ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
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nerve root block was the first term developed to describe
the technique for diagnosing the source of radicular pain
when imaging studies suggested a possible compression
of several roots. Early studies of selective nerve root injections
described an extra-foraminal approach, in which
the needle is advanced at a right angle to the spinal nerve
outside the neural foramina. Subsequently, a variation of
this procedure has emerged which has been termed selective
epidural and is also referred to as transforaminal epidural.
Sacroiliac Joint Injections
Sacroiliac joint has regained interest as a primary source
of low back pain in recent years, but confirming the diagnosis
of sacroiliac joint dysfunction and pain remains difficult.
Even though intra-articular sacroiliac joint injections
have provided information on pain referral patterns
(166, 167, 359), detecting symptomatic joints in patients
presenting with low back pain continues to be a difficult
venture (358, 360-371). Thus, provocative injections remain
the only direct method to distinguish symptomatic
from asymptomatic joints. Schwarzer et al (191), utilizing
single local anesthetic block reported a prevalence of 30%
in chronic low back pain population. Maigne et al (192),
utilizing a double block paradigm with comparative local
anesthetics reported prevalence in chronic low back pain
population of 19% with a false-positive rate of 29%.
An Algorithmic Approach
Two suggested algorithms for the application of interventional
techniques in conservative care of chronic spinal pain
describing steps for diagnosis and management are shown
in Fig. 3 and 4. These are only suggested algorithms and
are limited to the management of chronic spinal pain. Further,
clinical evaluation in spite of drawbacks is extremely
important, as is the documentation of indications for interventional
techniques.
The clinical algorithms presented on the following pages
show an effort to blend conscientious, explicit, and judicious
use of the current best evidence in making decisions
about the care of individual patients. When this is combined
with the clinician’s experience and judgment, and
patient preferences, it should result in improved outcomes
and significantly improved quality of care. These guidelines
are intended to establish a boundary of reasonable
care giving latitude to the individual physician.
THERAPEUTIC INTERVENTIONAL
Rationale
TECHNIQUES
The rationale for therapeutic interventional techniques in
the spine is based upon several considerations: the cardinal
source of chronic spinal pain, namely discs and joints,
are accessible to neural blockade; removal or correction
of structural abnormalities of the spine may fail to cure
and may even worsen painful conditions; degenerative processes
of the spine and the origin of spinal pain are complex;
and the effectiveness of a large variety of therapeutic
interventions in managing chronic spinal pain has not been
demonstrated conclusively (27-32, 66-69, 261-291, 421-
456). Tulder et al (421) evaluated conservative treatment
of chronic low back pain and studied the evidence for effectiveness
of numerous conservative modalities used in
managing chronic low back pain, including drug therapy,
manipulation, back schools, electromyographic biofeedback
therapy, exercise therapy, traction and orthoses, behavioral/cognitive/relaxation
therapy, and transcutaneous
electrical nerve stimulation. Overall results were highly
variable for various conservative modalities of treatment
in managing chronic low back pain. They have not studied
either the differences between various types of epidural
steroid injections, or lysis of adhesions. In addition,
they also omitted facet joint injections, facet joint nerve
blocks, and medial branch neurotomy. Similarly, surgical
treatment of lumbar disc prolapse and degenerative lumbar
disc disease was also without conclusive evidence
(290). There are a multitude of interventional techniques
in the management of chronic pain which include not only
neural blockade but also minimally invasive surgical procedures
ranging from peripheral nerve blocks, trigger-point
injections, epidural injections, facet joint injections, sympathetic
blocks, neuroablation techniques, intradiscal thermal
therapy, disc decompression, morphine pump implantation,
and spinal cord stimulation.
In developing these guidelines, we have evaluated the effectiveness
of the most common interventional therapeutic
interventions for chronic pain in general, and specifically
chronic spinal pain. Koes et al (66) concluded that
the methodological quality of clinical trials of the efficacy
of the commonly used interventions in low back pain was
disappointingly low. For these guidelines, a modest approach
including a blend of scientific evidence together
with expertise and consensus was utilized. All the trials
were scored according to the criteria described (45).
Whenever applicable, we used the original scores of pre-
Pain Physician Vol. 4, No. 1, 2001