Laxmaiah Manchikanti

Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions

BackgroundFacet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice.MethodsFive hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting.ResultsThe prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49% – 61%), with thoracic spine pain was 42% (95% CI, 30% – 53%), and in with lumbar spine pain was 31% (95% CI, 27% – 36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54% – 72%) in the cervical spine, 55% (95% CI, 39% – 78%) in the thoracic spine, and 27% (95% CI, 22% – 32%) in the lumbar spine.ConclusionThis study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.

Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks.

Study Design A retrospective review. Objectives Evaluation of the prevalence of facet or zygapophysial joint pain in chronic spinal pain of cervical, thoracic, and lumbar origin by using controlled, comparative local anesthetic blocks and evaluation of false-positive rates of single blocks in the diagnosis of chronic spinal pain of facet joint origin. Summary of Background Data Facet or zygapophysial joints are clinically important sources of chronic cervical, thoracic, and lumbar spine pain. The previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, with a prevalence of 15% to 67% variable in lumbar, thoracic, and cervical regions. False-positive rates of single diagnostic blocks also varied from 17% to 63%. Methods Five hundred consecutive patients receiving controlled, comparative local anesthetic blocks of medial branches for the diagnosis of facet or zygapophysial joint pain were included. Patients were investigated with diagnostic blocks using 0.5 mL of 1% lidocaine per nerve. Patients with lidocaine-positive results were further studied using 0.5 mL of 0.25% bupivacaine per nerve on a separate occasion. Medial branch blocks were performed with intermittent fluoroscopic visualization, at 2 levels to block a single joint. A positive response was considered as one with at least 80% pain relief from a block of at least 2 hours duration when lidocaine was used, and at least 3 hours or longer than the duration of relief with lidocaine when bupivacaine was used, and also the ability to perform prior painful movements. Results A total of 438 patients met inclusion criteria. The prevalence of facet joint pain was 39% in the cervical spine [95% confidence interval (CI), 32%-45%]; 34% (95% CI, 22%-47%) in the thoracic pain; and 27% (95% CI, 22%-33%) in the lumbar spine. The false-positive rate with a single block in the cervical region was 45%, in the thoracic region was 42%, and in the lumbar region 45%. Conclusions This retrospective review once again confirmed the significant prevalence of facet joint pain in chronic spinal pain.

Cervical Medial Branch Blocks for Chronic Cervical Facet Joint Pain : A Randomized, Double-Blind, Controlled Trial With One-Year Follow-up

Study Design. A double-blind, randomized, controlled trial. Objective. To determine the clinical effectiveness of therapeutic local anesthetic cervical medial branch blocks with or without steroid in managing chronic neck pain of facet joint origin. Summary of Background Data. The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Intra-articular injections, medial branch nerve blocks, and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin. Methods. A total of 120 patients were included, with 60 patients in each of the local anesthetic and steroid groups. All the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, and the inclusion criteria. Group I consisted of medial branch blocks with bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Numerical pain scores, Neck Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months, and 12 months. Results. Significant pain relief (≥50%) and functional status improvement was observed at 3 months, 6 months, and 12 months in over 83% of patients. The average number of treatments for 1 year was 3.5 ± 1.0 in the nonsteroid group and 3.4 ± 0.9 in the steroid group. Duration of average pain relief with each procedure was 14 ± 6.9 weeks in the nonsteroid group, and it was 16 ± 7.9 weeks in the steroid group. Significant relief and functional improvement was reported for 46 to 48 weeks in a year. Conclusion. Therapeutic cervical medial branch nerve blocks, with or without steroids, may provide effective management for chronic neck pain of facet joint origin.

Epidemiology of low back pain in adults.

Low back pain affects many individuals. It has profound effects on well‐being and is often the cause of significant physical and psychological health impairments. Low back pain also affects work performance and social responsibilities, such as family life, and is increasingly a major factor in escalating health‐care costs. A global review of the prevalence of low back pain in the adult general population has shown its point prevalence to be approximately 12%, with a one‐month prevalence of 23%, a one‐year prevalence of 38%, and a lifetime prevalence of approximately 40%. Furthermore, as the population ages over the coming decades, the number of individuals with low back pain is likely to increase substantially. This comprehensive review is undertaken to assess the increasing prevalence of low back pain and the influence of comorbid factors, along with escalating costs.

Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: a prospective evaluation

BackgroundFluoroscopic guidance is frequently utilized in interventional pain management. The major purpose of fluoroscopy is correct needle placement to ensure target specificity and accurate delivery of the injectate. Radiation exposure may be associated with risks to physician, patient and personnel. While there have been many studies evaluating the risk of radiation exposure and techniques to reduce this risk in the upper part of the body, the literature is scant in evaluating the risk of radiation exposure in the lower part of the body.MethodsRadiation exposure risk to the physician was evaluated in 1156 patients undergoing interventional procedures under fluoroscopy by 3 physicians. Monitoring of scattered radiation exposure in the upper and lower body, inside and outside the lead apron was carried out.ResultsThe average exposure per procedure was 12.0 ± 9.8 seconds, 9.0 ± 0.37 seconds, and 7.5 ± 1.27 seconds in Groups I, II, and III respectively. Scatter radiation exposure ranged from a low of 3.7 ± 0.29 seconds for caudal/interlaminar epidurals to 61.0 ± 9.0 seconds for discography. Inside the apron, over the thyroid collar on the neck, the scatter radiation exposure was 68 mREM in Group I consisting of 201 patients who had a total of 330 procedures with an average of 0.2060 mREM per procedure and 25 mREM in Group II consisting of 446 patients who had a total of 662 procedures with average of 0.0378 mREM per procedure. The scatter radiation exposure was 0 mREM in Group III consisting of 509 patients who had a total 827 procedures. Increased levels of exposures were observed in Groups I and II compared to Group III, and Group I compared to Group II.Groin exposure showed 0 mREM exposure in Groups I and II and 15 mREM in Group III. Scatter radiation exposure for groin outside the apron in Group I was 1260 mREM and per procedure was 3.8182 mREM. In Group II the scatter radiation exposure was 400 mREM and with 0.6042 mREM per procedure. In Group III the scatter radiation exposure was 1152 mREM with 1.3930 mREM per procedure.ConclusionResults of this study showed that scatter radiation exposure to both the upper and lower parts of the physicians body is present. Protection was offered by traditional measures to the upper body only.

Assessment of age-related acid aspiration risk factors in pediatric, adult, and geriatric patients.

One hundred inpatients scheduled for elective surgery were studied to determine the age-related risk of pulmonary aspiration as indicated by gastric acidity arid volume. Twenty-five patients from 6 months to 22 years old were included in the pediatric age group, 50 patients from 18 to 64 years old were included in the adult age group, and 25 patients older than 65 years old were included in the geriatric group. Mean gastric pH was 1.99, 2.40, arid 3.32 in the pediatric, adult, and geriatric age groups, respectively; the differences between the three groups were statistically significant. The proportions of patients with pH ≤ 2.50 were also significantly different among three groups: 92%, 76%, and 60% in the pediatric, adult, arid geriatric age groups, respectively. Mean gastric volumes were 0.49, 0.37, and 0.24 ml/kg arid proportions of patients with volumes ≧0.40 ml/kg were 60, 32, arid 12% in pediatric, adult, arid geriatric patients, respectively. Gastric contents with both pH ≤ 2.5 and volume ≥ 0.4 ml/kg were seen in 60, 28, and 12% in the three respective groups. Risk of acid aspiration pneumonitis theoretically is present in all age groups, with children being at greatest risk and geriatric patients with least risk. We have also noted a correlation between age and gastric contents because gastric acidity and volume both decreased as age increased. Increasing length of fasting period increased gastric acidity without significant effect on volume.

A Randomized, Controlled, Double-Blind Trial of Fluoroscopic Caudal Epidural Injections in the Treatment of Lumbar Disc Herniation and Radiculitis

Study Design. A randomized, controlled, double-blind trial. Objective. To assess the effectiveness of fluoroscopically directed caudal epidural injections in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis with local anesthetic with or without steroids. Summary of Background Data. The available literature on the effectiveness of epidural injections in managing chronic low back pain secondary to disc herniation is highly variable. Methods. One hundred twenty patients suffering with low back and lower extremity pain with disc herniation and radiculitis were randomized to one of the two groups: group I received caudal epidural injections with an injection of local anesthetic, lidocaine 0.5%, 10 mL; group II patients received caudal epidural injections with 0.5% lidocaine, 9 mL, mixed with 1 mL of steroid. The Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake were utilized with assessment at 3, 6, and 12 months posttreatment. Results. The percentage of patients with significant pain relief of 50% or greater and/or improvement in functional status with 50% or more reduction in ODI scores was seen in 70% and 67% in group I and 77% and 75% in group II with average procedures per year of 3.8 ± 1.4 in group I and 3.6 + 1.1 in group II. However, the relief with first and second procedures was significantly higher in the steroid group. The number of injections performed was also higher in local anesthetic group even though overall relief was without any significant difference among the groups. There was no difference among the patients receiving steroids. Conclusion. Caudal epidural injection with local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis. The present evidence illustrates potential superiority of steroids compared with local anesthetic at 1-year follow-up.

Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008.

Study Design. Analysis of the growth, utilization trends, and Medicare expenditures of spinal interventional pain management techniques from 2000 through 2008. Objective. To evaluate the use of epidural steroid injections, facet joint interventions, and sacroiliac joint interventions, and to analyze the trends of Medicare utilization and expenditures in multiple settings—namely, hospital outpatient departments, ambulatory surgery centers, and physician offices. Summary of Background Data. There has been an explosive growth of many invasive and noninvasive modalities designed to manage chronic spinal pain. Commonly used interventional techniques include epidural steroid injections, facet joint interventions, and sacroiliac joint interventions. However, their effectiveness and the appropriateness of their application continue to be debated. Methods. The present article provides an analysis of the growth of spinal interventional techniques, as described earlier, for managing the chronic spinal pain of Medicare beneficiaries from 2000 through 2008. The standard 5% national sample of the Centers for Medicare and Medicaid Services carrier claims that record data from 2000 through 2008 were utilized. Current procedural terminology codes from 2000 through 2008 were used to identify the number of procedures performed each year, as well as trends and expenditures. Results. Medicare recipients receiving spinal interventional techniques increased 107.8% from 2000 through 2008, with an annual average increase of 9.6%, whereas spinal interventional techniques increased 186.8%, an annual average increase of 14.1% per 100,000 beneficiaries. Conclusion. The study suggests explosive increases in spinal interventional techniques from 2000 to 2008, with some slowing of growth in later years.

Fluoroscopic caudal epidural injections with or without steroids in managing pain of lumbar spinal stenosis: one-year results of randomized, double-blind, active-controlled trial.

Study Design A randomized, double-blind, active-controlled trial. Objective To evaluate the effectiveness of caudal epidural injections with or without steroids in providing effective and long-lasting pain relief in the management of chronic low back pain related to lumbar spinal stenosis. Summary of Background Data Multiple interventions including surgery and interventional techniques such as epidural injections and adhesiolysis are commonly performed in managing pain related to spinal stenosis. There is continuing debate on the effectiveness of all interventions, and a paucity of literature regarding effectiveness. Methods One-hundred participants were randomly assigned to 1 of the 2 groups, with Group I participants receiving caudal epidural injections of local anesthetic (lidocaine 0.5%), whereas Group II participants received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid (nonparticulate Celestone). Outcomes Assessment Multiple outcome measures were used, including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months posttreatment. Significant pain relief and improvement in disability were defined as 50% or more. Results Overall, significant pain relief and functional status improvement (≥50%) were demonstrated in 48% in Group I and 46% in Group II. However, significant pain relief and functional status improvement were seen in 60% of the participants in both groups in the successful category when the participants were separated into successful and failed categories. The overall number of procedures was 3.1±1.3 or 3.6±1.1 in the successful category in Group I, with overall 2.9±1.4 or 3.5±1.2 in the successful category in Group II. Conclusion Caudal epidural injections of local anesthetic with or without steroids may be an effective treatment for a select group of patients with chronic function-limiting low back and lower extremity pain secondary to spinal stenosis.

Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data

BackgroundThe Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006.The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing spinal pain.MethodsThis analysis was performed to determine trends of frequency and cost of facet jointInterventions in managing spinal pain, utilizing the annual 5% national sample of the Centers forMedicare and Medicaid Services (CMS) for 1997, 2002, and 2006.Outcome measures included overall characteristics of Medicare beneficiaries receiving facet joint interventions, utilization of facet joint interventions by place of service, by specialty, reimbursement characteristics, and other variables.ResultsFrom 1997 to 2006, the number of patients receiving facet joint interventions per 100,000Medicare population increased 386%, facet joint visits increased 446%, and facet joint interventions increased 543%. The increases were higher in patients aged less than 65 years compared to those 65 or older with patients increasing 504% vs. 355%, visits increasing 587% vs. 404%, and services increasing 683% vs. 498%.Total expenditures for facet joint interventions in the Medicare population increased from over