Interventional Techniques In Chronic Spinal Pain Part II: Guidance And Recommendations

The evidence for accuracy of diagnostic selective nerve root blocks is limited in the lumbar spine in patients with an equivocal diagnosis and involvement of multiple levels. ()

Diagnostic selective nerve root blocks are recommended in the lumbar spine in select patients with an equivocal diagnosis and involvement of multiple levels.

The evidence for diagnostic accuracy for lumbar provocation discography is fair and the evidence for lumbar functional anesthetic discography is limited.

Lumbar provocation discography is recommended with appropriate indications in patients with low back pain to prove a diagnostic hypothesis of discogenic pain specifically after exclusion of other sources of lumbar pain.

The evidence for diagnostic lumbar facet joint nerve blocks is good with 75% to 100% pain relief as the criterion standard with controlled local anesthetic or placebo blocks.

Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain.

The evidence for diagnostic intraarticular sacroiliac joint injections is good with 75% to 100% pain relief as the criterion standard with controlled local anesthetic or placebo blocks, and fair due to the limitation of the number of studies with 50% to 74% relief with a dual block.

Controlled sacroiliac joint blocks with placebo or controlled comparative local anesthetic blocks are recommended when indications are satisfied with suspicion of sacroiliac joint pain.

The evidence for caudal epidural, interlaminar epidural, and transforaminal epidural injections is good in managing disc herniation or radiculitis; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal and lumbar interlaminar epidural injections, and limited with transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections.

The recommendation for epidural injections for disc herniation is that one of the 3 approaches may be used; for spinal stenosis any of the 3 approaches are recommended; whereas for axial or discogenic pain, either lumbar interlaminar or caudal epidural injections are recommended. However for transforaminal the evidence is limited for axial or discogenic pain and post surgery syndrome.

The evidence for lumbar conventional radiofrequency neurotomy is good, limited for pulsed radiofrequency neurotomy, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections.

Among the therapeutic facet joint interventions either conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks are recommended after the appropriate diagnosis with controlled diagnostic lumbar facet joint blocks.

The evidence for sacroiliac cooled radiofrequency neurotomy is fair; limited for intraarticular steroid injections; limited for periarticular injections with steroids or botulinum toxin; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy.

Due to emerging evidence for intraarticular injections, they are recommended in select cases with or without periarticular injections. Cooled radiofrequency neurotomy is recommended after appropriate diagnosis confirmed by diagnostic sacroiliac joint injections.

The evidence for lumbar epidural adhesiolysis in managing chronic low back and leg pain secondary to post lumbar surgery syndrome is fair to good and spinal stenosis is fair.

The evidence for IDET and biaculoplasty is limited to fair and is limited for discTRODE.

The evidence for various modes of percutaneous disc decompression is limited to fair for nucleoplasty, and limited for APLD, percutaneous lumbar disc decompression, and decompressor.

The CMS has issued a noncoverage decision for nucleoplasty.