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Letter to the editor: Re: Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34:1066–77. Spine (Phila Pa 1976) 2011; 36:590. [PMID: 21221057 DOI: 10.1097/brs.0b013e31820e44ca] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
BACKGROUND There are limited population-based studies of determinants of physical therapy use for chronic low back pain (LBP) and of the types of treatments received by individuals who see a physical therapist. OBJECTIVE The purposes of this study were: (1) to identify determinants of physical therapy use for chronic LBP, (2) to describe physical therapy treatments for chronic LBP, and (3) to compare use of treatments with current best evidence on care for this condition. DESIGN This study was a cross-sectional, population-based telephone survey of North Carolinians. METHODS Five hundred eighty-eight individuals with chronic LBP who had sought care in the previous year were surveyed on their health and health care use. Bivariate and multivariable analyses were conducted to identify predisposing, enabling, and need characteristics associated with physical therapy use. Descriptive analyses were conducted to determine the use of physical treatments for individuals who saw a physical therapist. Use of treatments was compared with evidence from systematic reviews. RESULTS Of our sample, 29.7% had seen a physical therapist in the previous year, with a mean of 15.6 visits. In multivariable analyses, receiving workers' compensation, seeing physician specialists, and higher Medical Outcomes Study 12-Item Short-Form Health Survey questionnaire (SF-12) physical component scores were positively associated with physical therapy use. Having no health insurance was negatively associated with physical therapy use. Exercise was the most frequent treatment received (75% of sample), and traction was the least frequent treatment received (7%). Some effective treatments were underutilized, whereas some ineffective treatments were overutilized. LIMITATIONS Only one state was examined, and findings were based on patient report. CONCLUSIONS Fewer than one third of individuals with chronic LBP saw a physical therapist. Health-related and non-health-related factors were associated with physical therapy use. Individuals who saw a physical therapist did not always receive evidence-based treatments. There are potential opportunities for improving access to and quality of physical therapy for chronic LBP.
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203
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van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. 12. Pain originating from the lumbar facet joints. Pain Pract 2011; 10:459-69. [PMID: 20667027 DOI: 10.1111/j.1533-2500.2010.00393.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although the existence of a "facet syndrome" had long been questioned, it is now generally accepted as a clinical entity. Depending on the diagnostic criteria, the zygapophysial joints account for between 5% and 15% of cases of chronic, axial low back pain. Most commonly, facetogenic pain is the result of repetitive stress and/or cumulative low-level trauma, leading to inflammation and stretching of the joint capsule. The most frequent complaint is axial low back pain with referred pain perceived in the flank, hip, and thigh. No physical examination findings are pathognomonic for diagnosis. The strongest indicator for lumbar facet pain is pain reduction after anesthetic blocks of the rami mediales (medial branches) of the rami dorsales that innervate the facet joints. Because false-positive and, possibly, false-negative results may occur, results must be interpreted carefully. In patients with injection-confirmed zygapophysial joint pain, procedural interventions can be undertaken in the context of a multidisciplinary, multimodal treatment regimen that includes pharmacotherapy, physical therapy and regular exercise, and, if indicated, psychotherapy. Currently, the "gold standard" for treating facetogenic pain is radiofrequency treatment (1 B+). The evidence supporting intra-articular corticosteroids is limited; hence, this should be reserved for those individuals who do not respond to radiofrequency treatment (2 B±).
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Affiliation(s)
- Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands.
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204
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Erratum to: Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations. PSYCHOLOGICAL INJURY & LAW 2011. [DOI: 10.1007/s12207-011-9101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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205
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Benoist M. The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the "medical" articles in the European Spine Journal, 2010. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:155-162. [PMID: 21221664 PMCID: PMC3030720 DOI: 10.1007/s00586-010-1678-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Indexed: 05/30/2023]
Affiliation(s)
- Michel Benoist
- Département de Rhumatologie, Service de Chirurgie Orthopédique, Hôpital Beaujon, Clichy, France.
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206
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207
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Peterson C, Hodler J. Adverse events from diagnostic and therapeutic joint injections: a literature review. Skeletal Radiol 2011; 40:5-12. [PMID: 19949787 DOI: 10.1007/s00256-009-0839-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 11/02/2009] [Accepted: 11/05/2009] [Indexed: 02/02/2023]
Abstract
This review article classifies the various adverse reactions arising from intra-articular injections by severity, diagnostic category, and whether they are due to corticosteroid, local anesthetic or viscosupplementation injections. Life-threatening and serious adverse events from intra-articular injections are rare and range from local complications to systemic afflictions. Measures to reduce the likelihood of an adverse event occurring are outlined and patients with significant features in their clinical histories, predisposing them to adverse events, are highlighted.
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Affiliation(s)
- Cynthia Peterson
- Radiology, Orthopaedic University Hospital of Balgrist, Forchstrasse 340, 8008, Zürich, Switzerland.
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Ma K, Yiqun M, Wu T, Wang W, Liu X, Huang X, Wang Y. Efficacy of Diclofenac Sodium in Pain Relief after Conventional Radiofrequency Denervation for Chronic Facet Joint Pain: A Double-Blind Randomized Controlled Trial. PAIN MEDICINE 2011; 12:27-35. [DOI: 10.1111/j.1526-4637.2010.00978.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Karaman H, Tufek A, Olmez Kavak G, Baysal Yildirim Z, Temel V, Celik F, Akdemir MS, Kaya S. Effectiveness of nucleoplasty applied for chronic radicular pain. Med Sci Monit 2011. [PMCID: PMC3539605 DOI: 10.12659/msm.881908] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Material/Methods Results Conclusions
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Affiliation(s)
- Haktan Karaman
- Department of Anesthesiology, Pain Management Center, Dicle University, Diyarbakir, Turkey
| | - Adnan Tufek
- Department of Anesthesiology, Dicle University, Diyarbakir, Turkey
| | | | | | - Vildan Temel
- Department of Anesthesiology, State Hospital of Gynecology and Obstetrics, Diyarbakir, Turkey
| | - Feyzi Celik
- Department of Anesthesiology, Dicle University, Diyarbakir, Turkey
| | | | - Sedat Kaya
- Department of Anesthesiology, Diyarbakir Training and Research Hospital, Diyarbakir, Turkey
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210
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Manchikanti L, Atluri S, Datta S. Lumbar Epidural Injections. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00161-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Davies SJ, Hayes C, Quintner JL. System plasticity and integrated care: informed consumers guide clinical reorientation and system reorganization. PAIN MEDICINE 2010; 12:4-8. [PMID: 21143757 DOI: 10.1111/j.1526-4637.2010.01016.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
SETTING Two Australian public hospital multidisciplinary pain centers (MPCs) situated on opposite sides of the country. OBJECTIVE Restructuring our services to become patient-centred and patient-driven by enabling entry to our MPCs through an education portal, inclusive of both knowledge and self-management skills, and to then be free to select particular treatment options on the basis of evidence of known efficacy (risk/benefit). DESIGN Group-based education to inform our patients of the current state of uncertainty that exists in Pain Medicine, both in regard to diagnostic and therapeutic practices. Using an interprofessional team approach, we aimed to present practical and evidence-based advice on techniques of pain self-management and existing traditional medical options. RESULTS Early, resource efficient, group intervention provides many patients with sufficient information to make informed decisions and enables them to partner us in engaging a whole person approach to their care. We have implemented routine comprehensive audits of clinical services to better inform the planning and provision of health care across health services. CONCLUSIONS System plasticity is as important to the process of integrated health care as it is to our understanding of the complexity of the lived experience of pain. Better-informed consumers partnered with responsive health professionals drive the proposed paradigm shift in service delivery. The changes better align the needs of consumers with the ability of health care providers to meet them, thus achieving the twin goals of patient empowerment and system efficiency.
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Affiliation(s)
- Stephanie J Davies
- School of Physiotherapy, Curtin University, Bentley, Western Australia, Australia.
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212
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Young G. Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations. PSYCHOLOGICAL INJURY & LAW 2010. [DOI: 10.1007/s12207-010-9092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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213
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Langevin P, Lowcock J, Weber J, Nolan M, Gross AR, Peloso PM, Roberts J, Graham N, Goldsmith CH, Burnie SJ, Haines T. Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis. J Rheumatol 2010; 38:203-14. [PMID: 21123322 DOI: 10.3899/jrheum.100739] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the effect of intramuscular botulinum toxin type A (BoNT-A) injections on pain, function/disability, global perceived effect, and quality of life (QOL) in adults with neck pain (NP). METHODS We searched Central, Medline, and Embase databases up to June 2010. A minimum of 2 authors independently selected articles, abstracted data, and assessed risk of bias and clinical applicability. We estimated standard mean differences (SMD) with 95% CI, relative risks (RR), and performed metaanalyses (SMD(p)) using a random-effects model for nonheterogeneous data. The approach of the Grading of Recommendations Assessment, Development, and Evaluation working group summarizes the quality of evidence. RESULTS We selected 14 trials. High-quality evidence suggested BoNT-A was no better than saline at 4 weeks [4 trials/183 participants; SMD(p) -0.21 (95% CI -0.50 to 0.07)] and 6 months for chronic NP. Moderate-quality evidence showed a similar effect for subacute/chronic whiplash-associated disorder (WAD) on pain [4 trials/122 participants; SMD(p) -0.21 (95% CI -0.57 to 0.15)], disability, and QOL. Very low-quality evidence indicated BoNT-A combined with exercise and analgesics was not significant for chronic NP reduction at 4 weeks [3 trials/114 participants; SMD(p) -0.08 (95% CI -0.45 to 0.29)] but was at 6 months [2 trials/43 participants; SMD(p) -0.66 (95% CI -1.29 to -0.04)]. CONCLUSION Current evidence does not confirm a clinically or statistically significant benefit of BoNT-A used alone on chronic NP in the short term or on subacute/chronic WAD pain, disability, and QOL. Larger trials, subgroups, and predictors of responses defined a priori (to facilitate selection of patients most likely to benefit) and factorial designs to explore BoNT as an adjunct treatment to physiotherapeutic exercise and analgesics are needed.
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Affiliation(s)
- Pierre Langevin
- Cliniques Physio Interactive, 3520 rue de l'Hêtrière, Local 202, St-Augustin-de-Desmaures, Québec G3A 0B4, Canada.
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A pilot study examining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial. Phys Ther 2010; 90:1717-29. [PMID: 20864600 DOI: 10.2522/ptj.20090260] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Therapeutic selective nerve root blocks (SNRBs) are a common intervention for patients with sciatica. Patients often are referred to physical therapy after SNRBs, although the effectiveness of this intervention sequence has not been investigated. OBJECTIVE This study was a preliminary investigation of the effectiveness of SNRBs, with or without subsequent physical therapy, in people with low back pain and sciatica. DESIGN This investigation was a pilot randomized controlled clinical trial. SETTING The settings were spine specialty and physical therapy clinics. PARTICIPANTS Forty-four participants (64% men; mean age=38.5 years, SD=11.6 years) with low back pain, with clinical and imaging findings consistent with lumbar disk herniation, and scheduled to receive SNRBs participated in the study. They were randomly assigned to receive either 4 weeks of physical therapy (SNRB+PT group) or no physical therapy (SNRB alone [SNRB group]) after the injections. INTERVENTION All participants received at least 1 SNRB; 28 participants (64%) received multiple injections. Participants in the SNRB+PT group attended an average of 6.0 physical therapy sessions over an average of 23.9 days. MEASUREMENTS Outcomes were assessed at baseline, 8 weeks, and 6 months with the Low Back Pain Disability Questionnaire, a numeric pain rating scale, and the Global Rating of Change. RESULTS Significant reductions in pain and disability occurred over time in both groups, with no differences between groups at either follow-up for any outcome. Nine participants (5 in the SNRB group and 4 in the SNRB+PT group) underwent surgery during the follow-up period. LIMITATIONS The limitations of this study were a relatively short-term follow-up period and a small sample size. CONCLUSIONS A physical therapy intervention after SNRBs did not result in additional reductions in pain and disability or perceived improvements in participants with low back pain and sciatica.
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215
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Stout A. Interventions for low back pain: conclusions. Phys Med Rehabil Clin N Am 2010; 21:817. [PMID: 20977963 DOI: 10.1016/j.pmr.2010.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Alison Stout
- Department of Rehabilitation, University of Washington, Seattle, WA, USA.
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216
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Bagnall D. The use of spinal cord stimulation and intrathecal drug delivery in the treatment of low back-related pain. Phys Med Rehabil Clin N Am 2010; 21:851-8. [PMID: 20977968 DOI: 10.1016/j.pmr.2010.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Spinal cord stimulation (SCS) and intrathecal drug delivery (IDD) are forms of neuromodulation, meaning that they are reversible and nondestructive. SCS is generally limited to conditions such as radiculopathy and pain of CNS origin. IDD is primarily effective for nociceptive or mixed pain, and its usage is generally limited to conditions within that realm.
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217
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Friedrich JM, Harrast MA. Lumbar epidural steroid injections: indications, contraindications, risks, and benefits. Curr Sports Med Rep 2010; 9:43-9. [PMID: 20071921 DOI: 10.1249/jsr.0b013e3181caa7fc] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The clinical use of lumbar epidural steroid injections has increased dramatically. Although there are certainly beneficial effects to using epidural steroid injections in a treatment regimen for lumbar radicular pain, there is a lack of well designed, placebo-controlled studies to define conclusively specific indications and techniques for different spinal diagnoses. This article reviews the pathophysiology of lumbar radiculopathy and the use of epidural steroid injections as one treatment option, as well as describes their risks and benefits. Based on current literature, we offer an evidence-based perspective regarding rational use of lumbar epidural steroid injections for certain indications and treatment goals.
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Affiliation(s)
- Jason M Friedrich
- University of Washington, Department of Rehabilitation Medicine, Seattle, WA98104, USA.
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220
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Peloso PMJ, Roberts J, Nolan M, Gross A, Langevin P, Weber J, Goldsmith CH, Haines T, Lowcock J. Botulinum toxin for subacute/chronic neck pain. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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221
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Kelekis AD, Filippiadis DK, Martin JB, Brountzos E. Standards of practice: quality assurance guidelines for percutaneous treatments of intervertebral discs. Cardiovasc Intervent Radiol 2010; 33:909-13. [PMID: 20676639 DOI: 10.1007/s00270-010-9952-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/01/2010] [Indexed: 12/19/2022]
Abstract
Percutaneous treatments are used in the therapy of small- to medium-sized hernias of intervertebral discs to reduce the intradiscal pressure in the nucleus and theoretically create space for the herniated fragment to implode inward, thus reducing pain and improving mobility and quality of life. These techniques involve the percutaneous removal of the nucleus pulposus by using a variety of chemical, thermal, or mechanical techniques and consist of removal of all or part of nucleus pulposus to induce more rapid healing of the abnormal lumbar disc. These guidelines are written to be used in quality improvement programs for assessing fluoroscopy- and/or computed tomography-guided percutaneous intervertebral disc ablative techniques.
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Affiliation(s)
- Alexis D Kelekis
- 2nd Radiology Department, Attikon University Hospital, Haidari, Athens, Greece.
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222
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Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci 2010; 7:124-35. [PMID: 20567613 PMCID: PMC2880841 DOI: 10.7150/ijms.7.124] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 05/26/2010] [Indexed: 02/07/2023] Open
Abstract
STUDY DESIGN A randomized, double-blind, controlled trial. OBJECTIVE To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin. SUMMARY OF BACKGROUND DATA Lumbar facet joints have been shown as the source of chronic pain in 21% to 41% of low back patients with an average prevalence of 31% utilizing controlled comparative local anesthetic blocks. Intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin. METHODS The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids. The inclusion criteria was based upon a positive response to diagnostic controlled, comparative local anesthetic lumbar facet joint blocks.Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. RESULTS Significant improvement with significant pain relief of >or= 50% and functional improvement of >or= 40% were observed in 85% in Group 1, and 90% in Group II, at 2-year follow-up.The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks, requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment. CONCLUSIONS Therapeutic lumbar facet joint nerve blocks, with or without steroids, may provide a management option for chronic function-limiting low back pain of facet joint origin.
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Van Boxem K, Cheng J, Patijn J, van Kleef M, Lataster A, Mekhail N, Van Zundert J. 11. Lumbosacral radicular pain. Pain Pract 2010; 10:339-58. [PMID: 20492580 DOI: 10.1111/j.1533-2500.2010.00370.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms and/or symptoms of decreased function. The annual prevalence in the general population, described as low back pain with leg pain traveling below the knee, varied from 9.9% to 25%, which means that it is presumably the most commonly occurring form of neuropathic pain. The patient's history may give a suggestion of lumbosacral radicular pain. The best known clinical investigation is the straight-leg raising test. Final diagnosis is made based on a combination of clinical examination and potentially additional tests. Medical imaging studies are indicated to exclude possible serious pathologies and to confirm the affected level in patients suffering lumbosacral radicular pain for longer than 3 months. Magnetic resonance imaging is preferred. Selective diagnostic blocks help confirming the affected level. There is controversy concerning the effectiveness of conservative management (physical therapy, exercise) and pharmacological treatment. When conservative treatment fails, in subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation, transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can be considered (2 B+/-), preferentially study-related. In patients with a therapy-resistant radicular pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended (2 A+). This treatment should be performed in specialized centers.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands.
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A Double-Blind, Controlled, Randomized Trial to Evaluate the Efficacy of Botulinum Toxin for the Treatment of Lumbar Myofascial Pain in Humans. Reg Anesth Pain Med 2010; 35:255-60. [DOI: 10.1097/aap.0b013e3181d23241] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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225
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Jamison RN. Unraveling the secrets to chronic pain and disability: more than meets the eye. THE JOURNAL OF PAIN 2010; 11:405-7. [PMID: 20439054 DOI: 10.1016/j.jpain.2010.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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226
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Injection therapy and denervation procedures for chronic low-back pain: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1425-49. [PMID: 20424870 PMCID: PMC2989278 DOI: 10.1007/s00586-010-1411-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 02/24/2010] [Accepted: 04/11/2010] [Indexed: 10/26/2022]
Abstract
Injection therapy and denervation procedures are commonly used in the management of chronic low-back pain (LBP) despite uncertainty regarding their effectiveness and safety. To provide an evaluation of the current evidence associated with the use of these procedures, a systematic review was performed. Existing systematic reviews were screened, and the Cochrane Back Review Group trial register was searched for randomized controlled trials (RCTs) fulfilling the inclusion criteria. Studies were included if they recruited adults with chronic LBP, evaluated the use of injection therapy or denervation procedures and measured at least one clinically relevant outcome (such as pain or functional status). Two review authors independently assessed studies for eligibility and risk of bias (RoB). A meta-analysis was performed with clinically homogeneous studies, and the GRADE approach was used to determine the quality of evidence. In total, 27 RCTs were included, 14 on injection therapy and 13 on denervation procedures. 18 (66%) of the studies were determined to have a low RoB. Because of clinical heterogeneity, only two comparisons could be pooled. Overall, there is only low to very low quality evidence to support the use of injection therapy and denervation procedures over placebo or other treatments for patients with chronic LBP. However, it cannot be ruled out that in carefully selected patients, some injection therapy or denervation procedures may be of benefit.
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Abstract
Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
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Affiliation(s)
- Stephane Genevay
- Division of Rheumatology, University Hospitals of Geneva, Switzerland, Tel: 0041 22 382 36 73, Fax: 0041 22 382 35 35
| | - Steven J Atlas
- General Medicine Division, Massachusetts General Hospital, Boston MA, USA, Tel: 617-724-4736, Fax: 617-724-3544
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Re: Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009;34: 1078-93. Spine (Phila Pa 1976) 2010; 35:841; author reply 841-2. [PMID: 20357643 DOI: 10.1097/brs.0b013e3181d2ad36] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Peterson C, Hodler J. Evidence-based radiology (part 1): Is there sufficient research to support the use of therapeutic injections for the spine and sacroiliac joints? Skeletal Radiol 2010; 39:5-9. [PMID: 19730856 DOI: 10.1007/s00256-009-0783-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 08/14/2009] [Accepted: 08/17/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This review article addresses the best evidence currently available for therapeutic injection therapy for conditions targeting the spine and sacroiliac joints. The article is presented by spinal region. Controversies and areas of interest for further studies are identified. DISCUSSION There is conclusive evidence supporting the effectiveness of the caudal approach for the administration of epidural steroid injections for patients with low back pain from a variety of causes. In general, there is moderate-to-strong evidence supporting the use of transforaminal therapeutic epidural injections for lumbar nerve-root compression and facet injections for joint pain arising from these joints in the cervical, thoracic and lumbar spine, but further subgroup analysis is needed to help predict which specific patients may receive the most benefit from these procedures. CONCLUSION No randomized controlled trials, meta-analyses or systematic reviews addressing the effectiveness of therapeutic sacroiliac joint injections have been found. For some injections, corticosteroids may not provide better outcomes compared to local anesthetic injections alone.
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Affiliation(s)
- Cynthia Peterson
- Radiology, Orthopaedic University Hospital of Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland.
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Herrmann WA, Geertsen MS. Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study. Int J Clin Pract 2009; 63:1613-21. [PMID: 19832818 DOI: 10.1111/j.1742-1241.2009.02187.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIM The efficacy and safety of oral lornoxicam (LNX) as early treatment of acute sciatica/lumbo-sciatica was compared with placebo and diclofenac in a 5-day double-blind, randomised study. METHODS Male or female patients (n = 171) aged 18-70 years with acute sciatica or lumbo-sciatica [acute sciatica defined as typical radiation of pain along the sciatic nerve (including radiating pain below the knee) and worsening of pain as defined by Lasegue's leg-raising test (< 60 degrees ) within 72 h and previous attack ceased > 3 months previously; lumbo-sciatica defined as symptoms of sciatica with concurrent lumbar pain and a predefined minimum pain score]. The dosage of study treatment was 8-24 mg/day LNX, 100-150 mg/day diclofenac or placebo. The primary end-point was the difference in pain intensity difference from baseline to 6 h (PID(0-6 h)) after the first dose of study treatment. Secondary end-points were pain relief, the cumulative sums of pain intensity difference and total pain relief on day 1 and on days 2-4. RESULTS In total, 164 patients completed the study. Significant differences in PID between LNX and placebo were seen in the time interval 3-8 h after the first dose including PID(0-6 h) (p = 0.015). Secondary end-points favoured LNX vs. placebo, but in general were not significantly different. LNX and diclofenac had similar analgesic effect. Incidence and severity of adverse events were comparable for the three treatments; overall tolerability was rated as very good/good by 93% of the patients. CONCLUSION These data indicate that the analgesic efficacy of LNX is superior to placebo and similar to diclofenac in acute sciatica/lumbo-sciatica.
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Debating “Interventions” for Chronic Axial Low Back Pain. PM R 2009; 1:964-72. [DOI: 10.1016/j.pmrj.2009.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 09/22/2009] [Indexed: 11/21/2022]
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Godfrey JR, Dugan SA. Toward optimal health: advances in chronic back pain management for women. J Womens Health (Larchmt) 2009; 18:1533-7. [PMID: 19788369 DOI: 10.1089/jwh.2009.1688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. PAIN MEDICINE 2009; 10:1035-45. [PMID: 19694977 DOI: 10.1111/j.1526-4637.2009.00692.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Confusion persists concerning the nature and efficacy of procedures variously known as facet denervation, lumbar medial branch radiofrequency neurotomy, and radiofrequency neurotomy or denervation for the treatment of back pain. Systematic reviews have not recognized the importance of patient selection and correct surgical technique when appraising the literature. As a result, negative conclusions about procedures have been drawn because lack of efficacy of one procedure has been misattributed to other, cognate, but different procedures. OBJECTIVES To demonstrate how the rationale and efficacy of lumbar medial branch neurotomy depends critically on correct selection of patients and use of surgically correct technique. METHODS A narrative review and description of the available evidence, drawn from the personal libraries of the authors and from the bibliographies of systematic reviews. RESULTS Three studies, commonly accepted as evidence of lack of effectiveness, were not valid tests of lumbar medial branch neurotomy because of errors in selection of patients or errors in surgical technique, or both. Two descriptive studies and three controlled studies that used valid or acceptable techniques consistently showed that lumbar medial branch neurotomy had positive effects on pain and disability. All valid, randomized controlled trials showed medial branch neurotomy to be more effective than sham treatment. DISCUSSION Negative results have been reported only in studies that selected inappropriate patients or used surgically inaccurate techniques. All valid studies showed positive outcomes that cannot be attributed to placebo. Inappropriate conclusions have been drawn by systematic reviews that misrepresent invalid studies as providing evidence against the efficacy of lumbar medial branch neurotomy.
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Affiliation(s)
- Nikolai Bogduk
- University of Newcastle, Newcastle Bone and Joint Institute, Newcastle, Australia.
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Chou R. Same trials, different conclusions: sorting out discrepancies between reviews on interventional procedures of the spine. Spine J 2009; 9:679-89. [PMID: 19540814 DOI: 10.1016/j.spinee.2009.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 04/18/2009] [Accepted: 05/08/2009] [Indexed: 02/03/2023]
Affiliation(s)
- Roger Chou
- Department of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34:1066-77. [PMID: 19363457 DOI: 10.1097/brs.0b013e3181a1390d] [Citation(s) in RCA: 369] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Clinical practice guideline. OBJECTIVE To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain. SUMMARY OF BACKGROUND DATA Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain. METHODS A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. RESULTS Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations. CONCLUSION Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.
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