Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques
were developed to provide recommendations to clinicians in the United States.
Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of
chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists
from academic and clinical practices.
Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing
conclusions and statements about relationships between clinical interventions and outcomes.
Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review,
consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included
the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS)
criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III
(moderate), Level IV (limited), to Level V (indeterminate).
Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography,
whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective
nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence
for diagnostic sacroiliac joint injections is limited.
The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas,
it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence
for medial branch neurotomy is moderate.
The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic
low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar
epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas,
for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid
injections is strong for short-term and moderate for long-term improvement in managing lumbar
nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain
secondary to lumbar post laminectomy syndrome and spinal stenosis.
The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis,
the evidence is strong for short-term relief and moderate for long-term relief.
For sacroiliac intraarticular injections, the evidence is limited. The evidence for radiofrequency
neurotomy for sacroiliac joint pain is limited.
The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic
low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited
for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for
nucleoplasty and for DeKompressor technology.
For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty.
The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for shortterm relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term
relief and moderate for long-term relief.
Conclusion: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic
spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment
recommendations. These guidelines also do not represent a “standard of care.”
Key words: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions,
epidural injections, epidural adhesiolysis, discography, radiofrequency, disc decompression, vertebroplasty, kyphoplasty, spinal cord
stimulation, intrathecal implantable systems
The value of short-term pain relief in predicting the long-term outcome of ‘indirect’ cervical epidural steroid injections