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

Publication Date: November 1, 2013
Last Updated: March 14, 2022

Recommendations

Management of Low Back Pain

Diagnostic Selective Nerve Root Blocks

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

The evidence for diagnostic accuracy for lumbar provocation discography is fair and the evidence for lumbar functional anesthetic discography is limited.
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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.
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Diagnostic Lumbar Facet Joint Nerve Blocks

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

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

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.
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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.
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Therapeutic Lumbar Facet Joint Interventions

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.
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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.
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Therapeutic Sacroiliac Joint Interventions

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.
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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.
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Percutaneous Adhesiolysis

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.
• Percutaneous adhesiolysis is recommended after failure of conservative management and fluoroscopically directed epidural injections.
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Thermal Annular Procedures

The evidence for IDET and biaculoplasty is limited to fair and is limited for discTRODE.
• IDET and biaculoplasty may be performed in a select group of patients with discogenic pain nonresponsive to conservative modalities including epidural injections.
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Percutaneous Disc Decompression

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.
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The CMS has issued a noncoverage decision for nucleoplasty.
• APLD and percutaneous lumbar disc decompression and nucleoplasty are recommended in select cases.
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Management of Neck Pain

Cervical Provocation Discography

The evidence for the diagnostic accuracy of cervical discography is limited.
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Cervical discography is indicated to test the diagnostic hypothesis of discogenic pain of the cervical spine in individuals who have been properly selected and screened to eliminate other sources of cervical pain.
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Diagnostic Cervical Facet Joint Nerve Blocks

The evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with placebo or local anesthetic controlled diagnostic blocks. ()
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Diagnostic cervical facet joint nerve blocks are recommended for the diagnosis of cervical facet joint pain.
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Therapeutic Cervical Interlaminar Epidural Injections

The evidence is good for cervical disc herniation or radiculitis; whereas, it is fair for axial or discogenic pain, pain of spinal stenosis, and pain of post cervical surgery syndrome. ()
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Cervical interlaminar epidural injections are recommended for patients with chronic neck and upper extremity pain secondary to disc herniation, spinal stenosis, and post cervical surgery syndrome.
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Therapeutic Cervical Facet Joint Interventions

The evidence is fair for cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections.
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Conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks are recommended in managing chronic neck pain after the appropriate diagnosis from controlled diagnostic blocks.
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Management Of Thoracic Pain

Thoracic Provocation Discography

The evidence for thoracic discography is limited. Thoracic discography is recommended to decide if an intervertebral disc is painful or not in rare circumstances.
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Diagnostic Thoracic Facet or Zygapophysial Joint Nerve Blocks

The evidence for diagnostic accuracy of thoracic facet joint nerve blocks is good with a criterion standard of at least 75% pain relief with placebo or local anesthetic controlled diagnostic blocks.
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The diagnostic thoracic facet or zygapophysial joint nerve blocks are recommended in the diagnosis of chronic thoracic pain.
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Thoracic Epidural Injections

The evidence for thoracic epidural injection in treating chronic thoracic pain is fair.
• Thoracic epidural injections are recommended for thoracic discogenic, disc-related, post surgery syndrome, or spinal stenosis pain.
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Therapeutic Thoracic Facet or Zygapophysial Joint Nerve Blocks

The evidence is fair for therapeutic thoracic facet or zygapophysial joint nerve blocks, limited for radiofrequency neurotomy, and none for thoracic intraarticular injections.
• Therapeutic thoracic facet or zygapophysial joint nerve blocks are recommended.
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However, radiofrequency neurotomy and conventional radiofrequency neurotomy may be performed based on emerging evidence.
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Implantables

Spinal Cord Stimulation

The evidence for SCS is fair in managing patients with FBBS.
• Spinal cord stimulation is indicated in chronic low back pain with lower extremity pain secondary to FBBS, after exhausting multiple conservative and interventional modalities.
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Implantable Intrathecal Drug Administration Systems

The evidence for intrathecal infusion systems is limited in managing chronic noncancer pain. • The recommendations for intrathecal infusion pumps include recalcitrant chronic noncancer pain.
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Antithrombotic and Antiplatelet Therapy

Nonsteroidal anti-inflammatory agents including low dose aspirin do not increase the risk of spinal epidural hematoma and are not a contraindication for interventional techniques.
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However, high dose aspirin and combination of multiple drugs should be taken into consideration and may or may not be discontinued based on clinical judgment of individual risk and benefits assessment. In this regard, the simultaneous use of multiple agents that possess anticoagulant properties (e.g. NSAIDs or aspirin along with SSRIs, fish oil, etc.) will increase the risk of morbidity and/or mortality.
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Platelet aggregation inhibitors including ticlopidine (Ticlid), clopidogrel (Plavix), and prasugrel (Effient) may be continued or discontinued prior to interventional techniques. (F)
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Based on patient factors and managing cardiologist’s opinion, if a decision is made to discontinue, the current recommendations are that they may be discontinued for 7 days with clopidogrel and prasugrel and/or 10 to 15 days with ticlopidine. (F)
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There is also emerging evidence that discontinuation of 3 days may be effective. (L)
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If a clinician chooses to discontinue, they may be discontinued for 7 days. (L)
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Warfarin may be continued or discontinued based on INR achieved during therapy. (G)
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For high risk interventional techniques including interlaminar epidural injections, percutaneous adhesiolysis, disc decompression, sympathetic blocks, and placement of implantables, warfarin must be discontinued for an appropriate period of time and INR of 1.4 or less must be achieved. (G)
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For intermediate risk procedures such as caudal epidural injection, paravertebral interventional techniques, and peripheral joint injections, warfarin must be continued for an appropriate period of time and an INR of 2 or less may be considered. (L)
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Unfractionated heparin or LMWH may be discontinued approximately 12 hours prior to providing interventional techniques. (L)
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Dabigatran (Pradaxa) may be stopped 2 to 4 days for major interventional techniques with high risk of bleeding in patients with creatinine clearance greater than 50 mL per minute. For low risk or paravertebral interventional techniques and caudal, it may be stopped for one day in patients with normal renal function. May be stopped at least 4 to 5 days for those with creatinine less than 50 mL per minute. (L)
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Rivaroxaban (Xarelto) may be stopped for one day or longer. (L)
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Recommendation Grading

Overview

Title

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

Authoring Organization

Publication Month/Year

November 1, 2013

Last Updated Month/Year

September 13, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain.

Target Patient Population

Patient with chronic spinal pain

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospice, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D059350 - Chronic Pain, D013116 - Spinal Cord, D062187 - Spinal Cord Stimulation

Keywords

spinal cord injury, interventional devices, chronic pain

Source Citation

Pain Physician: April 2013; 16:S49-S283

Methodology

Number of Source Documents
2424
Literature Search Start Date
May 1, 2013
Literature Search End Date
April 1, 2014