Pain physician
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A 2-year review of literature from October 2004 to December 2006 was completed to update current scientific evidence on diagnostic utility of facet joint injections. Diagnostic injections are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. There is no physical examination technique, laboratory test, or imaging modality that can precisely identify the spinal structure causing pain, distinguish the culprit from a variety of potential targets, and predict response to a therapeutic intervention. Zygapophysial joint injections, commonly called facet injections (intraarticular joint injections and medial branch blocks) are local anesthetic injections of the facet joint or its nerve supply. These are diagnostic procedures used to determine if pain is arising from facet joints, distinguish painful from nonpainful joints and prognosticate response to therapeutic facet joint interventions. Diagnostic injections must meet the cardinal features of a diagnostic test i.e., accuracy, safety, and reproducibility. Accuracy is based on comparison with a "gold standard" to confirm presence or absence of a disease. There is, however, no available gold standard to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. ⋯ The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.
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The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. ⋯ The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.
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Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques used to treat patients with refractory low back pain due to epidural scarring. Standard epidural steroid injections are often ineffective, especially in patients with prior back surgery. Adhesions in the epidural space can prevent the flow of medicine to the target area; lysis of these adhesions can improve the delivery of medication to the affected areas, potentially improving the therapeutic efficacy of the injected medications. ⋯ Percutaneous adhesiolysis and spinal endoscopy may be effective interventions to treat low back and lower extremity pain caused by epidural adhesions.
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Facet joints are considered to be a common source of chronic spinal pain. Facet joint interventions, including intraarticular injections, medial branch nerve blocks, and neurotomy (radiofrequency and cryoneurolysis) are used to manage chronic facet-mediated spinal pain. A systematic review of therapeutic facet interventions published in January 2005, concluded that facet interventions were variably effective for short-term and long-term relief of facet joint pain. ⋯ With intraarticular facet joint injections, the evidence for short- and long-term pain relief is limited for cervical pain and moderate for lumbar pain. For medial branch blocks, the evidence is moderate for short- and long-term pain relief. For medial branch neurotomy, the evidence is moderate for short- and long-term pain relief.
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Review Case Reports
Spinal cord stimulation for refractory angina pectoris and peripheral vascular disease.
Spinal cord stimulation has been used in clinical practice for more than three decades. The primary use of this therapy has been in spine-related disorders. ⋯ Increasingly, interest has piqued in using this mode of treatment for refractory angina and ischemic pain secondary to peripheral vascular disease. In this publication, we review the current literature on these two indications and present case examples of both therapies.