Audit of Conservative Management of Chronic Low Back Pain in a Secondary Care Setting – Part I: Facet Joint and Sacroiliac Joint Interventions

Comparative Efficacy of Fluoroscopy-guided Sacroiliac Joint Block versus Conservative Management in Sacroiliitis: A Prospective Cohort Study

Introduction

Dysfunction of the sacroiliac joint is a frequently overlooked etiology for lumbosacral and gluteal pain. This study compares the efficacy of fluoroscopy-guided sacroiliac joint (SIJ) blocks versus conservative management in patients with sacroiliitis.

Materials and Methods

A prospective cohort study was done involving 88 patients diagnosed with sacroiliitis. Group I (n = 48) received conservative management, while Group II (n = 40) underwent fluoroscopy-guided SIJ blocks. Outcomes were assessed using Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire at baseline and 6 months.

Results

Significant progress was observed in both groups, but Group II demonstrated superior outcomes. The mean VAS reduction was greater in Group II (5.3 points) compared to Group I (3.1 points). Similarly, functional improvement measured by ODI was higher in Group II (55%) than Group I (39.9%). The EQ-5D-5L index value increased more substantially in Group II (0.42-0.79) than in Group I (0.41-0.67), with statistically significant differences between groups (P = 4.51 × 10-8).

Conclusion

Fluoroscopy-guided SIJ blocks provide significantly better pain relief, functional improvement, and life quality enhancement as compared to conservative management in patients diagnosed with sacroiliitis. This intervention should be considered for patients with inadequate response to conservative treatment.

Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review

BACKGROUND

Low back pain is a significant spinal disorder that affects much of the population at some point during their lives.

OBJECTIVE

While proper diagnosis is key, diagnosing the underlying cause of low back pain may often be unclear.

METHOD

In this review article, we discuss lumbar instability as an etiology of low back pain and its treatment by prolotherapy.

RESULTS

Spinal ligaments may be an underlying culprit in the development of lumbar instability with resultant low back pain and associated disorders.

CONCLUSION

In these cases, adequate treatment consisting of non-biologic prolotherapy or cellular prolotherapy, including platelet rich plasma (PRP), can be beneficial in restoring spinal stability and resolving chronic low back pain.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

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

Objective

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

Design

Comprehensive systematic review.

Methods

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

Outcome Measures

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

Results

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

Conclusions

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

Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures

PURPOSE

To evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain.

METHODS

This prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment.

RESULTS

One hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures.

CONCLUSION

Lumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.

Surgical versus injection treatment for injection-confirmed chronic sacroiliac joint pain

Study design: Systematic review.

Study rationale: Chronic sacroiliac joint pain (CSJP) is a common clinical entity with highly controversial treatment options. A recent systematic review compared surgery with denervation, but the current systematic review compares outcomes of surgical intervention with therapeutic injection for the treatment of CSJP and serves as the next step for evaluating current evidence on the comparative effectiveness of treatments for non-traumatic sacroiliac joint pain.

Objective or clinical question: In adult patients with injection-confirmed CSJP, does surgical treatment lead to better outcomes and fewer complications than injection therapy?

Methods: A systematic review of the English-language literature was undertaken for articles published between 1970 and June 2012. Electronic databases and reference lists of key articles were searched to identify studies evaluating surgery or injection treatment for injection-confirmed CSJP. Studies involving traumatic onset or non-injection–confirmed CSJP were excluded. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, development and evaluation (GRADE) system, and disagreements were resolved by consensus.

Results: We identified twelve articles (seven surgical and five injection treatment) meeting our inclusion criteria. Regardless of the type of treatment, most studies reported over 40% improvement in pain as measured by Visual Analog Scale or Numeric rating Scale score. Regardless of the type of treatment, most studies reported over 20% improvement in functionality. Most complications were reported in the surgical studies.

Conclusion: Surgical fusion and therapeutic injections can likely provide pain relief, improve quality of life, and improve work status. The comparative effectiveness of these interventions cannot be evaluated with the current literature.

A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain

OBJECTIVES

Controversy exists regarding the efficacy of ligament prolotherapy in alleviating sacroiliac joint pain. The inconsistent success rates reported in previous studies may be attributed to variability in patient selection and techniques between studies. It was hypothesized that intra-articular prolotherapy for patients with a positive response to diagnostic block may mitigate the drawbacks of ligament prolotherapy. The purpose of this study was to evaluate the efficacy and long-term effectiveness of intra-articular prolotherapy in relieving sacroiliac joint pain, compared with intra-articular steroid injection.

DESIGN

This was a prospective, randomized, controlled trial.

SETTINGS/LOCATION

The study was conducted at an outpatient pain medicine clinic at Chonnam National University Hospital in Gwang-ju, Korea.

SUBJECTS

The study included patients with sacroiliac joint pain, confirmed by ≥50% improvement in response to local anesthetic block, lasting 3 months or longer, and who failed medical treatment.

INTERVENTIONS

The treatment involved intra-articular dextrose water prolotherapy or triamcinolone acetonide injection using fluoroscopic guidance, with a biweekly schedule and maximum of three injections.

OUTCOME MEASURES

Pain and disability scores were assessed at baseline, 2 weeks, and monthly after completion of treatment.

RESULTS

The numbers of recruited patients were 23 and 25 for the prolotherapy and steroid groups, respectively. The pain and disability scores were significantly improved from baseline in both groups at the 2-week follow-up, with no significant difference between them. The cumulative incidence of ≥50% pain relief at 15 months was 58.7% (95% confidence interval [CI] 37.9%-79.5%) in the prolotherapy group and 10.2% (95% CI 6.7%-27.1%) in the steroid group, as determined by Kaplan-Meier analysis; there was a statistically significant difference between the groups (log-rank p < 0.005).

CONCLUSIONS

Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. Further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol.

The diagnosis and management of common non-specific back pain - a clinical review

The assessment and management of common non-specific back pain that is associated with considerable personal morbidity and cost to society is reviewed and set in a bio-psycho-social context.

The therapeutic efficacy of sacroiliac joint blocks with triamcinolone acetonide in the treatment of sacroiliac joint dysfunction without spondyloarthropathy

STUDY DESIGN

Prospective case series.

OBJECTIVE

The study aimed to investigate the therapeutic efficacy of sacroiliac joint (SIJ) blocks with triamcinolone acetonide in patients with SIJ pain without spondyloarthropathy.

SUMMARY OF BACKGROUND DATA

Numerous studies have demonstrated that SIJ blocks with corticosteroid/anesthetic provide long-term pain relief in seronegative spondyloarthropathy. However, only one report on SIJ dysfunction patients without spondyloarthropathy shows promising results.

METHODS

We conducted a prospective observational study of patients at a University Spine Center from March 2005 to May 2006. The above mentioned SIJ blocks were performed in 150 patients, and dual SIJ blocks confirmed SIJ pain in 39 patients (26%).

RESULTS

Twenty-six patients (66.7%) experienced significant pain reduction for more than 6 weeks; the overall mean duration of pain reduction in these responders was 36.8 +/- 9.9 weeks. SIJ blocks were ineffective in 13 patients (33.3%); the mean duration of pain reduction in these patients was 4.4 +/- 1.8 weeks. Univariate analysis revealed that treatment failure was significantly associated with a history of lumbar/lumbosacral fusion (P = 0.03).

CONCLUSION

SIJ blocks with triamcinolone acetonide are beneficial for some patients with SIJ pain without spondyloarthropathy. The SIJ blocks showed a long-lasting efficacy in two-thirds of the patients; however, the duration of its efficacy was shorter in patients with a history of lumbar/lumbosacral fusion. These findings suggest the need for further studies.

Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment

The sacroiliac joint is an underappreciated cause of low back and buttock pain. It is thought to cause at least 15% of low back pain. It is more common in the presence of trauma, pregnancy, or in certain athletes. The pelvic anatomy is complex, with the joint space being variable and irregular. The joint transmits vertical forces from the spine to the lower extremities and has a role in lumbopelvic dynamic motion. History and physical examination findings can be helpful in screening for sacroiliac joint pain, but individual provocative maneuvers have unproven validity. Fluoroscopically guided injections into the joint have been found to be helpful for diagnostic and therapeutic purposes. Conservative treatment, which also can include joint mobilization, antiinflammatory medicines, and sacroiliac joint belts, generally is effective. Surgical arthrodesis should be considered a procedure of last resort.