Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes)

Injective Treatments for Sacroiliac Joint Pain: A Systematic Review and Meta-analysis

Background

The most effective injective treatment approach for sacroiliac joint (SIJ) pain remains unclear. Aim of this study was to quantify the safety and effectiveness of the available injective strategies to address SIJ pain.

Methods

A systematic review and meta-analysis of the literature was conducted on PubMed, Scopus, and Embase databases from inception until January 2023. Inclusion criteria were studies written in English, comparative and non-comparative studies regardless of the minimum follow-up, and case series on SIJ injections. Safety and efficacy of the different injection therapies for the SIJ were quantified. A meta-analysis was conducted on the available data of the documented injective therapies. The "Checklist for Measuring Quality" by Downs and Black was used to assess the risk of bias and the quality of papers.

Results

The literature search retrieved 43 papers (2431 patients): 16 retrospective case series, 2 retrospective comparative studies, 17 prospective case series, 3 prospective comparative studies, and 5 randomized controlled trials. Of the selected studies, 63% examined the effect of steroid injections, 16% of PRP injections, while 21% reported other heterogeneous treatments. The failure rate was 26% in steroid injections and 14% in PRP injections. The meta-analysis showed a statistically significant reduction in pain with the VAS score for both steroids and PRP: steroids improvement at mid-term 3.4 points (p < 0.05), at long-term 3.0 (p < 0.05), PRP improvement at mid-term 2.2 (p = 0.007), at long-term 2.3 points of the VAS pain scale (p = 0.02).

Conclusions

Steroids are the most documented injective approach, with studies showing an overall safety and effectiveness. Still, the high number of failures underlined by some studies suggest the need for alternative procedures. Early PRP data showed promise, but the limitations of the current literature do not allow to clearly define the most suitable injective approach, and further studies are needed to identify the best injective treatment for SIJ patients.

Cryoneurolysis versus radiofrequency ablation outcome on pain experience in chronic low back pain (COPE): a single-blinded randomised controlled trial

OBJECTIVE

A comparison of cryoneurolysis or radio frequency (RF) with placebo in patients with facetogenic chronic low back pain (LBP) for patient global impression of change (PGIC), pain intensity, function and quality of life, with 1-year follow-up.

DESIGN

Single-centre, single-blinded placebo-controlled randomised controlled trial.

SETTING

Single-centre study.

PARTICIPANTS

Inclusion from March 2020 to September 2022: consenting adults over 18 years of age, LBP>3 months, average Numeric Rating Scale LBP≥4 average last 14 days and a positive response to a diagnostic medial branch block (>50% pain reduction after 60 min).

INTERVENTIONS

120 patients were block randomised 1:1:1 to cryoneurolysis, RF or placebo of the medial branch nerves. Physical therapy was added after 4 weeks for all groups.

MAIN OUTCOME MEASURES

Primary outcome was PGIC 4 weeks after the intervention. Secondary outcomes included pain intensity (Numeric Rating Scale, NRS), quality of life (Short Form 36, EQ-5D-5L), disability (Oswestry Disability Index), depression (Major Depression Inventory) and catastrophising (Pain Catastrophising Scale). Outcomes were measured at 4 weeks, 3, 6 and 12 months.

RESULTS

There was no statistically significant difference in PGIC at 4 weeks between cryoneurolysis and placebo (risk ratio (RR) 2; 95% CI 0.75 to 5.33, p=0.17) and RF and placebo (RR 1.6; 95% CI 0.57 to 4.49, p=0.37), except PGIC for cryoneurolysis at 6-month follow-up (RR 5.1; 95% CI 1.20 to 22.03, p=0.03). No statistically significant differences were found in secondary follow-up endpoints.

CONCLUSIONS

Denervation of the medial branch nerve by either cryoneurolysis or RF compared with placebo did not demonstrate significant improvement in PGIC, pain intensity, function and quality of life in patients with facetogenic chronic LBP at short-term or long-term follow-up.

TRIAL REGISTRATION NUMBER

NCT04786145.

Isometric vs Isotonic Core Stabilization Exercises to Improve Pain and Disability in Patients with Non-specific Chronic Low Back Pain: A Randomized Controlled Trial

Background

Non-specific chronic low back pain (NSCLBP) is a prevalent condition that affects 90% of individuals experiencing low back pain. Core stabilization exercises (CSE) stand out as the most commonly employed therapeutic approach for managing NSCLBP. Nevertheless, there remains uncertainty regarding the superior effectiveness between isometric (ISOM) and isotonic (ISOT) types of CSE in the treatment of NSCLBP.

Objectives

The primary objective of this study was to compare the efficacy of ISOM and ISOT exercises concerning pain and disability in patients with NSCLBP. Additionally, the study aimed to assess the effectiveness of both ISOM and ISOT in comparison to no intervention concerning these variables in these patients.

Methods

This study was a randomized controlled trial that involved 41 men and women experiencing NSCLBP. Participants were randomly allocated to three groups: ISOM CSE (n = 13), ISOT CSE (n = 14), and a waitlist control (n = 14). The exercise training was administered for 40 - 60 minutes three times a week over a period of up to 8 weeks. Pain (assessed using the Visual Analog Scale or VAS) and disability (evaluated through the Oswestry Disability Index or ODI) variables were measured before and after the interventions.

Results

Based on the results, there was no significant difference between the 2 exercise groups (ISOM and ISOT) regarding pain and disability. However, the ISOM group demonstrated numerically better results than the ISOT group. Both the ISOM and ISOT groups exhibited a significant decrease in pain levels, with the VAS score decreasing from 5.5 to 2.7 for ISOM and from 5.8 to 3.7 for ISOT, as compared to the control group (P < 0.001 and P = 0.001, respectively). Additionally, the average disability showed a significant improvement in both the ISOM (ODI score from 17 to 11) and ISOT (ODI score from 15.4 to 11) groups compared to the control group (P < 0.001).

Conclusions

Both ISOM and ISOT methods are effective in alleviating pain and disability in patients with NSCLBP. However, there is no significant difference in the benefits between them. Numerically, ISOM exercises were found to be superior. Further studies are needed to obtain a more accurate answer regarding their superiority.

The Kumar Technique: A Novel and Effective Approach to Transforaminal Epidural Steroid Injections

Background Transforaminal epidural steroid injections (TFESIs) are widely used as a minimally invasive treatment for lumbar radicular pain. This study presents an alternative approach for lumbar TFESI, the Kumar Technique, which utilizes a more lateral and inferior needle starting point to better align the trajectory of the needle with the neural foramen. We hypothesize the Kumar Technique will result in safer and more effective outcomes than the traditional approach to TFESI. This article was previously presented as a poster at the 2023 University of Florida College of Medicine Celebration of Research on February 27-28, 2023, and as an abstract and poster at the 2023 University of Florida Department of Anesthesiology Celebration of Research on March 29, 2023. Methods The charts for 1,424 patients who received lumbar TFESIs were retrospectively reviewed, and patients were stratified into groups receiving either the traditional approach or the Kumar Technique. Outcomes measures included numerical pain scores, measures of functional status and activity limitations, duration of pain relief, and procedural complications. Results Compared to the group undergoing the traditional approach, patients receiving the Kumar Technique reported a significantly greater decrease in average pain (-2.3 (95% CI: -3.0 to -1.6) vs -1.1 (95% CI: -1.4 to -0.7)) and maximum pain (-2.4 (95% CI: -3.2 to -1.6) vs -1.3 (95% CI: -1.8 to -0.9)). Patients receiving the Kumar Technique had a significantly greater likelihood of reporting any pain relief (OR: 2.10, 95% CI:1.59 to 2.79) compared to those undergoing the traditional approach. In addition, a greater percentage of patients receiving the Kumar Technique experienced at least one month of pain relief compared to the traditional approach (54% vs 40%; z = 3.85, p < 0.001). The occurrence of complications did not significantly vary between the modified (4.1%) and the traditional (3.0%) approaches. Conclusions The Kumar Technique is a modified TFESI approach that allows for improved access to the nerve roots through a more lateral and inferior needle entry point. The analysis supports the benefits of the Kumar Technique with patients experiencing a greater reduction in pain and longer durations of pain relief without increasing the risk of complications.

Interventional non-operative management of low back and neck pain

Background

Chronic neck and back pain are among the most commonly encountered health problems in neurosurgical practice. Many cases fail prolonged pharmacological and physical therapy and are not proper candidates for surgical interventions, or had refused proposed surgical treatment.

Objective

To provide an informative critical summary of the literature about the topic of interventional management of axial neck and low back pain and highlighting the new trends and pieces of evidence.

Methods

The English literature published over the last two decades was reviewed by the author for recent and relevant data about the principles of interventional management of chronic neck and low back pain. A PubMed search was performed through phrase searching and combined searching using Boolean operators. The articles thought to be most relevant to the study aim and the neurosurgeons’ practice were extracted.

Results

Neck and low back pain continue to be among the most common musculoskeletal health problems and the most common cause of disability worldwide. A detailed understanding of relevant spine anatomy is crucial for interventionists who should deal with the concept of “functional spine unit” with multiple potential pain generators. Chronic spinal pain is best managed through a dedicated multidisciplinary team in well-equipped healthcare facilities. An algorithmic approach for the diagnosis and management of spinal pain is the mainstay of providing the best patient care and should be based on the commonality and treatability of pain generators, values of patients and available resources.

Conclusion

Management of chronic neck and back pain can represent a clinical dilemma due to the multiplicity of pain generators that may coexist in the same individual resulting in a complex type and pattern of pain. Approach to these patients requires contributions from the members of a multidisciplinary team, implementing a standardized approach in a well-equipped healthcare facility.

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.

Interventional surgery effectiveness in treatment of the cervical spine and shoulder joint chronic pain

Relevance. Degenerative diseases of the spine are among the most common pathologies that cause significant medical, social and economic losses. Thus, a retrospective analysis of the Humana database from 2008 to 2014 indicates a sharp increase in discogenic neurocompression lesions of the cervical spine, which is 42 %. Degenerative processes are characterized by metabolic and structural changes in the intervertebral discs (IVD), which lead to the loss of its properties. The aim of the study was to analyze the results of intervertebral disc nucleoplasty and radiofrequency denervation of the facet joints in patients with cervical joint hernias. Materials and Methods . Intervertebral disc nucleoplasty and radiofrequency denervation of the facet joints in patients with hernias of the cervical spine was performed in 55 patients aged 18 to 74 years (mean age 36.28 ± 2.19 years), of which 56.36 % (31 patients) were men and 43.64 % (24 people) were women. Results and Discussion. The results demonstrate a significant improvement (p0.001) in VAS and ODI in patients after treatment. The majority of patients (45.45 %) rated their health status as “good”, 41.82 % of respondents believe that after the intervention, their health status can be assessed as “excellent”. Only 3 patients (5.45 %) indicated an unsatisfactory condition, which may be due to individual psychological characteristics, comorbidities, or a reduced sensitivity threshold. Conclusion. Nucleoplasty of the intervertebral disc and radiofrequency denervation of the facet joints is an effective and safe method for the treatment of intervertebral hernias of the cervical spine.

Management of pain using magnesium sulphate: A narrative review

Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of systemic opioid and regional analgesia techniques has facilitated a decrease in the occurrence and gravity of pain. Magnesium has an evolving role in pain management. Magnesium sulphate (MgSO4), the pharmacological form of magnesium, is a physiological voltage-dependent blocker of N-methyl-D-aspartate (NMDA)-coupled channels. In terms of its antinociceptive role, magnesium blocks calcium influx, which inhibits central sensitization and decreases preexisting pain hypersensitivity. These properties have encouraged the research of magnesium as an adjuvant agent for intra- and post-operative analgesia. Moreover, the mentioned magnesium impacts are also detected in patients with neuropathic pain. Intravenous magnesium sulphate, followed by a balanced analgesia, decreases opioid consumption. This review has focused on the existing evidence concerning the role of magnesium sulphate in pain management in situations including neuropathic pain, postherpetic neuralgia, trigeminal neuralgia, migraine, and post-operative pain. Additional studies are required to improve the use of magnesium sulphate for pain to increase the quality of life of patients.

Development of a novel model of intervertebral disc degeneration by the intradiscal application of monosodium iodoacetate (MIA) in rat

BACKGROUND CONTEXT

Low back pain is one of the most common musculoskeletal disorders. Although, the pathology of intervertebral disc (IVD) degeneration has been modeled using various biological methods, these models are inadequate for simulating similar pathologic states in humans.

PURPOSE

This study investigated whether monosodium iodoacetate (MIA) injection into the IVD of rats could generate a reliable model of IVD degeneration.

STUDY DESIGN/SETTINGS

In vivo animal study.

METHODS

MIA was injected into two-disc spaces (L4-5 and L5-6) of Sprague-Dawley rats. Their behaviors were examined by measuring weight load shifts from hind to forefoot, rearing, and von Frey tests. We examined the inhibition of pain behavior through intraperitoneal morphine injection and measured cyclooxygenase-2 (COX-2) and transcription factor nuclear factor-kappa B (NF-κB) levels in the IVD and dorsal root ganglion (DRG) by Western blot. Bone alterations were assessed by microfocus computed tomography (micro-CT), and IVD and/or cartilage changes were evaluated by hematoxylin and eosin and safranin-O staining and inducible nitric oxide synthase (iNOS) immunohistochemistry. The other authors declare no conflicts of interest. This project funded by the Memorial Fund and the National Research Foundation of Korea (NRF).

RESULTS

We observed increased weight load shifts to the forefoot and decreased rearing. Morphine-injected rats showed reduced pain. NF-κB and COX-2 expression increased in the IVD and left and/or right DRG. Micro-CT analyses suggested progressive bone deformation. Histologic examination showed decreased IVD width and nucleus pulposus area. Cartilaginous changes indicated epiphyseal growth plate loss. Finally, iNOS expression was increased in the subchondral endplate.

CONCLUSIONS

These results suggest that low back pain (LBP) models can be developed by MIA injection into the IVDs of rats and that an animal model is useful for exploring degenerative alterations in the affected discs. Therefore, MIA injection may be a useful model for the study of changes in the IVD to elucidate the mechanisms underlying clinical symptoms, such as LBP, in patients with IVD degeneration.

CLINICAL SIGNIFICANCE

This model in which MIA was injected into the disc better represented the human histologic and behavioral characteristics than the existing puncture model.

Implanted spinal neuromodulation interventions for chronic pain in adults

BACKGROUND

Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity.

OBJECTIVES

To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence.

MAIN RESULTS

We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported  device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.

Antibiotics for Spinal Cord Stimulation Trials and Implants: A Survey Analysis of Practice Patterns

Background

Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. Published guidelines exist to aid physicians in proper antibiotic use during and after spinal cord stimulation trials and implants. In this brief review, we present and analyze the current antibiotic practice patterns of clinicians.

Methods

The study protocol was reviewed and granted an exemption by an Institutional Review Board. The survey queried practice parameters in regards to spinal cord stimulation therapy. The American Society of Regional Anesthesia and Pain Medicine (ASRA) and Society of Interventional Spine (SIS) distributed the survey to their active members by emails with a web link to the survey.

Results

Our results indicate that 82% and 69% of physicians do not utilize nasal swabs for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA), respectively, prior to SCS trial and implantation. During trials, 47% providers administer a single dose of antibiotics, 35% administer antibiotics for the duration of the trial, and 17% do not administer antibiotics. During implantation, 44% of physicians administer a single dose during the procedure, 11% administer antibiotics up to 24 hours, 24% administer antibiotics between 3-5 days, 14% administer antibiotics for more than 5 days, and 4% do not administer antibiotics.

Conclusions

Our study suggests a portion of pain physicians do not adhere to the Neuromodulation Appropriateness Consensus Committee (NACC) guidelines in regards to antibiotic administration for SCS trial and implantation. Further analysis and surveys would allow insight into common practices. More information and education would be beneficial to optimize peri-procedure antibiotic use to reduce infection risk and decrease antimicrobial resistance.

The Immediate Adverse Events of Lumbar Interventional Pain Procedures in 4209 Patients; an Observational Clinical Study

OBJECTIVE

Lumbar interventional pain procedures (LIPP) are frequently used in low back pain and show an increasing trend in recent years. LIPP are highly effective when performed by properly trained physicians. However, some adverse events are seen during interventional procedures. Our aim in this study is to determine the immediate adverse events rates of LIPP and to inform our colleagues about possible adverse events.

STUDY DESIGN

Retrospective, observational study.

SETTING

A university hospital pain management center.

METHODS

After approval of the institutional ethics committee, a retrospectively evaluation of patients, who received fluoroscopy guided LIPP between January 2015 and December 2020, were performed. This observational study was conducted with 4209 patients who underwent LIPP including epidural steroid injections, sacroiliac and facet joint injections, medial branch blocks or RF, dorsal root ganglion pulse RF, epidural catheter or spinal cord stimulator applications.

RESULTS

No major adverse events were detected during the procedures. Minor adverse events were detected in a 60 patients and adverse events rate was found to be 1.4% (95% confidence interval [CI]: 1.0-1.8%). Minor adverse events rates vary between 0.7-2.3% according to the procedures type. The most common adverse events was determined as vasovagal reactions (26/60). Facial numbness, cramps, and seizures were detected as rare adverse events.

CONCLUSION

There were no major adverse events were seen during 4209 patients. The rate of minor adverse events were 1.4% with no sequelae in any of the events. When evidence-based guidelines are followed, interventional pain procedures are performed safely.

Prolotherapy for chronic low back pain: a review of literature

INTRODUCTION

Low back pain is common and imposes major societal burdens for patient suffering and costs. Prolotherapy injections are used for musculoskeletal conditions including tendinopathies, osteoarthritis and low back pain to enhance soft-tissue healing. This review aims to clarify the place of prolotherapy in chronic low back pain (CLBP).

SOURCES OF DATA

Using multiple databases, a systematic search was performed to identify studies detailing the use of prolotherapy to manage CLBP. A total of 12 articles was included in the present work.

AREAS OF AGREEMENT

Considering the level of evidence and the quality of the studies assessed using the modified Coleman Score, prolotherapy is an effective management modality for CLBP patients in whom conservative therapies failed.

AREAS OF CONTROVERSY

The presence of co-interventions and the clinical heterogeneity of the work contributes to confound the overall conclusions.

GROWING POINTS AND AREAS FOR RESEARCH

The analysis of the studies included in the review, using appropriate tools, showed how their quality has decreased over the years, reflecting the need for appropriately powered well planned and performed randomized control trials.

Dorsal Root Ganglion (DRG) and Chronic Pain

Context

Chronic neuropathic pain is a common condition, and up to 11.9% of the population have been reported to suffer from uncontrolled neuropathic pain. Chronic pain leads to significant morbidity, lowered quality of life, and loss of workdays, and thus carries a significant price tag in healthcare costs and lost productivity. dorsal root ganglia (DRG) stimulation has been recently increasingly reported and shows promising results in the alleviation of chronic pain. This paper reviews the background of DRG stimulation, anatomical, and clinical consideration and reviews the clinical evidence to support its use.

Evidence Acquisition

The DRG span the length of the spinal cord and house the neurons responsible for sensation from the periphery. They may become irritated by direct compression or local inflammation. Glial cells in the DRG respond to nerve injury, producing inflammatory markers and contribute to the development of chronic pain, even after the resolution of the original insult. While the underlying mechanism is still being explored, recent studies explored the efficacy of DRG stimulation and neuromodulation for chronic pain treatment.

Results

Several reported cases and a small number of randomized trials were published in recent years, describing different methods of DRG stimulation and neuromodulation with promising results. Though evidence quality is mostly low, these results provide evidence to support the utilization of this technique.

Conclusions

Chronic neuropathic pain is a common condition and carries significant morbidity and impact on the quality of life. Recent evidence supports the use of DRG neuromodulation as an effective technique to control chronic pain. Though studies are still emerging, the evidence appears to support this technique. Further studies, including large randomized trials evaluating DRG modulation versus other interventional and non-interventional techniques, are needed to further elucidate the efficacy of this method. These studies are also likely to inform the patient selection and the course of treatment.

Improved Pain Control with Combination Spinal Cord Stimulator Therapy Utilizing Sub-perception and Traditional Paresthesia Based Waveforms: A Pilot Study

Background

Chronic back and neck pain affects 20% of Americans. Spinal cord stimulation (SCS) is an effective therapy for otherwise refractory chronic pain. Traditional SCS relies on low-frequency stimulus in the 40 - 60 Hz range causing robust paresthesia in regions overlapping with painful dermatomes.

Objectives

This study aims to determine the effect of superimposing sub-perception stimulation in patients who previously had good long-term relief with paresthesia.

Methods

This is a prospective observational trial examining patients who had previously been implanted with paresthesia based SCS for failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). These patients presented for implantable pulse generator (IPG) replacement based on battery depletion with an IPG capable of combined sub-perception and paresthesia based SCS therapy. Patients were assessed immediately following the exchange and four weeks later using a telephone survey. Their pain was assessed on each follow up using a Numerical Rating scale (NRS); the primary outcome was the change in NRS after four weeks from the exchange day. Secondary outcomes included paresthesia changes, which included the subjective quality of sensation generated, the overall subjective coverage of the painful region, subjective variation of coverage with positional changes, and global perception of the percentage improvement in pain.

Results

Based on our clinic registry, 30 patients were eligible for IPG exchange, 16 were consented for follow up and underwent an exchange, and 15 were available for follow up four weeks following. The average NRS decreased from 7.47 with traditional SCS to 4.5 with combination therapy. 80% of patients reported an improvement in the quality of paresthesia over traditional SCS therapy, and in most patients, this translated to significantly improved pain control.

Conclusions

Our findings suggest improved pain relief in patients who had previously had good results with paresthesia based therapy and subsequently underwent IPG exchange to a device capable of delivering combined sub-perception stimulation. The mechanism of action is unclear though there may be an additive and/or synergistic effect of the two waveforms delivered. Larger studies with long-term follow-up are needed to elucidate the durability of pain relief and the precise mechanism by which combined subperception and paresthesia based SCS may improve overall patient outcomes.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review

Context

Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies.

Evidence Acquisition

Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

Results

Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications.

Conclusions

Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

Prevalence and Factors Associated with Back Pain among Patients Undergoing Spinal Anesthesia at the University of Gondar Comprehensive and Specialized Hospital, North West Ethiopia: An Institutional Based Cross-Sectional Study

BACKGROUND

Back pain is often reported as a common complaint after surgery. Many studies showed that the prevalence of back pain after spinal anesthesia is high and its magnitude is considerable in developing countries. It is highly related to reduced quality of life, loss of work productivity, burden of health care costs, and satisfaction regarding health care service; therefore, measures should be taken to reduce or prevented postspinal back. The aim of this cross-sectional study was to assess the prevalence and factors associated with back pain among patients undergoing spinal anesthesia at the University of Gondar Comprehensive and Specialized Hospital, Northwest Ethiopia. Methodology. An institutional based cross-sectional study was conducted from March to May 2020. A total of 215 participants were enrolled in this study. A convenience sampling technique was used to get the study participants. Both univariable and multivariable logistic regression were used to identify factors associated with postspinal back pain. Variables with a p value less than <0.2 in the bivariable analysis were fitted into the multivariable analysis. In the multivariable analysis, a variable with a p value of <0.05 was considered statistically significant.

RESULTS

The overall prevalence of postspinal back pain was 40.5% (95% CI: 34.0, 47.4). Being overweight (AOR = 3.8; 95% CI: 1.47, 9.96) and obese (AOR = 4.9; 95% CI: 1.19, 20.4), using big spinal needles (AOR = 5.9; 95% CI: 1.04, 33.4), two attempts of lumbar puncture (AOR = 5.5; 95% CI: 1.74, 17.59), more than three attempts of lumbar puncture (AOR = 4.9; 95% CI: 1.63, 15.2), and the number of bone contacts during spinal anesthesia procedure (AOR = 3.1; 95% CI: 1.14, 8.45) were positively associated with postspinal back pain. Conclusion and Recommendation. The overall incidence of back pain is high. Body mass index, size of spinal needle, number of attempts, and number of bone contacts are significantly associated with the incidence of back pain following spinal anesthesia. Thus, it is better to minimize the number of lumbar puncture attempts and bone contacts during spinal anesthesia to reduce postspinal back pain. In addition, using smaller size spinal needle is a good choice.

Discitis Following Radiofrequency Nucleoplasty: A Case Report

Introduction

Radiofrequency nucleoplasty is a minimally invasive procedure to treat chronic low back pain, especially mild degenerative disc diseases. Discitis after radiofrequency nucleoplasty is a rare case.

Case Presentation

A 62-year-old male patient with a chief complaint of 10 years low back pain, gradually worsening for the last two years, a history of hypertension, chronic kidney disease, and routine dialysis twice a week, referred to the center. He underwent a lumbar medial branch block using radiofrequency and radiofrequency nucleoplasty procedure of lumbar 4-5 (L4-L5). Three weeks after the intervention, he could not move his legs, associated with urinary and fecal incontinence. MRI (magnetic resonance imaging) of the lumbar spine was performed, and the results indicated hyperintensity in L4-L5, suspicious of discitis. Laminectomy at L4 and L5 was performed. Eight months after surgery, the patient could feel and lift legs, and urinary and fecal incontinence was also controlled.

Conclusions

Early diagnosis of discitis is critical and challenging. Delay in diagnosis may lead to treatment delay and the development of neurological deficits. Comprehensive treatment with bed rest, antimicrobial therapy, and sensible application of timely surgery are essentials to an optimal outcome.

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.

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.

Função, atividade e participação na percepção do paciente com dor lombar crônica: estudo em um grupo focal

Objetivo: Identificar a percepção da dor lombar (DL) crônica em usuários de uma unidade de reabilitação fisioterapêutica de um município de Minas Gerais, Brasil. Métodos: Trata-se de uma pesquisa exploratória descritiva e qualitativa. Realizaram-se grupos focais com usuários do serviço de saúde de ambos os sexos com idade superior a 18 anos, diagnóstico médico de DL crônica, e em reabilitação física. As unidades norteadoras foram: conversando sobre dor e tratamentos prévios para alívio da dor, programadas por roteiro semiestruturado. Emergiram as unidades: fala dos profissionais de saúde e a fala dos colegas de trabalho e familiares. As falas foram gravadas, transcritas e analisadas utilizando a Técnica de Elaboração e Análise de Unidades de Significado. Utilizou-se o escore de dor do Índice de Incapacidade de Oswestry (IIO) e o IIO completo para avaliação da dor e da funcionalidade. Resultados: 14 pacientes (média de idade 52 ± 3 anos), na maioria mulheres, relataram DL crônica em média há 5 ± 5 anos. O valor médio do escore de dor foi de 1,37 ± 1,72 e média de incapacidade de 21,96% (IC95% 15,43 – 28,50%).  Os relatos sobre a dor foram: ‘um incômodo’, ‘uma doença’, ‘incapacidade’, tratada com remédios e Fisioterapia; profissionais da saúde demonstram ‘negligência’, ‘agressão’ ou ‘proibição’; enquanto família e colegas de trabalho demonstram ‘desprezo’, ‘represália’ ou ‘apoio’. Conclusão: A percepção da DL crônica equivale a incômodo, desconforto, doença, restrições, agressão, negligência, desprezo, represália ou apoio a um misto de sensações físicas e psicológicas.

Short-Term Efficacy of Epidural Injection of Triamcinolone Through Translaminar Approach for the Treatment of Lumbar Canal Stenosis

Background

Epidural steroid injection is a non-operative minimally invasive procedure for pain relief in spinal canal stenosis. However, there is no significant consensus regarding its efficacy.

Objectives

In this study, we aimed to evaluate the effectiveness of translaminar injection of triamcinolone in lumbar canal stenosis.

Methods

In a retrospective study, we included 111 patients with MRI-confirmed spinal canal stenosis who were irresponsive to 12 weeks of conservative treatment and underwent epidural injection of triamcinolone through the translaminar approach. Outcome measures were routinely checked before the intervention and four weeks after the intervention, which included the Visual Analog scale (VAS) for low back pain, VAS for lower-limb pain, and Oswestry Disability index (ODI).

Results

The study population included 32 (28.8%) males and 79 (71.2%) females with the mean age of 61 ± 13.4 years. The mean ODI, VAS for low back pain, and VAS for lower-limb pain significantly improved at the final evaluation session (P < 0.001, P = 0.001, and P < 0.001, respectively). The levels of improvement in ODI, VAS for low back pain, and VAS for lower-limb pain were considerably more in patients with single-level involvement (P < 0.001, P = 0.04, and P < 0.001, respectively). Improvement of lower-limb VAS was negatively correlated with age (r = -0.400, P < 0.001) and BMI (r = -0.525, P < 0.001). The ODI improvement was also negatively correlated with BMI (r = -0.569, P < 0.001).

Conclusions

Epidural injection of triamcinolone through the translaminar approach could be regarded as an efficacious method for the alleviation of pain and disability in patients with spinal canal stenosis.

Comparison of Transforaminal Triamcinolone and Dexmedetomidine in Radicular Low-Back Pain: A Randomized Double-Blind Clinical Trial

Background

Administration of steroids in the lumbar transforaminal block for lumbar radicular pain is considered one of the preferred treatment methods though it is associated with some complications.

Objectives

The effects and side effects of triamcinolone and dexmedetomidine in the lumbar transforaminal block were investigated in the present study.

Methods

In this study, 30 patients, aged 40 - 70 years, suffering from lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and dexmedetomidine (D). They all underwent lumbar transforaminal blocks. An injection solution of triamcinolone (20 mg) plus ropivacaine (0.2%) and another one containing dexmedetomidine (50 μg) plus ropivacaine (0.2%) were administered in the triamcinolone and dexmedetomidine groups, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR or lasègue’s test), and Fasting Blood Sugar (FBS) were measured at 0, 2 weeks, 1, 3, and 6 months post-procedure. The levels of calcium, magnesium, and vitamin D, as well as potential complications, were also evaluated.

Results

Significant differences were found in the VAS and ODI during the measurement times within each group. The VAS and ODI were remarkably different between the dexmedetomidine group and the triamcinolone group. In addition, there were considerable differences in the increased FBS and reduced calcium and vitamin D levels in the triamcinolone group from changes in the dexmedetomidine group.

Conclusions

The lumbar transforaminal block with triamcinolone or dexmedetomidine attenuates the lumbar radicular pain. Further, dexmedetomidine exerts a more potent pain relief effect than triamcinolone.

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

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

Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain

STUDY DESIGN

A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted.

OBJECTIVE

The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures.

MATERIALS AND METHODS

English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included.

RESULTS

Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients.

CONCLUSIONS

These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.

Health Needs in Patients Suffering from Chronic Back Pain: A Qualitative Study

Background

Chronic back pain is a disease many people suffer from it and they have different problems and needs.

Objectives

Due to the vague nature of these needs and lack of information in this regard, the present research was aimed to identify the needs of the patients suffering from chronic back pain.

Methods

This qualitative study was conducted using content analysis method. Here, 29 participants entered the study using a purposive sampling; they were interviewed one by one, face to face, and in a semi-structural mode. Gathering the data, transcribing the interviews, and analyzing them were performed simultaneously using Graneheim and Lundman method. First, codification and meaning similarities were revised and the subthemes were identified; then, in the second revision, the related subthemes were put in one category. The data were analyzed using the max Q software version 2007.

Results

Analyzing the results led to deriving four main themes and nine categories. The main themes were related to the needs of the patients suffering from chronic back pain, including teaching and informing, religious-spiritual dimension, socio-economic dimension, and physical-psychological dimension.

Conclusions

This study provided a comprehensive understanding of the health-related needs of the patients suffering from chronic back pain in Iran. According to the obtained criteria from this study, identifying the needs, planning for them, and evaluating the measures taken for the patients suffering from chronic back pain will become possible.

Interventional therapeutic procedures to treat degenerative and inflammatory musculoskeletal conditions: state of the art

Imaging-guided interventional procedures have become increasingly popular in the treatment of several pathologic conditions in the musculoskeletal system. Besides oncological treatments, musculoskeletal procedures can be performed to treat different degenerative or inflammatory conditions. This paper is aimed to review clinical indications and technical aspects of these kinds of procedures. In particular, we revise the general aspects common to most procedures and the different imaging-guided interventions which can be performed around joints, soft tissues, and spine.

Pulsed Radiofrequency Versus Continuous Radiofrequency for Facet Joint Low Back Pain: A Systematic Review

OBJECTIVE

To compare pulsed radiofrequency (PRF) treatment with continuous radiofrequency (CRF) to improve pain, functionality, and safety profile in patients with facet joint chronic low back pain.

METHODS

A systematic, critical review of recent literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, Cochrane, Clinical Trials, and LILACS databases were searched. Medical Subject Heading terms were "low back pain," "zygapophyseal joint," and "pulsed radiofrequency treatment." Original research articles in peer-reviewed journals were included in the review. The articles were thoroughly examined and compared on the basis of study design and outcomes. Only studies that met the eligibility criteria were included.

RESULTS

Three randomized clinical trials comprising 103 patients (39 in PRF group, 44 in CRF group, and 20 in control group) were included in the final analysis. Two trials compared PRF with CRF, and 1 trial compared 3 groups: PRF, CRF, and control with intervention as conventional treatment. The studies reported greater pain control and better functionality with CRF compared with PRF. PRF showed a decrease in visual analog scale and Oswestry Disability Index in 2 studies, and 1 study reported increased pain and disability after the intervention. No side effects were reported.

CONCLUSIONS

PRF treatment is less effective than CRF regarding pain control and return of functionality in patients with facet joint chronic low back pain. We recommend CRF with a large safety profile after conventional treatment.

Electromyographic Findings After Epidural Steroid Injections in Patients with Radicular Low Back Pain: A Prospective Open-Label Study

Epidural steroid injections (ESIs) are commonly used in the management of chronic lower back and leg pain. The aim of this study was to investigate the short- and long-term electromyographic and clinical outcome of patients with chronic radicular pain after ESIs. This prospective, open-label study, included patients with chronic radicular pain due to disc herniation or spinal stenosis, who underwent interlaminar, fluoroscopy-guided ESIs. Patients were assessed before ESIs, as well as after 6 and 12 months, clinically (VAS 0-10, BPI, DN4, Rolland Morris, DASS, STAI) and electromyographically for the improvement of spontaneous activity (SA) and of motor unit recruitment/interference pattern (IP/MUR). A total of 39 patients were studied, 20 (51.3%) who had a significant improvement in VAS, RM, DN4 and BPI were revealed, mainly during the first 6 months (P < 0.05). Statistically significant improvement was revealed in MUR/SA for almost all nerve roots studied. Patients with disc herniation showed a greater improvement in mean difference of MUR/SA (P < 0.05) (with a prognostic value of radicular LBP versus spinal stenosis in short- [VAS P = 0.042] and long-term improvement of pain [VAS P = 0.009]. The independent variables “MUR” and “SA” had a significant prognostic value for improvement of pain (VAS: R² = 0.287, P = 0.032 and VAS: R² = 0.277, P = 0.036 respectively). Electromyographic and clinical findings indicated a benefit from epidural steroid injections. Patients with disc herniation exhibited a better outcome, especially during the first 6 months post-treatment.

A Comparison of Continuous Thoracic Epidural Analgesia with Bupivacaine Versus Bupivacaine and Dexmedetomidine for Pain Control in Patients with Multiple Rib Fractures

Background

The control of pain in traumatic patients with chest injury leading to rib fracture is one of the primary goals in traumatic patients. The efficacy of the thoracic epidural approach in comparison with other approaches for relieving post-thoracotomy pain is unknown. The goal of the present study was to compare thoracic epidural analgesia with bupivacaine alone and in combination with dexmedetomidine in patients with multiple rib fractures.

Methods

64 traumatic patients with multiple rib fractures were selected and randomly assigned to two similar groups. For pain relief, a thoracic epidural catheter was inserted to infuse bupivacaine alone or the combination of bupivacaine and dexmedetomidine. Then, we recorded and analyzed pain scores and ABG changes.

Results

Based on the results, the two approaches could result in proper analgesia, but analgesia with the combination of bupivacaine and dexmedetomidine was significantly improved compared to bupivacaine alone (P < 0.05). In addition, ABG of patients significantly changed when the combination of bupivacaine and dexmedetomidine was used within 2 to 4 days (P < 0.05).

Conclusions

The results of the present study showed that epidural infusion of a combination of bupivacaine and dexmedetomidine could provide better control of rib fracture pain in traumatic patients, and is a proper alternative for bupivacaine alone.

Mindfulness-based interventions for chronic pain: Evidence and applications

Chronic pain is estimated to occur in from 5.5% to 33% of the world's adult population (Gureje et al., 1998). Chronic pain is frequently treated with opiates, which has produced an opiate addiction crisis (Dowell et al., 2016). Several non-pharmacological treatment alternatives can help manage chronic pain. There is moderate evidence that mindfulness-based interventions (MBIs) such as meditation, yoga, and stress reduction lower the perception of pain, increase mobility, improve functioning and well-being. By integrating MBIs and other therapeutic interventions in a multi-disciplinary pain management plan, clinicians can improve treatment outcomes and potentially decrease pain-related medication utilization.

Effects of ozone on the pain and disability in patients with failed back surgery syndrome

Introduction:

Low back pain is one of the painful disorders of higher prevalence. It has several etiologies and surgery may be indicated in the presence of neurological deficits or compression syndromes. However, in up to 40% of cases, patients develop worsening of pain and failed back surgery syndrome (FBSS), which is an important cause of chronic pain with high morbidity and disability. In the last two decades, ozone has been shown to be a new therapeutic option for FBSS due to its analgesic and anti-inflammatory properties.

Objective:

To evaluate the effect of ozone therapy on pain and disability in patients with failed back surgery syndrome.

Method:

We selected 19 patients undergoing epiduroscopy and injection of ozone. Patients were evaluated preoperatively and 21 days after the procedure, using the following instruments: Visual Analogue Scale (VAS), Brief Pain Inventory, Roland-Morris Questionnaire Disability, Oswestry Disability Index (ODI), Neuropathic Pain Symptom Inventory and Douleur Neuropathique 4.

Results:

The patients showed significant pain relief, but no improvement was observed in the functional scales.

Conclusion:

Our results suggest that epidural ozone therapy can be a treatment option in FBSS to reduce the intensity of the pain.

The Results of Treating Failed Back Surgery Syndrome by Adhesiolysis: Comparing the One- and Three-Day Protocols

Background

The optimal treatment of failed back surgery syndrome (FBSS) is controversial. Limited studies have demonstrated the satisfactory outcomes of percutaneous adhesiolysis in FBSS, which can be performed as a 1 day or 3 days procedure. In the current randomized clinical trial, we compared the clinical and functional outcomes of these 2 techniques.

Methods

In this study, 60 patients with FBSS were randomly assigned into 2 equal groups: 1 day group and 3 days group. Before and at 4 and 12 weeks after the procedure, pain intensity was measured using visual analogue scale (VAS). The Oswestry disability index (ODI) was also completed. Pain reduction of 50% or more was defined as treatment success.

Results

Significant pain relief and ODI improvement were obtained in the 2 groups with adhesiolysis (P < 0.001). However, pain intensity remained the same before and at 4 and 12 weeks after adhesiolysis. ODI score was significantly lower in 1 day group in the 1 month visit (P < 0.001). Treatment was successful in 76.7% and 83.3% of the patients in 1 day and 3 days groups, respectively (P = 0.519).

Conclusions

Adhesiolysis is an effective treatment for pain relief and functional improvement in FBSS. The results of 1 day and 3 days procedures are comparable. Based on these findings, the authors recommend using 1 day technique, which can potentially decrease the patients' discomfort, hospital stay, and cost of treatment.

Comparison of facet joint degeneration in firefighters and hospital office workers

Background

There are few published studies on the relationship between occupational lumbar load and facet joint degeneration (FJD). This cross-sectional study was conducted to evaluate the effect of physical lumbar load on FJD by comparing magnetic resonance imaging (MRI) findings of firefighters (FFs) and hospital office workers (HOWs).

Methods

We randomly sampled 341 male FFs and 80 male HOWs by age stratification. A questionnaire and clinical examination, including MRI of the lumbar spine (T12-S1), were conducted. FJD was diagnosed and graded by using the classification of Pathria et al., and reclassified into two groups as follows: no FJD (grade 0) and FJD (grades 1, 2, and 3). The prevalence of FJD was analyzed according to occupational group.

Results

The prevalence of FJD ranged from 31% (L1–L2) to 75% (L4–L5) in the FFs, and from 18% (L1–L2) to 69% (L4–L5) in the HOWs. After adjustment for age, body mass index, and frequency of physical exercise, the adjusted odds ratios (OR) for FJD in the FFs were significantly higher than those in the HOWs at all lumbar spinal levels, except for L3–L4 (L1–L2: OR, 2.644; 95% confidence interval [CI], 1.317–5.310; L2–L3: OR, 2.285; 95% CI, 1.304–4.006; L4–L5: OR, 1.918; 95% CI, 1.037–3.544; L5–S1: OR, 1.811; 95% CI, 1.031–3.181).

Conclusion

This study shows that FFs exhibit a greater likelihood of having FJD than HOWs after controlling for other risk factors of FJD. This suggests that the physical occupational demands of FFs affect their risk of developing FJD.

Comparison of Quadrapolar™ radiofrequency lesions produced by standard versus modified technique: an experimental model

Lower back pain (LBP) is a global public health issue and is associated with substantial financial costs and loss of quality of life. Over the years, different literature has provided different statistics regarding the causes of the back pain. The following statistic is the closest estimation regarding our patient population. The sacroiliac (SI) joint pain is responsible for LBP in 18%–30% of individuals with LBP. Quadrapolar™ radiofrequency ablation, which involves ablation of the nerves of the SI joint using heat, is a commonly used treatment for SI joint pain. However, the standard Quadrapolar radiofrequency procedure is not always effective at ablating all the sensory nerves that cause the pain in the SI joint. One of the major limitations of the standard Quadrapolar radiofrequency procedure is that it produces small lesions of ~4 mm in diameter. Smaller lesions increase the likelihood of failure to ablate all nociceptive input. In this study, we compare the standard Quadrapolar radiofrequency ablation technique to a modified Quadrapolar ablation technique that has produced improved patient outcomes in our clinic. The methodology of the two techniques are compared. In addition, we compare results from an experimental model comparing the lesion sizes produced by the two techniques. Taken together, the findings from this study suggest that the modified Quadrapolar technique provides longer lasting relief for the back pain that is caused by SI joint dysfunction. A randomized controlled clinical trial is the next step required to quantify the difference in symptom relief and quality of life produced by the two techniques.

High-Density in Spinal Cord stimulation: Virtual Expert Registry (DISCOVER): Study Protocol for a Prospective Observational Trial

Background

Spinal cord stimulation (SCS) is a proven and effective treatment for neuropathic pain conditions such as failed back surgery syndrome (FBSS). The hypothesis that different settings for SCS parameters activate unique, pain-relieving mechanisms has boosted the development of various SCS paradigms. High density spinal cord stimulation (HD-SCS) is one of those promising, novel stimulation forms characterized by subthreshold stimulation, delivering more pulses per second and a higher pulse density to the spinal cord than conventional SCS.

Objectives

The aim of DISCOVER is to gather evidence about the effectiveness, feasibility, and (possible) side effects of HD stimulation.

Methods

The prospective, non-interventional, multi-center, clinical study, DISCOVER, is currently restricted to Belgium where 19 neuromodulation centers were selected. Patient recruitment started in October 2016 and is expected to end in October 2017. Subjects included are (1) patients with insufficient pain relief from conventional SCS or (2) neurostimulation-naïve patients suited for SCS. Patients will be assessed 1 month, 3 months, and 12 months after conversion to HD-SCS settings. Each patient’s visit will include: a numerical rating scale (NRS), Oswestry disability index (ODI), Pittsburgh sleep quality index (PSQI), EQ-5D, a pain map, registration of SCS settings, and a list of used pain medication.

Conclusions

Although promising results have been reported, adequate registration of its effectiveness and (possible) side-effects remains an unmet need. Main results are expected in 2019.

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

Background

Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP.

Methods

Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours.

Results and Conclusions

No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.

Contribution of Low-Dose Computerized Tomography With Digital Multiplanar Reconstructions in Thoracic Epidurography and Correlation With Sensory Block in Postoperative Analgesia

Background

The level of sensory block in postoperative epidural analgesia has been correlated with conventional contrast epidurography in only one study, while low-dose CT scan epidurography with multiplanar reconstruction may be a better tool for this purpose.

Objectives

The primary objective of this study was to evaluate, by CT imaging and digital multiplanar reconstruction, the spread and distribution of contrast medium injected into the epidural space through a catheter inserted in a low thoracic position for postoperative analgesia.

Materials and Methods

Ten patients undergoing major abdominal cancer surgery with effective epidural analgesia were prospectively included at postoperative day three. Two consecutive boluses of 5 mL of a mixture of ropivacaine and contrast medium were injected at 15 minutes intervals into the epidural space. Multislice low-dose CT scan epidurography and an assessment of the sensory block were performed before and after injection of the second bolus. The primary objective was to assess the contribution of CT scan epidurography to predict a correlation between the level of sensory block and the spread of the contrast medium in the epidural space; the secondary objective was to determine the agreement between the two methods.

Results

The spread of contrast material and the clinical sensory block significantly increased after the second injection (32%; P < 0.05). However, no highly significant correlation was observed between the two methods. A gap of two spinal segments of CT opacification was observed in two patients and was confirmed by clinical assessment.

Conclusions

CT epidurography is not closely correlated with a clinical assessment of epidural block; thus, a clinical assessment of the sensory block is mandatory. The use of opioid analgesia in combination with local anesthetics may compensate for the lack of efficacy of local anesthetics alone.

Percutaneous Lumbar Decompression With SpineJet Hydrosurgery in the Treatment of Lumbar Spinal Stenosis Secondary to Ligamentum Flavum Hypertrophy

Introduction

Lumbar spinal stenosis with symptomatic neurogenic claudication is a frequently encountered clinical entity which requires endoscopic or open spine surgery once the patients fail to respond to conservative therapies. In this case report we present a novel minimally invasive decompression technique using a fluid jet device (HydroCision Inc, Billerica, MA, USA) for a patient with symptomatic spinal stenosis secondary to ligamentum flavum hypertrophy. To our knowledge this approach has never been described in the medical literature.

Case Presentation

An 85 years old patient presented because of intractable right leg pain with minimal activities. She was diagnosed with significant right foraminal stenosis and she failed conservative non-invasive therapies.

Conclusions

Percutaneous lumbar hydro decompression can be a promising method for the treatment of the patients with lumbar spinal stenosis and neurogenic claudication secondary to ligamentum flavum hypertrophy.

Delayed onset of a spinal epidural hematoma after facet joint injection

The treatment of chronic back pain is a challenging problem. Facet joint infiltration is an established treatment for chronic low back pain caused by arthrosis of the lumbar facet joints. Due to the increasing number of patients with chronic low back pain, this therapy has become more frequent. We treated a 51-year-old male patient, who developed an epidural hematoma 2 months after infiltration therapy. Our case shows that even a delayed onset of spinal epidural hematoma is possible and should be kept in mind as a possible cause of acute myelopathy after spinal intervention.

Health Care Workers' Knowledge, Attitude, and Practice About Chronic Pain Management, Shiraz, Iran

Background

Pain can adversely affect every aspect of a patient’s daily activity, and consequently, it has a great influence on the quality of life. Studies have shown that health care professionals have little knowledge of and inadequate attitudes toward the assessment of pain and its treatment with analgesics.

Objectives

This cross-sectional study was designed to evaluate the knowledge, attitudes, and practice of health care professionals regarding chronic pain management. It was carried out in six different educational hospitals affiliated with Shiraz University of Medical Sciences in Shiraz, Iran.

Patients and Methods

Participants were given a questionnaire containing 46 questions and demographic characteristics to fill out independently. In total, 213 health care professionals (114 nurses and 99 medical residents) volunteered to take part in this study. In order to ease further analysis, the questions were grouped into three categories: narcotic drugs, non-narcotic drugs, and non-drug-related questions.

Results

The mean correct response rate was 43.13% ± 11.10. Medical residents scored 51.23% ± 9.02% and nurses 36.10% ± 7.31% (P < 0.001). There was no statistically significant relation between field of specialty and the mean scores of medical residents. Narcotic drug questions received the lowest (39.02%) and non-narcotic drug questions received the highest (57.32%) percentages of correct responses. Only 9.3% of participants believed that they had received adequate education about pain and its management.

Conclusions

The findings of this study support concern about inadequate knowledge, attitudes, and practice regarding chronic pain management. We believe that further education and practical training will be needed for adequate pain management.

Effects of Extracorporeal Shock Wave Therapy on Pain in Patients With Chronic Refractory Coccydynia: A Quasi-Experimental Study

Background

Several nonsurgical and surgical treatment modalities are available for patients with chronic coccydynia, with controversial results. Extracorporeal shock wave therapy (ECSWT) is effective in the treatment of many musculoskeletal disorders; however, it has not been tested for chronic coccydynia.

Objectives

We performed the current study to determine the effects of ECSWT on pain in patients with chronic coccydynia.

Patients and Methods

This quasi-interventional clinical study included 10 patients with chronic coccydynia without acute fracture. All the patients received ECSWT with a radial probe delivering 3,000 shock waves of 2 bar per session at 21 Hz frequency directed to the coccyx. Each patient received four sessions of ECSWT at one-week intervals. The pain severity was recorded according to the visual analog scale (VAS) at one, two, three, and four weeks after initiation of therapy. The VAS score was also evaluated at one and six months after ending the therapy.

Results

Most of the participants were women (90.0%), and the participants’ mean age was 39.1 ± 9.1 (ranging from 28 to 52) years. The VAS score did not decrease significantly seven months after therapy when compared to baseline (3.3 ± 3.6 vs. 7.3 ± 2.1; P = 0.011). However, the VAS score at two months (2.6 ± 2.9 vs. 7.3 ± 2.1; P = 0.007) and at four weeks (3.2 ± 2.8 vs. 7.3 ± 2.1; P = 0.007) significantly decreased when compared to baseline. The decrease in VAS scores was not persistent after cessation of the therapy.

Conclusions

ECSWT is an effective modality in relieving the pain intensity in patients with refractory chronic coccydynia for the early period after intervention.

Clinical Evaluation of Percutaneous Caudal Epidural Adhesiolysis With the Racz Technique for Low Back Pain Due to Contained Disc Herniation

Objectives

The authors evaluated the effectiveness of percutaneous epidural adhesiolysis (PEA) in patients with low back pain due to contained disc herniation.

Patients and Methods

Twenty patients with low back pain due to contained disc herniation underwent PEA treatment with the Racz technique. The patients were evaluated for pain score, medication intake, significant pain relief, and complications.

Results

At three days, one month, three months, and six months after PEA compared to pre-PEA evaluations, the pain scores and medication intake were significantly decreased. Significant pain relief declined from 95% at three days to 75% at six months.

Conclusions

PEA for low back pain due to contained disc herniation is a safe and effective procedure. Therefore, it may be considered as an option for treatment before invasive operations are performed.