoost) classifier was implemented to develop a predictive model identifying patients at risk for re-HNP. The model was exported to a web application software for clinical utility.

RESULTS

There were 1608 males and 1022 females, 114 of whom experienced re-HNP. Primary herniations were central (65.8%), paracentral (17.6%), and far lateral (17.1%). The XGBoost algorithm identified multiple re-HNP predictors and was incorporated into an open-access web application software, identifying patients at low or high risk for re-HNP. Preoperative VAS leg, disability, alignment parameters, elevated body mass index, symptom duration, and age were the strongest predictors.

CONCLUSIONS

Our predictive modeling via an ML approach of our large-scale cohort is the first study, to our knowledge, that has identified significant risk factors for the development of re-HNP after initial lumbar decompression. We developed the re-herniation after decompression (RAD) profile index that has been translated into an online screening tool to identify low-high risk patients for re-HNP. Additional validation is needed for potential global implementation.

Effects of Thrust Magnitude and Duration on Immediate Postspinal Manipulation Trunk Muscle Spindle Responses

OBJECTIVE

The purpose of this study was to characterize trunk muscle spindle responses immediately after high-velocity, low-amplitude spinal manipulation (HVLA-SM) delivered at various thrust magnitudes and thrust durations.

METHODS

Secondary analysis from multiple studies involving anesthetized adult cats (N = 70; 2.3-6.0 kg) receiving L6 HVLA-SM. Muscle spindle afferent recordings were obtained from L6 dorsal rootlets before, during, and immediately after HVLA-SM. L6 HVLA-SM was delivered posteriorly-to-anteriorly using a feedback motor with peak thrust magnitudes of 25%, 55%, and 85% of cat body weight (BW) and thrust durations of 25, 50, 75, 100, 150, 200, and 250 ms. Time to the first action potential and muscle spindle discharge frequency at 1 and 2 seconds post-HVLA-SM were determined.

RESULTS

A significant association between HVLA-SM thrust magnitude and immediate (≤2 s) muscle spindle response was found (P < .001). For non-control thrust magnitude, pairwise comparisons (25%, 55%, 85% BW), 55% BW thrust magnitude had the most consistent effect on immediate post-HVLA-SM discharge outcomes (false discovery rate < 0.05). No significant association was found between thrust duration and immediate post-HVLA-SM muscle spindle response (P > .05).

CONCLUSION

The present study found that HVLA-SM thrust magnitudes delivered at 55% BW were more likely to affect immediate (≤2 s) post-HVLA-SM muscle spindle response.

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients.

METHODS

The PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification.

RESULTS

Seventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (- 8.6 [- 13.4; - 3.9]) and 3 months (- 5.2 [- 10.1; - 0.2]) for leg pain and at 6 weeks for functional status (- 4.1 [- 6.5; - 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low.

CONCLUSION

The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.

Chemogenetics: Beyond Lesions and Electrodes

The field of chemogenetics has rapidly expanded over the last decade, and engineered receptors are currently utilized in the lab to better understand molecular interactions in the nervous system. We propose that chemogenetic receptors can be used for far more than investigational purposes. The potential benefit of adding chemogenetic neuromodulation to the current neurosurgical toolkit is substantial. There are several conditions currently treated surgically, electrically, and pharmacologically in clinic, and this review highlights how chemogenetic neuromodulation could improve patient outcomes over current neurosurgical techniques. We aim to emphasize the need to take these techniques from bench to bedside.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Long-term outcome of targeted therapy for low back pain in elderly degenerative lumbar scoliosis

PURPOSE

Treatment of low back pain (LBP) associated with elderly degenerative lumbar scoliosis (DLS) remains controversial. We have developed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) targeting to the intervertebral vacuum as a minimally invasive surgery. The present study compared the long-term clinical outcomes of PIPI to that of nonoperative treatment.

METHODS

Patients with de novo DLS, aged ≥ 65 years, who had LBP with visual analog scale (VAS) of ≥ 50 for ≥ 6 months with intervertebral vacuum on computed tomography and bone marrow edema (BME) on magnetic resonance imaging were included. The clinical outcomes were evaluated using VAS and the Oswestry Disability Index (ODI) at baseline, 1, 6, 12, 24 months, and at the final follow-up. The course of BME was also evaluated.

RESULTS

One hundred and one patients underwent PIPI and 61 received nonoperative treatment. The mean follow-up duration after PIPI and nonoperative treatment was 63.7 ± 32.4 and 43.9 ± 20.9 months, respectively. VAS and ODI after PIPI were significantly improved compared to post-nonoperative treatment. BME decreased substantially in the PIPI group and it was significantly correlated with VAS and ODI improvement. Following PIPI, LBP recurred in 28 patients (35%). LBP recurrence was identified at the same level of PIPI in 10 patients, at the adjacent level of PIPI in 11 patients, and at the non-adjacent level of PIPI in seven patients. Eighteen patients underwent additional PIPIs, and both VAS and ODI were significantly improved after additional PIPIs.

CONCLUSION

Bone marrow lesions of the endplate are strongly associated with the presence of LBP. PIPI can be considered as an effective, safe and repeatable treatment for LBP in elderly DLS patients.

Crosswalking the Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Pain Intensity Scores to the Roland-Morris Disability Questionnaire and the Oswestry Disability Index

OBJECTIVE

To link scores from 2 condition-specific measures for chronic low back pain (CLBP), the Oswestry Disability Index (ODI) and the Roland-Morris Disability Questionnaire (RMDQ), to Patient Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, and pain intensity scores.

DESIGN

Ordinary least squares regression analyses of existing data to link the PROMIS scores with the ODI and RMDQ.

SETTING

Not applicable.

PARTICIPANTS

Samples of adults with CLBP (N=2279) obtained from the Center for Excellence in Research for Complementary and Integrative Health (CERC) Study (n=1677), the Assessment of Chiropractic Treatment for Low Back Pain and Smoking Cessation in Military Active Duty Personnel (ACT) (n=384), and the pain subsample of the PROMIS 1 Wave 2 Pain and Depression study (PROMIS 1 W2) (n=218).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PROMIS physical function, pain interference, and pain intensity (CERC, ACT, and PROMIS 1 W2), ODI (CERC and PROMIS 1 W2), and RMDQ (ACT and PROMIS 1 W2).

RESULTS

In predicting PROMIS scores, the ODI model R² values ranged from 0.26-0.56 and the RMDQ model R² values ranged from 0.13-0.50. ODI and RMDQ models were the least precise in predicting the PROMIS pain intensity score (R² value range, 0.13-0.41) relative to the other PROMIS scores. Models with the 3 PROMIS scores as predictors yielded R² values ranging from 0.64-0.68 and 0.46-0.58 for the ODI and RMDQ, respectively. Models using combined data from 2 studies (ie, PROMIS 1 W2 and ACT, or PROMIS 1 W2 and CERC) tended to be more precise than models using only a single study sample.

CONCLUSIONS

Model results reported here can be used to translate PROMIS physical function, pain interference, and pain intensity scores to and from the ODI and RMDQ. The empirical linkages can facilitate comparisons across CLBP interventions and broaden interpretation of study results.

Trends in Utilization and Cost of Inpatient Spinal Cord Stimulation: Analysis of Data from 2008 to 2014

OBJECTIVE

In this study, we sought to characterize contemporary trends in cost and utilization of spinal cord stimulation (SCS).

METHODS

The Healthcare Cost and Utilization Project-National Inpatient Sample was queried for inpatient admissions from 2008 to 2014 where SCS was performed. We then determined the rates and costs of SCS performed in this time frame to treat diagnoses that we classified as device-related complications, degenerative spine disease, pain syndromes, and neuropathies/neuritis/nerve lesions. Least-squares regression was performed to determine the yearly trends for each indication adjusted by the total number of yearly hospitalizations for that diagnosis.

RESULTS

We identified a total of 6876 admissions in whom an SCS was performed. The overall rate of inpatient SCS procedures performed has decreased by 45% from 2008 to 2014 (14.0 to 7.7 procedures per 100,000 admissions). Adjusted analysis for yearly trends also demonstrated a declining trend for all indications; however, this was not found to be statistically significant, except for device-related complications (P = 0.004). The median inflation-adjusted cost of an admission where SCS was performed increased slightly by 7.4% from $26,200 (IQR: $16,700-$33,800) in 2008 to $28,100 (IQR: $19,600-$36,900) in 2014. Billed hospital charges demonstrated a significant increase with median inflation-adjusted admission charge of $66,068 in 2008 to $110,672 in 2014.

CONCLUSIONS

Despite a declining contemporary trend in inpatient SCS, an increase was noted in admission costs and hospital charges. A significant declining trend was noted in revision SCS implantations due to device-related complications.

Facet Joint Replacement: Intermediate- and Long-Term Outcome in a Large Case Series

BACKGROUND

 The long-term outcome of facet joint replacement (FJR) still is to be proven.

METHODS

 We present a prospective case series of 26 (male-to-female ratio of 1:1; mean age: 61 years) patients undergoing FJR with a follow-up of at least 1 year (range: 12-112; mean: 67 months). Visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 12-Item Short Form Health Survey (SF-12) were applied pre- and postoperatively (after 3, 6, and 12 months) as well as at the last follow-up (N = 24). Using X-rays of the lumbar spine (N = 20), the range of motion (ROM) and disk height in the indicator and adjacent levels were assessed.

RESULTS

 FJR was performed at L3/L4 (N = 7), L4/L5 (N = 17), and L5/S1 (N = 2). Mean VAS (mm) for back pain decreased from 71 to 18, mean VAS for right leg pain from 61 to 7, and from 51 to 3 for the left leg. Mean ODI dropped from 51 to 22% (for all p < 0.01). Eighty seven percent of patients were satisfied and pretreatment activities were completely regained in 78.3% of patients. Disk height at the indicator and adjacent levels and ROM at the indicator segment and the entire lumbar spine were preserved. No loosening of implants was observed. Explantation of FJR and subsequent fusion had to be performed in four cases (15.4%).

CONCLUSIONS

 In selected cases, long-term results of FJR show good outcome concerning pain, quality of life, preservation of lumbar spine motion, and protection of adjacent level.

Therapeutic Facet Joint Interventions in the Lumbar Spine: An Economic Value Perspective

OBJECTIVE

In this narrative review, the current literature on therapeutic interventions for low back pain of facet joint etiology is assessed from an economic value perspective.

SUMMARY OF BACKGROUND DATA

The efficacy and economics of facet joint interventions in the treatment of lumbar back pain is a controversial topic. Trends show that facet joint interventions are becoming increasingly used, perhaps as physicians become more averse to treating chronic low back pain with opioids. With the emphasis on value-based spine care and changing reimbursement models, the perspective of rigorously evaluating the outcomes these interventions provide and the costs they incur is particularly relevant.

DISCUSSION

Although the evidence is noted to be limited, most systematic reviews fail to demonstrate the therapeutic utility of intra-articular facet joint injections in low back pain because of high study heterogeneity. A few good quality studies and systematic reviews describe moderate evidence for the utilization of therapeutic medial branch blocks and radiofrequency neurotomies in alleviating facet joint pain.

CONCLUSION

Consequently, there is a need for high-quality cost-effectiveness studies for facet joint interventions so that evidence-based and economically viable solutions can be used to optimize patient care at a societally affordable price.

Efficacy of a Psychosocial Pain Management Intervention for Men and Women With Substance Use Disorders and Chronic Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs.

OBJECTIVE

To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020.

INTERVENTIONS

ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT.

MAIN OUTCOMES AND MEASUREMENTS

The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months.

RESULTS

Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use.

CONCLUSIONS AND RELEVANCE

Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372267.

A protocol for chronic pain outcome measurement enhancement by linking PROMIS-29 scale to legacy measures and improving chronic pain stratification

BACKGROUND

Substantial investment has gone into research on the efficacy and effectiveness of pharmaceutical and nonpharmacologic interventions for chronic pain. However, synthesizing this extensive literature is challenging because of differences in the outcome measures used in studies of similar or competing interventions. The absence of a common metric makes it difficult to replicate findings, pool data from multiple studies, resolve conflicting conclusions, or reach consensus when interpreting findings.

METHODS

This study has a seven-member Advisory Council of chronic pain experts. Preliminary analyses will be performed on data from several large existing datasets; intermediate analyses will be performed using primary data collected from Amazon's Mechanical Turk (MTurk); and cross-validation will use primary data collected from a nationally-representative, probability-based panel. Target sample size for both primary datasets is 1500. The three study aims are as follows: Aim 1 will develop and evaluate links between the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS®-29) and legacy measures used for chronic pain such as the Roland-Morris Disability Questionnaire (RMDQ) and the Oswestry Disability Index (ODI). We will assess the best method of score linking and create crosswalk tables. Aim 2 will evaluate and refine the Impact Stratification Score (ISS) based on 9 PROMIS-29 items and proposed by the NIH Research Task Force on chronic low back pain. We will evaluate the ISS in terms of other indicators of condition severity and patient prognosis and outcomes and identify cut-points to stratify chronic pain patients into subgroups. Aim 3 will evaluate the strengths and limitations of MTurk as a data collection platform for estimating chronic pain by comparing its data to other data sources.

DISCUSSION

The accomplishment of Aims 1 and 2 will allow direct comparison of results across past and future studies of chronic pain. These comparisons will help us to understand different results from seemingly similar studies, and to determine the relative effectiveness of all pharmaceutical and nonpharmacologic interventions for chronic pain across different trials. Aim 3 findings will provide valuable information to researchers about the pros and cons of using the MTurk platform for research-based data collection.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04426812 ; June 10, 2020.

EFFECT OF BASIC FITNESS FUNCTION ACCORDING TO WHOLE-BODY VIBRATION STIMULUS WITH SLOPE DURING DEADLIFT

We aimed to investigate the effect of basic fitness function according to whole-body vibration (WBV) stimulus with slope during deadlift in adults. A total of 15 subjects performed deadlift exercise with a sound-wave vibrator. The subjects consisted of three groups: no slope and WBV group (control), WBV only group (group 1), and slope and WBV group (group 2). Slope was set at [Formula: see text], and the frequency and amplitude of WBV were 10[Formula: see text]Hz and 5[Formula: see text]mm, respectively. The participants performed Romanian deadlift 2 days a week for 4 weeks, including 10 trials per set and five sets a day. We measured basic fitness function factor including the isokinetic muscle contraction test using biodex system3. All groups showed an increase in strength of approximately [Formula: see text]%. Group 2 showed the highest increase. Moreover, maximal peak torque of the lumbar joint showed an increase trend similar to that of back muscle strength. An increase of 15.72%, 24.86%, and 51.44% was noted in the control, group 1, and group 2, respectively. The findings indicate that WBV exercise with slope is the most efficient exercise protocol for improving muscle function of the trunk. WBV with slope could help stimulate trunk muscles more and efficiently, could result in a more positive effect on muscle function compared with WBV only, and could be included in an exercise program for efficient patient rehabilitation.

Dysphagia rates in single- and multiple-level anterior cervical discectomy and fusion surgery: a meta-analysis

Background

To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery.

Methods

Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I² was used to explore heterogeneity.

Results

Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I²=32%).

Conclusions

Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.

Performance of Pain Interventionalists From Different Specialties in Treating Degenerative Disk Disease-Related Low Back Pain

OBJECTIVES

To examine the utilization of current common treatments by providers from different specialties and the effect on delaying spinal surgery in patients with disk degenerative disease (DDD) related low back pain.

DESIGN

Retrospective observational study using data from the MarketScan Commercial Claims and Encounters database (2005-2013).

SETTING

Not applicable.

PARTICIPANTS

Patients (N=6229) newly diagnosed with DDD-related low back pain who received interventional treatments from only 1 provider specialty and continuously enrolled in the database for 3 years after diagnosis.

MAIN OUTCOME MEASURES

Measures of treatment utilization and cost were constructed for patients who received spinal surgery within 3 years after diagnosis. Cox proportional hazards models were used to examine time to surgery among provider specialties and generalized linear models were used to examine cost differences among provider specialties.

RESULTS

Of the 6229 patients, 427 (6.86%) underwent spinal surgery with unadjusted mean interventional treatment costs ranging from $555 to $851. Although the differences in mean costs across provider specialties were large, they were not statistically significant. Cox proportional hazards models showed that there was no significant difference between provider specialties in the time from DDD diagnosis to spinal surgery. However, patients diagnosed with DDD at a younger age and receiving physical therapy had significantly delayed time to surgery (hazard ratio, 0.66; 95% confidence interval [CI], 0.54-0.81 and hazard ratio, 0.77; 95% CI, 0.62-0.96, respectively).

CONCLUSIONS

Although there were no statistically significant differences among provider specialties for time to surgery and cost, patients receiving physical therapy had significantly delayed time to surgery.

Treatment of a Large Cohort of Veterans Experiencing Musculoskeletal Disorders with Spinal Cord Stimulation in the Veterans Health Administration: Veteran Characteristics and Outcomes

OBJECTIVE

Spinal cord stimulator (SCS) implantation is used to treat chronic pain, including painful musculoskeletal disorders (MSDs). This study examined the characteristics and outcomes of veterans receiving SCSs in Veterans Health Administration (VHA) facilities.

METHODS

The sample was drawn from the MSD Cohort and limited to three MSDs with the highest number of implants (N=815,475). There were 1490 veterans with these conditions who received SCS implants from 2000 to 2012, of which 95% (n=1414) had pain intensity numeric rating scale (NRS) data both pre- and post-implant.

RESULTS

Veterans who were 35-44 years old, White, and married reported higher pain NRS ratings, had comorbid inclusion diagnoses, had no medical comorbidities, had a BMI 25-29.9, or had a depressive disorder diagnosis were more likely to receive an SCS. Veterans 55+ years old or with an alcohol or substance use disorder were less likely to receive an SCS. Over 90% of those receiving an SCS were prescribed opioids in the year prior to implant. Veterans who had a presurgical pain score ≥4 had a clinically meaningful decrease in their pain score in the year following their 90-day recovery period (Day 91-456) greater than expected by chance alone. Similarly, there was a significant decrease in the percent of veterans receiving opioid therapy (92.4% vs 86.6%, p<0.0001) and a significant overall decrease in opioid dose [morphine equivalent dose per day (MEDD) =26.48 vs MEDD=22.59, p<0.0003].

CONCLUSION

Results offer evidence of benefit for some veterans with the examined conditions. Given known risks of opioid therapy, the reduction is an important potential benefit of SCS implants.

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.

Patient perspectives on interventional pain management: thematic analysis of a qualitative interview study

Background

Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient’s perspective to understand the process better.

Methods

A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed.

Results

The subjects’ perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as “gained empowerment” during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to.

Conclusions

Many of the themes evolved in relation to the subjects’ contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment.

Trial registration

Clinicaltrials.gov 2013-04-24 (Protocol ID SE-Dnr-2012-446-31 M-3, ClinicalTrials ID NCT01838603).

Utilization Review in Workers' Compensation: Review of Current Status and Recommendations for Future Improvement

: Utilization review (UR) is a process that assesses aspects of a treating provider's care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc, concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers' compensation (WC) system and is mandated in several states and jurisdictions. This guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) reviews structural elements of UR programs and proposes a possible template for operational standards. UR has a unique role in protecting patients and educating providers on evidence-based guidelines, new research, and best practices.

Perioperative adverse events after different fusion approaches for single-level lumbar spondylosis

Background

Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion).

Methods

Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts.

Results

In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events.

Conclusion

The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion.

Summary Sentence

Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.

The effect of exercise load deviations in whole body vibration on improving muscle strength imbalance in the lower limb

BACKGROUND

The amount of patients with muscle imbalance of the left and right side increases rapidly due to an incorrect lifestyle.

OBJECTIVE

We investigated the optimal exercise load required to improve muscle imbalance.

METHODS

Thirty participants were enrolled in the study. They performed squat exercises according to a whole body vibration (WBV) frequency protocol over a period of eight weeks. The exercises were performed three days a week and comprised five sets of fifteen trials per set per day. We validated muscle imbalance improvement using WBV by comparing and analyzing the results at different vibration frequencies. The participants were divided into three WBV protocol groups: no WBV, low-frequency WBV (25 Hz and 5 mm amplitude), and high-frequency WBV (50 Hz and 5 mm amplitude). We estimated the isokinetic muscle functions of the hip, knee, and ankle joints using BIODEX system 3. Ultimately, low-frequency WBV improved balance 10.2 ∼ 26.5% more than high-frequency WBV.

RESULTS

Continuous load-deviation motions during low-frequency WBV were more effective at improving muscle imbalance than high-frequency WBV. WBV load variation methods improved muscle function and contractility more than external weights or loads by directly transferring kinetic energy into the body.

CONCLUSION

In this clinical study, we demonstrated that low-frequency WBV was more effective at improving muscle imbalance. The WBV protocol can be used in rehabilitation programs to improve imbalance without requiring elderly or physically decompensated patients to participate in excessive exercise.

The effect of exercise load deviations in whole body vibration on improving muscle strength imbalance in the lower limb

BACKGROUND:

The amount of patients with muscle imbalance of the left and right side increases rapidly due to an incorrect lifestyle.

OBJECTIVE:

We investigated the optimal exercise load required to improve muscle imbalance.

METHODS:

Thirty participants were enrolled in the study. They performed squat exercises according to a whole body vibration (WBV) frequency protocol over a period of eight weeks. The exercises were performed three days a week and comprised five sets of fifteen trials per set per day. We validated muscle imbalance improvement using WBV by comparing and analyzing the results at different vibration frequencies. The participants were divided into three WBV protocol groups: no WBV, low-frequency WBV (25 Hz and 5 mm amplitude), and high-frequency WBV (50 Hz and 5 mm amplitude). We estimated the isokinetic muscle functions of the hip, knee, and ankle joints using BIODEX system 3. Ultimately, low-frequency WBV improved balance 10.2 ∼ 26.5% more than high-frequency WBV.

RESULTS:

Continuous load-deviation motions during low-frequency WBV were more effective at improving muscle imbalance than high-frequency WBV. WBV load variation methods improved muscle function and contractility more than external weights or loads by directly transferring kinetic energy into the body.

CONCLUSION:

In this clinical study, we demonstrated that low-frequency WBV was more effective at improving muscle imbalance. The WBV protocol can be used in rehabilitation programs to improve imbalance without requiring elderly or physically decompensated patients to participate in excessive exercise.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

[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.

Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature

Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients’ outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, p < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, p < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients’ pain, disability status and patient outcome in our study.

Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique

Objective

To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques.

Design

Comprehensive systematic review.

Methods

A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.

Outcome Measures

The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes.

Results

Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months.

Conclusions

This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

Quality of chronic pain interventional treatment guidelines from pain societies: Assessment with the AGREE II instrument

BACKGROUND AND OBJECTIVE

Procedures to relieve pain are performed frequently but there are concerns about patient selection, appropriate image guidance, frequency and training for physicians. Patients, healthcare providers, policymakers and licensing bodies seek evidence-based recommendations to use these interventions judiciously. In this review we appraised the methodological quality of recent clinical practice guidelines (CPGs) for interventional pain procedures.

DATABASE AND DATA TREATMENT

A systematic search of the medical literature was performed. Three trained appraisers independently evaluated the methodological quality of the CPGs using a validated instrument, the Appraisal of Guidelines in Research and Evaluation II (AGREE II). Six domains were considered: 1) score and purpose; 2) stakeholder involvement; 3) rigour of development; 4) clarity of presentation; 5) applicability and 6) editorial independence. A total of 23 items were scored. CPGs were deemed 'high quality' if a mean scaled score above 60% for rigour of development and for two other domains was obtained.

RESULTS

Mean scaled domain quality scores ranged from 61.72% to 69.99%. Despite being based on modest levels of evidence, two of the four included CPGs were considered to be of high methodological quality. The AGREE II scores across the four guidelines exhibited good inter-rater reliability. None of the guidelines involved key stakeholders such as patients, other healthcare providers, and payers.

CONCLUSIONS

All four CPGs were limited by a weak execution of the guideline development process. There is a need to develop methodologically sound evidence-based guidelines for the use of interventional pain procedures using a rigorous process that involves all relevant stakeholders.

SIGNIFICANCE

This systematic review appraises the methodological quality of existing CPGs on interventional procedures using a validated epidemiological tool (AGREE II). The aims of this review were to identify methodological and knowledge gaps in existing CPGs. Findings of this study will help in development of a high-quality CPG that can assist healthcare providers and patients in making informed decisions while ensuring that the right intervention is performed for the right patient at the right time. The quality of the evidence provided by the CPGs provided in support of their recommendations was also evaluated.

Facet joint injections for management of low back pain: a clinically focused review

Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.

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

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

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

ANTECEDENTS AND OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

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

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

STUDY DESIGN

Markov model.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4.