What is the role of a spinal interventional procedure for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

Pain sensitive spinal structures within the 3 joint complex (composed of the disk and 2 posteriorly situated facet joints) include the nerve roots, dura, posterior longitudinal ligaments, outer annular fibers of the disk, facet joints, joint capsules, and cancellous bone. Intraspinal structures without proven pain innervation include the ligament flavum, inner annulus and nucleus pulposus. Spinal interventional techniques can isolate potential pain generators, and also provide therapeutic relief from pain and associated neurologic symptoms. Identification of a pain–producing structure can be inferred when the patient's characteristic pattern is provoked by radiocontrast agents or saline. Furthermore, diagnostic value can be derived from the patient's response to an injected local anesthetic, and sometimes the use of corticosteroids or neurolysis can provide durable therapeutic value. Safety and accuracy are enhanced when the practitioner performing these procedures is knowledgeableofspinalanatomy,experienced with the use of fluoroscopy, and skilled at steering needles within the soft tissues of the back.

The decision to perform a spinal interventional procedure should be based on sound medical evidence. Evidence-based medicine is a strategic approach to managing cost by managing care. It is the judicious use of the current best evidence for making decisions about the care of individual patients. Therefore, when clinical and research evidence support the benefit of a specific procedure for a particular patient problem, it can be considered and even advocated. If medical evidence suggests that no clear benefit is derived from a procedure for a specific indication, or if the procedure may harm the patient, either directly through adverse events or indirectly by wasting medical resources, then it should be avoided.

A pivotal 2007 evidence-synthesis and review of the literature cites the authors evaluation of the relative strength of the evidence that supports the use of spinal interventional techniques for providing short and long-term relief from chronic spinal pain. Table I outlines their analysis of the benefit from the application of several procedures that are predominantly used for treatment in the lumbar region.

Table 1. Therapeutic Interventional Techniques [15] (Open Table in a new window)

Facet Joint Interventions

Short-term

Long-term

Intra-articular injections

Moderate

 

Medial branch blocks

Strong

Moderate

Radiofrequency

Strong

Moderate to strong

Epidural Steroid Injections

 

 

Interlaminar

Strong

Limited

Caudal

Strong

Moderate

Transforaminal

Strong

Moderate

Adhesiolysis

 

 

Percutaneous

Strong

Strong

Endoscopic

Strong

Moderate

Intradiscal Therapy

 

 

IDET

Strong

Moderate

Nucleoplasty

Limited

Limited

 

When insufficient evidence exists to determine whether the procedure is beneficial, then the operating practitioner can depend on clinical experience and operate within standard of care or conservative guidelines. Manchikanti and colleagues have defined guidelines that classify the strength of experimental evidence that supports decisions as to whether specific interventional pain procedures should be performed. This analysis includes the prevalence of specific spinal pain generators and the efficacy of performing specific procedures for therapeutic or diagnostic purposes. [16]


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