Edgar Ross MD
Back pain is the most common cause of chronic pain in the United States, yet the most effective treatment of low back pain remains elusive. There is no general consensus on best practices for either diagnosis or treatment of back pain. Because of the high incidence in the work force, disability from back pain is very high and costly. Because of the lack of consensus, the cost of diagnosis and treatment remain very high. The high costs of back pain come not just from the pain but also from the disability secondary to the pain, needless diagnostic tests, and ineffective treatment.
Most of the diagnostic testing that is ordered is not needed. Even the most sophisticated diagnostic testing often cannot objectively validate most of the spinal pain that is reported by patients. Numerous guidelines have been published that attempt to clarify this problem. For example, the nationally recognized guidelines published by the Agency for Healthcare Research and Quality can assist clinicians in deciding which diagnostic tests are appropriate and which treatment approaches are effective. Diagnosing and treating low back pain efficiently, avoiding ineffective procedures, and minimizing the harmful effects of a sedentary lifestyle can have a substantial impact on patient suffering, lost income, disability, and health care costs.
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Back pain is the second leading reason for physician office visits in the United States today. The prevalence of spinal pain in the United States has been reported as up to 37%, and the peak incidence is found between 45 to 60 years of age. This incidence translates into the fact that 80% of all Americans will seek care at some point in their lives for acute back pain. Notably the age range of 45 to 60 is usually the most productive time period for most workers. This observation is most likely the reason that back pain is responsible for more than one-third of the total disability payments in the United States. The indirect costs of lost earnings are even higher.
Natural History of Back Pain
Table 13-1 presents the duration of symptoms and the prognosis for acute, subacute, and chronic pain. In general, treatment in the good prognosis groups should be supportive with avoidance of interventional therapies (such as surgical procedures), which could carry more risk than benefit. On the other hand, patients who are not improving as expected should be reexamined, and further diagnostic testing performed to rule out potentially serious occult conditions. With persistent pain, referrals to chronic pain programs should be made promptly. This proactive approach can be helpful in avoiding the consequences of deconditioning and resultant long-term disability.
The following classification categories are based on the presenting symptoms and are very useful for determining prognosis, planning treatment, and diagnostic testing:
Table 13-1. Duration of Symptoms and Prognosis of Acute, Subacute, and Chronic Pain.
The most common diagnosis is nonspecific spinal pain. Although many theories have been suggested to explain this type of pain, none have been conclusively validated. Despite the many diseases that are known to be associated with back pain, the pathophysiology of the most common diagnostic group remains unknown. Nonspecific spinal pain is generally thought to be secondary to musculoskeletal dysfunction, but no consistent and specific finding has ever been found. For the rest of the potential diagnoses, the pathophysiology of back pain depends on the disease process underlying the patient's complaints.
Radicular back pain is usually associated with spinal nerve irritation or compression. Table 13-3 outlines the differential diagnosis of back pain and includes potentially serious spinal conditions-the last classification.
Etiology of Benign Back Pain
At present, the evolution of chronic back pain is thought to begin with end plate damage. The disk receives most of its blood supply from the end plate. Disk degeneration begins with this compromise in blood supply first near the end plate and later in the disk nucleus. In support of this mechanism, arteriosclerosis of the vascular tree leading to lumbar segmental arteries is also associated with increased incidence of disk degeneration and back pain complaints. Considerable evidence now suggests that the healthy lumbar disk is primarily innervated in the annulus and to a limited extent in the pulposis. With degenerative changes, innervation progresses and extends deeper into the nucleus pulposus. Inflammatory mediators have also been identified inside the disk during discography in patients who report concordant pain. Along with the pathologic process described, the loss of disk height has important consequences on spinal dynamics. The vertebral body has a three-joint articulating relationship with its adjoining vertebral bodies. The change in dynamics, and structural relationships stresses the synovial facet joints, which leads to osteoarthritis, with the potential of subluxation, segmental instability, and chronic pain. The paradoxical reports of patients with advanced radiographic degenerative findings and little discomfort could be explained by the conclusion of this process through complete loss of mobility in the spinal segment by autofusion. Genetics is also thought to play a role in the susceptibility to back pain. A particular person's susceptibility is determined by the reaction to an injury as initiated by inflammatory mediators that are released and expressed along with differences in the underlying structural composition of the disk. Genetics appear to be significant early in a person's life; other risk factors, such as injury, lifestyle and nutrition, have a more important role after the second decade.
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Mahmud MA et al. Clinical management and the duration of disability for work-related low back pain. J Occup Environ Med. 2000;42:1178.
Table 13-2. Back Pain Classification Based on Pathophysiology.
Table 13-3. Overview of Differential Diagnosis of Back Pain.
Table 13-4. A Methodical Approach to Rule Out Serious Causes (Red Flags) of Back Pain.
The evaluation of a patient with back pain is often not a straightforward process. The true cause of back pain is found in only 20% of cases. Despite this, the need to rule out serious illnesses that present as back pain requires a thorough evaluation of the patient in a methodical and cost-effect approach (Table 13-4). Usually, the initial history and physical examination along with basic laboratory tests are sufficient to identify patients who are at risk for serious disease or who have “red flags” (see Table 13-4) or who require further workup. Notice that obtaining radiographic films is not part of the initial evaluation.
Because of the long-term nature of low back pain, patients often request additional diagnostic testing; the temptation is to respond to patient's concerns even when no clear-cut reason exists. Understanding key points of a patient's history and the pathophysiology of spinal pain can be helpful in providing the appropriate care for these difficult cases. Patients who are not responding to treatment as expected should be reevaluated with consideration given to a potential alternate diagnosis. Table 13-5 outlines disease categories, differential diagnosis along with key points, and the presumed underlying pathophysiology.
Despite the myriad of conditions that can cause back pain as listed in Table 13-5, discogenic back pain is
thought to be the most common source of pain for nonspecific back pain. The evolution process begins with disk degeneration. As the process continues, secondary deterioration of facet joints, ligaments, and muscles follows, leading to a change in movement dynamics. Despite the temptation to associate structural changes seen on radiographic imaging of the spine with the cause of a person's pain, no such correlation has ever been proven. In addition, degenerative spinal conditions, which are asymptomatic but can be seen radiographically, do not necessarily predict future back pain complaints.
Table 13-5. Key Points for Spinal Pain.
Evaluation of Musculoskeletal Back Pain
Estimates have suggested that as much as 98% of back pain arises from the disruption of the musculoskeletal system supporting the back. Despite this high incidence, finding the pain generator that explains the source of back pain is often elusive. This is in part secondary to the many different components of the spine that are pain sensitive. In addition, any particular injury may effect one or more painful components of the spine. Pain sensitive structures of the spine include:
These pain sensitive structures-separately or in combination-form many of the common clinical diagnoses that are thought to underlie mechanical back pain.
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Table 13-3 presents an overview of a differential diagnosis of back pain that include less benign causes of back pain. Rheumatic conditions often present with significant morning stiffness. With light exertion, the pain commonly improves; later in the day with sustained activity the pain begins to increase again. Typically, the spine is more generally affected in rheumatic conditions. In some instances, the disease is confined to a discrete area; the diagnostic approach for discrete areas of pain is covered in the mechanical spinal pain section. Although helpful, a complete history and physical examination are rarely diagnostic. A specific history of symptoms involving the eyes, skin, and gastrointestinal tract can be very helpful for some of these diagnoses. Laboratory tests and radiologic imaging are frequently necessary for definitive diagnosis. Table 13-6 presents a diagnostic approach to the rheumatic pain conditions.
There are a couple of characteristic findings that differentiates neoplastic spinal pain from benign spinal pain. First, pain that wakes a patient up at night typically indicates neoplastic pain. Second, percussion of the spine is often painful with neoplastic disease but not benign spinal pathology.
Table 13-7 lists nonmechanical causes of spinal pain, clinical findings, and potentially helpful diagnostic approaches.
Structural Pathologies of Back Pain
Discogenic Back Pain
The disk is the largest avascular structure found in the body. Back pain, which arises from this structure, is known as discogenic back pain. Degeneration of the disk results from desiccation of the disk secondary to the breakdown of nucleus pulposis constituents, including proteoglycans and loss of collagen protein crosslinking. Repetitive daily activities, such as chronic axial and rotational forces, can lead to a weakened disk causing the development of microtears of the annulus and healing with fibrosis formation. This eventually leads to diminishing of the blood supply and further degeneration. Periodic complaints of back pain with resolution are thought to be secondary to this process. Acute annular tears may be the most common cause of back pain. Patients often report a feeling of a pop, which began with a flexion motion while lifting an object. Pain associated with this injury is increased by flexion and sitting (especially in a car). Unless the spinal nerve is compromised, the pain is nonradicular, with the physical examination revealing paraspinal muscle spasm but no neurologic deficits. Straight leg-raising test is negative, but patients sometimes report increased back pain. Flexion of the spine is limited. Internal disk disruption is a similar condition that is also associated with back pain. The frequency of leg pain is more common. Magnetic resonance imaging (MRI) studies often show a desiccated disk seen as dark shading in the involved level. The pain is thought to be from annulus tears leading to inflammation and abnormal movement of the spinal segment. Provocative discography followed by computed tomography (CT) scan showing leakage of contrast into the epidural space is confirmatory. Further injury to the disk, which includes progressive annular disruption, can lead to the protrusion of nucleus pulposis into the outer annulus seen as a bulging disk. At first, the posterior longitudinal ligament contains the disk material. If the posterior longitudinal ligament weakens, the nucleus pulposis may herniate and lead to either nerve root inflammation or frank compression, or both. Nociceptors found in the dural sleeve, dura, and posterior and anterior longitudinal ligaments contribute to the back and leg pain commonly found in these patients. Midline herniation of the disk can leave the patient only with back pain and little or no leg pain. Herniated disks are often associated with a flexion-type of injury associated with lifting and twisting. Patients may report a snap or pop at the time of injury. Severe pain is not always reported immediately but may worsen over several days. Large disk herniations can cause significant spinal stenosis with neurologic compromise, leading to cauda equina syndromes. These conditions must be looked for because they could require emergent surgeries to avoid irreversible neurologic injury. In these conditions, the patient may have a history of muscle weakness and the loss of bowel or bladder control. Physical examination reveals ipsilateral or bilateral positive straight leg-raising. True bilateral positive straight leg-raising is considered to be nearly confirmatory for spinal nerve root irritation.
Table 13-6. Diagnostic Approaches in Evaluating Rheumatologic Conditions Causing Back Pain.
Table 13-7. Nonmechanical Conditions That Cause Spinal Pain.
MRI or CT scan is confirmatory. Myofascial pain, degenerative spine disease, foraminal stenosis, epidural fibrosis, and even peripheral neuropathies should also be part of the differential diagnosis for this type of clinical presentation.
The long-term degenerative changes of the intervertebral disks leads to significant changes in the loading and stress of movement in the facet joints, postural muscles, and ligaments of the spine. Once begun, these processes can lead to spine instability and further mechanical disruption, which also eventually extends to neighboring vertebral bodies. Early in the course of spinal stenosis, the neuroforamen remain open with extension but narrow with flexion. At this stage, patients will only report pain with flexion. The continued trauma can lead to spinal nerve adhesions causing traction on the nerve root resulting in pain. Reparative processes lead to new bone growth resulting in spurring, calcification of ligaments, narrowing of the spinal canal and the neuroforamen. If the narrowing continues, the spinal stenosis can become critical, which leads to neurogenic claudication. Congenital spinal stenosis that is rarely significant at a younger age places a patient at higher risk for developing clinical significant symptoms later in life. Patients often report low back pain, either intermittent or constant, that may radiate to one or both legs. Pain is increased with ambulation and decreased by rest. Pain is relieved by rest or lying down. Critical spinal stenosis leads to a feeling of leg heaviness and diffuse anterior thigh numbness and occasional pain. The classic description of neurogenic claudication by a patient is calf pain relieved by rest and ambulation distance improved by a hunched forward gait facilitated by a cane, walker or grocery cart. The disease may or may not be progressive. On physical examination, neurologic changes may or may not be present. CT and MRI scans confirm the diagnosis; CT scanning shows the bony elements best, and MRI visualizes the microelements better. Significant spinal stenosis can also be caused by spondylolisthesis. The pain arises from either disk pathology or the posterior longitudinal ligament through shearing forces because of abnormal movement. Instability of the vertebral body only worsens the clinical picture. Flexion and extension films showing the pathologic movement confirms this diagnosis.
Facet Joint Pain
The dual facet joints found superior and inferior on each vertebral body form the basic articulation surface along with the intervertebral disk that allows spinal column movement. The facet joint is a true diarthroidal joint with articular cartilage and a synovial capsule that is richly innervated with nociceptors. Thus, the facet joint has the potential of significant pain, although making a clinical diagnosis remains very difficult and controversial. Despite the importance of the facet joint in spinal mechanics, the true incidence of pain from this structure remains unknown. As with all synovial joints, chronic inflammation and stresses that come from change in articulation forces as seen with disk degeneration lead to loss of articular surface and potentially chronic pain. Further deterioration leads to abnormal motion, subluxation and increased instability, eventually evolving into spondylolisthesis. Synovial cysts with nerve irritation or compression can also lead to radicular pain. In addition, the sclerosis induced by this process can lead to foraminal stenosis and or even spinal canal stenosis. Because of the proximity to the spinal foramen, inflammation, instability, and stenosis can lead to either local or radicular pain patterns. Patients with facet joint pain often report nonspecific back pain radiating at times to buttocks and even down the legs stopping at the knees. Pain is increased with rotation of the back, standing erect, spine extension, and lying prone. Neurologic examination is normal. Paravertebral muscle tenderness can also be elicited by palpation. Radiographic examination is not diagnostic. Single photon emission computed tomography (SPECT) scanning may be helpful for detecting inflammation involving the joints. The only definitive way to diagnose facet joint pain is selective joint injection using local anesthetic and radiographic guidance.
Postspinal Surgery Pain
Persistent pain after back surgery is commonly seen in pain management centers. This diagnosis applies to those patients in whom an appropriate diagnostic workup has been done and no other new or recurrent disease can be identified. The etiology of postspinal surgery pain remains unknown, but proposed causes include the following:
Patients presenting with this syndrome often give a history of short-term relief from the original surgery followed by reoccurrence. Patients also report multiple surgical procedures because of failed fusions and persistent or recurrent disk pathology. The pain is often described in terms that suggest a neuropathic component. Since the clinical picture is often one of longstanding pain, severe deconditioning and psychological comorbidities are commonly seen. Pain is continuous and seems to be
independent of activity. MRI with gadolinium enhancement usually confirms the presence of epidural scarring. Whether the epidural scarring and the persistent pain are causally related remains unproven.
Myofascial Back Pain
Low back pain from a primary injury to the back muscles and ligaments is thought to be a very common cause of back pain. Patients usually report localized symptoms caused by either an associated increase in activity from their usual norm or from acute injury. On examination, muscle tenderness and spasm are usually noted with decreased range of motion. Trigger points may also be palpable. No neurologic changes are noted. The patient with involvement of the piriformis muscle may report radicular symptoms. Patients with a history of diminished activity are at higher risk for this type of injury. However, when no clear cause can be found, nonspecific back pain is often the diagnosis in many patients.
Table 13-8 summarizes the different mechanical causes of spinal pain as well as the clinical presentation and imaging findings that can be used to further confirm the diagnosis.
Hip & Sacroiliac Joint Pathology
Both the hip and sacroiliac (SI) joints are often an unrecognized source of pain attributed to the back pain. Table 13-9 describes clinical considerations useful in the diagnosis.
Psychological Aspects of Back Pain
Longstanding chronic back pain often has a significant psychological component, which can impact the diagnostic workup, prognosis, and treatment. A chronic back pain history should also include a patient's mood, work history (if relevant), family dynamics, and any potential for secondary gain. Because of the nonspecific nature of back pain, a patient's level of pain is often called into question. Waddell signs have often been used to verify a patient's back pain complaints. The presence of Waddell signs should not interfere with the therapeutic relationship between physician and patient. The presence of three or more Waddell signs can be indicative of significant psychological distress. The five Waddell criteria follow:
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Waddell G et al. Observation of overt pain behaviour by physicians during routine clinical examination of patients with low back pain. J Psychosom Res.1992;36:77..
Diagnostic Approach to Back Pain
In general, mechanical back pain located in the lumbar and lower thoracic regions is associated with a change in posture. In higher areas of the back, movement or traction on the involved area induces pain. Commonly, mechanical pain is increased with loading of the back. Usually, postures such as sitting are more painful than standing. Lying down typically improves the pain in mechanical spine disorders. Figure 13-1 presents a stepwise diagnostic approach to mechanical back pain. This diagnostic algorithm (see end of chapter) can be very helpful in determining most causes of back pain. Because of the presence of multiple different causes or nondiagnostic clinical histories, physical examinations, or radiographic imaging, some back pain needs to be investigated further. Diagnostic procedures can be helpful in these situations to further refine the diagnosis and focus therapy that is likely to be more effective. Occasionally, diagnostic procedures can serve a dual purpose of providing therapy as well (see Treatment section below).
Because of the difficulty in diagnosing the source of a patient's back pain, considerable interest has always been expressed in selective neural blockade for more definitive diagnosis. Typically, a diagnostic procedure (with the exception of discography) consists of inserting a needle that is guided radiographically to the area believed to be responsible for the patient's pain; local anesthetic and corticosteroid (to enhance the analgesia and potentially provide long-term relief) are then injected. Using
the patient's report of pain relief as a guide, a diagnosis is then made that would allow more specific treatment or help plan a surgical procedure, if needed. Although this idea is very attractive, a consensus on the reliability and specificity of these procedures remain illusive. Several factors may be present that call into question the diagnostic validity of these procedures:
Table 13-8. Mechanical Causes of Back Pain.
Table 13-9. Clinical Considerations for SI and Hip Joint Pain.
These caveats should not lead to the conclusion that diagnostic nerve blocks have no usefulness. Caution should be used in interpreting the results, as with any diagnostic test. Most procedures used for treatment of back pain have a dual use, with the exception of discography (see Treatment section below).
Because of the poor correlation of radiographic imaging for discogenic pain, discography has been advocated as the definitive test. Radiographic guidance along with contrast can define a painful disk and provide information regarding abnormal structural anatomy. Changes in contrast spread along with the patient's pain report can be used to identify a diseased disk. In addition, discography may be used to complement other tests, such as myelogram or event MRI. Discography can also be used to define a painful disk when other imaging options, such as MRI in failed spinal surgery, are nonspecific. Multilevel positive discography can be suggestive of poor outcomes for fusion surgery as well. Injection of the disk with a corticosteroid has also been noted to have therapeutic value, although with an increased risk of disk infection. The components of the normal lumbar disk are made of gelatinous nucleus pulposis and outer dense laminated fibroelastic layer known as the annulus fibrosis. Unlike the cervical area, the facet joints in the lumbar area do not protect the nerve roots. Therefore, a posterior and lateral herniation of the disk with impingement of the spinal nerves is not uncommon. Discography is indicated when traditional diagnostic approaches, such as imaging studies and electromyography, have failed to determine
a cause of persistent pain. Discography seeks to provoke pain that reproduces the patient's pain complaint; this is known as concordant pain. Discordant pain is pain that does not simulate the patient's pain. The procedure should be done on at least three levels, including an asymptomatic level for a control. For the procedure, water-soluble contrast is used to identify the appropriate needle location. Resistance to injection is noted, along with any pain that the patient reports. A healthy disk is not painful, and some resistance is normal.
Figure 13-1. Diagnostic approach to mechanical back pain. Complete history and physical examination fail to reveal “red flags”. CT, computed tomography; MRI, magnetic resonance imaging; SPECT, single photon emission computed tomography.
A syringe attached to a pressure manometer is often used to avoid over pressurization of the disk. The limit should be 100mmHg. Based on the patient's pain report, a second control disk is injected. If failure to elicit pain or discordant pain is reported, other levels may be done to identify the painful disk. Postprocedure CT scan can detect extravasation of contrast indicating a torn annulus. Although there are many variations of this procedure, the patient is placed in a prone oblique position. Under radiographic guidance, a 7-inch 22-gauge needle is inserted 1.5 inches from the midline and just below the level of the spinous process. Care should be taken to avoid advancement through the disk. Anteroposterior and lateral views are continuously obtained to ensure appropriate placement. A more lateral approach can facilitate the procedure in patients with extensive facet joint arthritic changes or significant disk degeneration. The L5-S1 disk is sometimes difficult to reach especially in females. If necessary, a paramedian or transthecal approach can be used at this level.
Antibiotic prophylaxis is mandatory for this procedure. Some experienced practitioners suggest intradiscal antibiotic either in addition to or instead of intravenous prophylaxis. In patients who are not allergic, cefoxitin is the preferred antibiotic because of its ability to penetrate the disk and its coverage of Staphylococcus epidermidis.
Pain secondary to the procedure is the most common complication and is usually self-limited. Other, more significant complications include discitis, trauma to the nerve roots, local damage to blood vessels, and even epidural hematoma.
Selective Nerve Root Injections
Selective nerve root injections have been used for a long time for both therapeutic and diagnostic goals (see Treatment section below).
Facet Joint Injections
Facet joint injections have been advocated as a significant treatment of mechanical back pain (see Treatment section below). Guided injections into facet joints with or without placebo injections have been suggested as a diagnostic tool. Minimal support for this approach for surgical decisions is found in the literature. As a diagnostic tool for radiofrequency procedures, this procedure has considerably more support.
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Despite reports of severe pain, most spinal pain is self-limited. In the absence of “red flags,” treatment should consist of appropriate medications for both neuropathic and nociceptive elements. Consensus recommendations based on the guidelines published by the Agency for Healthcare Research and Quality suggest a limited role for bed rest. Prolonged bed rest has no place in the treatment of spinal pain. Disuse muscle atrophy and generalized deconditioning can quickly develop, making treatment much more difficult.
Patient activity is often limited because of pain, so sufficient analgesia becomes extremely important to maintain appropriate activity. The management of chronic back pain treatment is based on the following three principles:
Table 13-10. Pharmacologic Management of Back Pain.
Table 13-11. Overview of Psychological Therapies.
Table 13-12. Rehabilitative Therapies Useful for Back Pain.
Table 13-13. Procedure Efficacy and Diagnosis.
Multiple different procedures are known to be effective in mechanical back pain. Because of the overlap of pathology that is commonly seen in patients with mechanical back pain, efficacy of a procedure is sometimes used to establish a diagnosis (Table 13-13).
Procedures are often used to treat back pain. As both the structural and neuroanatomy have become better understood, many new procedures have been developed to treat backpain. Considerable controversy exists regarding how and when to use many of these procedures. Procedures are often introduced for widespread use before they have been sufficiently studied. In addition, because of the significant variability in presentation, studies of outcomes of treatment approaches in the medical literature are often difficult to interpret. When to use a procedure and what symptoms respond the best as well as the efficacy in various conditions remain unclear. In a recent review of 15,000 studies and 150 expert reviews using criteria that controlled for methodologic quality, only two procedures had enough literature support to definitively determine whether benefit was obtained. This review showed that epidural steroid injections showed short-term benefit, and spinal cord stimulation had a lack of overall benefit despite many studies showing that 50% improvement was noted in 50% of patients at 5 years. Yet, all pain practitioners know patients who have derived long-term benefits from the large variety of procedures. This discrepancy can only be explained by what has been known for a long time. As the specificity and selectivity of available procedures increase, the need to understand the patient and make an accurate diagnosis is paramount. The key points in using procedures to treat pain are patient selection; making an accurate diagnosis along with determining what the pain generator is in each patient; and avoidance of repeated procedures, which provide little or no long-term response.
Epidural Steroid Injections
Administration of a combination of depot steroid injections and local anesthetic is helpful in a variety of conditions including radiculopathies, localized nonradiating spine pain, spondylosis, vertebral compression fractures, postherpetic neuralgias, and malignant pain syndromes secondary to localized metastasis.
Usually, a series of three injections are performed 1 month apart. For patients with partial relief, an evaluation should be undertaken before each injection to determine whether additional injections are needed. There is no evidence to suggest that more than three injections are of additional benefit within a 6-month period. For patients reporting continued pain, a comprehensive evaluation should be undertaken with reevaluation of the treatment plan.
Epidural steroid injections should not be performed in the presence of local or systemic infections. Coagulation status must be normal to avoid epidural hematoma. Despite these precautions, epidural infection and hematoma can still occur. Other serious complications can include spinal cord injury and total spinal anesthesia with resultant respiratory depression, hypotension, and cardiovascular collapse. Unrecognized intravenous injections leading to local anesthetic toxicity of the central nervous system, heart arrhythmias, and even completeatony have occurred. Less serious complications include persistent paresthesia and worsened of the pain from needle trauma. Inadvertent dural puncture is a common complication with an incidence of at least 1% in experienced hands. Concerns have been expressed periodically regarding potential detrimental effects of corticosteroids on the meninges leading to arachnoiditis. Despite many years of experience, no association has been documented.
Systemic corticosteroid absorption can have detrimental effects on patients with diabetic tendency. In addition, the potential of adrenal gland suppression should also be kept in mind. Adrenocortical suppression is certainly possible and is one of the limiting factors for repeating this procedure.
Epidural steroid injection is one of the most common procedures done for back pain. There is substantial evidence for at least short-term efficacy in the treatment of radiculopathies. Other nonmalignant conditions have less support, with mainly expert opinion and case series found in the literature. For malignant pain syndromes, epidural injections have been shown to be effective in cohort studies and case series. Patients with subacute back and leg pain are thought to be the ideal candidates. Efficacy is also better in patients without previous surgery. Patients with leg pain only have the best long-term outcomes. Patients with spinal stenosis usually have a less favorable prognosis, unless there is an acute increase in recent pain. Patients with preexisting psychosocial issues may have a less favorable outcome.
Caudal Epidural Injection
The entrance to the caudal canal is found through the sacral hiatus. This hiatus is formed in the midline by the incomplete fusion of the posterior elements of S4 and S5. The sacrococcygeal ligament covers this U-shaped area and is a landmark guiding needle placement.
Lumbar Selective Nerve Root Injection
The lumbar nerves exit the intraspinal canal through their respective foramen, which are located immediately below the transverse process. The nerve divides almost immediately and gives off a branch to the adjacent facet joint. The para vertebral nerve also gives off branches to the sympathetic chain. The spinal nerve is accessible for blockade just distal to the spinal foramen.
Neuropathic pain syndromes with etiologies such as herniated disk or malignant tumors will respond to this block. In addition, this procedure is used to diagnose pain conditions of the chest wall and lower abdominal area.
Complications are usually rare. Intracord injections are rare. Occasionally, persistent paresthesias have been reported. Other complications include nerve root injury and intrathecal injection by errant needle placement or through a larger than expected dural cuff.
There is substantial evidence for short-term efficacy for treatment of radiculopathies. Other nonmalignant conditions have less support, with mainly expert opinion and case series found in the literature. For malignant pain syndromes, epidural injections have been shown to have efficacy with cohort studies and case series published. The selective nature and radiographic guidance used in this procedure may improve response and efficacy rates. This procedure is also used as part of the presurgical evaluation of radiculopathy.
Sacral Nerve Root Injections
The sacrum is the terminal portion of the spine. It has a very irregular surface with four paired sacral foramina nerves. The five sacral nerves exit the spinal canal via the sacral hiatus. The sacral nerves provide sensation and motor innervation to the external anal sphincter and levator ani muscles. The second through the fourth sacral nerves provide the majority of sensation to pelvic viscera and external genitalia.
Sacral nerve root injections can be used to diagnose neuropathic conditions of the sacral nerves and treat pelvic pain syndromes as well as radiculopathies.
The sacral nerves can be blocked using a transforaminal approach with radiographic guidance; the beam is angled to visualize the approach through the posterior foramen. The needle is then inserted through the identified angle. A nonradiographic approach can also be used after identifying standard bony landmarks.
Nerve root injections have been shown in case series to be effective for nerve compression symptoms involving the sacrum. This procedure can also be used as part of a diagnostic workup for back, SI joint pain, or hip joint pain.
Lumbar Facet Joint Injection
The facet joints are formed by the articulations of the superior and inferior articular facets of the lamina of the adjacent vertebrae. The joints are true synovial joints and extensively innervated. Each joint receives innervation
from above and below as well as the level at which it is located.
Lumbar facet joint injection is indicated for paraspinal thoracic pain secondary to trauma from twisting, acceleration-deceleration injuries, fractures, and neoplasm.
Lumbar facet joint injection must be done under fluoroscopic guidance. Two approaches are described, either injection into the capsule of the joint known as a medial bundle branch block (MBB) or intra-articular joint injection. Depending on the procedure, the fluoroscopic beam must be aligned obliquely to visualize the joint or be in the anteroposterior position for the MBB. The needle is advanced to the middle of the articular pillar where the medial branch passes. With the intra-articular procedure, the joint surfaces are visualized by an oblique position of the fluoroscopic camera.
Numerous studies have shown efficacy for these procedures. No differences in outcomes have been documented for facet joint injections or MBBs. These injections have also been used to predict response to radiofrequency lesioning of MBB at the same levels.
Facet Joint Denervation
The approach for facet joint denervation is essentially the same as the approach for an MBB.
Facet denervation is indicated for patients who have reported short-term pain relief with a local anesthetic injection using the procedure as described for an MBB. Using RFL or other denervation techniques, longer-term relief can be obtained.
For all procedures, the needle is advanced under radio-graphic guidance. For lumbar denervation procedures, a needle is advanced to the junction of the superior articular and transverse process. Sensory testing to determine appropriate location of the needle as well as anteroposterior and lateral views of the needle are required. Denervation is usually done after injection of a small amount of local anesthetic.
Many cohort studies and some randomized trials have provided evidence for efficacy.
Ablative Procedures for Discogenic Pain
Intradiscal electrothermaplasty (IDET), nucleoplasty, percutaneous disk decompression, and radiofrequency lesioning are all newly described procedures for discogenic back pain. Each procedure has different physiologic effects on the structure of the disk. In contrast to IDET, nucleoplasty as well as percutaneous decompression procedures improve radicular symptoms.
Ablative procedures are indicated for chronic discogenic back pain that has lasted for at least 6 months and for patients who have not had satisfactory improvement after an aggressive exercise program. The patient should have a complete examination of the source of pain, including MRI without nerve compression, as well as normal findings on neurologic examination. The patient should have proven concordant pain as determined by discography, ideally at one level only. These procedures are most often used for a single painful disk with a minimum of 50% preservation of normal height. Contraindications include inflammatory arthritis, anticoagulation therapy, advanced spinal disease, and segmental instability.
The approach is essentially the same as discography. A 17-gauge needle is inserted to guide placement of a probe, which is placed into the nucleus pulposis. Occasionally, bilateral approaches are needed to cover the entire disk. Using either radiofrequency or a heating element, the collagen and nociceptors are denatured after careful placement. Company-specific equipment is required to perform IDET, with defined protocols on the length and level of energy programmed into the energy source. With the disk decompression procedure, a battery-operated device is inserted through the introducer needle that has been placed into the disk. The procedure is completed by turning on the device, which then mechanically decompresses the disk. Postprocedure rehabilitation is thought to be extremely important in successful outcomes.
The complications are similar to discography, with the additional risk of thermal damage to the spinal cord and the spinal nerves. Several cases have been reported where the catheter has broken inside the confines of the disk. No long-term complications have been reported by leaving the broken portion of the catheter in place.
Several randomized studies and a number of short-term nonrandomized studies have shown efficacy. Long-term outcomes > 1 year in patients receiving these procedures remain unknown. Some studies have shown that outcomes compare favorably to spinal fusion.
The relevant anatomy consists of the vertebral body, which is located between the disk spaces of the lumbar and thoracic spine. Little information exists regarding using this procedure in the cervical area.
Vertebroplasty is performed for compression fractures with loss of height in the vertebral column secondary to osteoporosis or malignancies.
Vertebroplasty must be done under radiographic guidance. Often monitored anesthesia care or conscious sedation is required. There are two different types of vertebroplasty, using methyl-methacrylate alone or a balloon filled with methyl-methacrylate. The approach of this procedure depends on the location of the fracture. The usual approach in the thoracic spine involves placement through the vertebral lamina. In the lumbar area, the approach is paravertebrally directly into the body. A 17-gauge needle is inserted through the lamina into the vertebral body bilaterally. The needle then serves as a guide for the cannula, which is then inserted into the fracture. The cement is usually mixed with radio-opaque materials, such as barium, to allow for visualization. Cement volume is usually equally divided into bilateral injection sites, which prevents unequal height restoration. Cement volume can vary from 0.5 mL to 4.0 mL. Care should be taken to avoid increased injection pressures, which can lead to extrusion of the cement, which could lead to complications. Postprocedure CT scan is undertaken for verification of appropriate cement placement.
Many serious but rare complications have been reported for the methyl-methacrylate, including cement embolism, spinal cord injury by unrecognized injection into the epidural space, and somatic nerve injury from placement of the cannula.
Many case series have reported efficacy for this procedure with long-term follow-up.
Intraspinal Neurolytic Procedures
See description under nerve root injections, above.
Intraspinal neurolytic procedures are indicated for malignant conditions in patients with limited life-expectancy.
Care must be taken to carefully select patients in whom loss of motor function and loss of bowel or bladder control would not adversely affect their quality of life. This procedure has little place in the treatment of noncancer pain. Some investigators are advocating the use of pulse radiofrequency lesioning of the dorsal root ganglion in chronic radicular neuropathic pain syndromes.
Neurolytic procedures on selected nerve roots can be done in patients with malignancies. Approaches include selective rhizotomies or neurolysis of the involved nerve root using either extradural or intradural techniques, most often done with radiographic guidance. Usually, the nerve root is first blocked with local anesthetic to determine pain relief potential and possible loss of function. The neurolytic procedure is then scheduled at a different time. For selective intrathecal rhizotomies, the patient is placed in a lateral position. When alcohol is used, the patient is positioned with the painful side up to allow for the hypobaric nature of alcohol. The volume of fluid used is specifically tailored to the levels required to achieve analgesia. High volumes can be used for patients in sitting positions to treat sacral nerve roots. Smaller volumes are needed for individual nerve root rhizotomies. These procedures should only be performed in extreme circumstances when adjacent to nerves controlling bowel, bladder, or limb function or in the upper cervical levels. For epidural procedures, the patient is often prone, and a catheter is placed at the appropriate level. Phenol is the preferred epidural neurolytic agent.
Unintended loss of function is the primary complication that may be minimized by using small volumes and carefully selecting patients. Proximity to areas of the spinal cord controlling limb function increases risk.
There is substantial case experience in the literature to support use in cancer pain. There is very little evidence supporting the use of these procedures for chronic non-cancer pain.
The most common entry point is the caudal canal. Please see caudal steroid injections for more details regarding the anatomy and technique.
Proponents of epiduroscopy suggest that direct visualization of the spinal canal can add an extra dimension
to diagnosing spinal disease. The promise of a visually guided procedure would potentially increase the efficacy rates. In addition, spinal adhesions that are not able to be diagnosed by any other method could be seen and lysed by direct visualization.
The scope is inserted into the epidural space often using radiographic guidance through a previously placed cannula. Irrigation is used to improve visualization.
Complications are similar to other catheter procedures in the epidural space and include infection; bleeding, potentially leading to epidural hematomas and nerve compression; and nerve damage with permanent impairment of function. In addition to visualization of spinal pathology, a specialized technique using a wire reinforced catheter known as epidural lysis of adhesions has been described. This catheter can be placed either with an epidural needle or the epidural scope.
There are no randomized prospective clinical trials available to verify the increased efficacy that proponents of this procedure suggest. With further development, this procedure and appropriate instruments hold the promise of a whole new approach to the treatment of difficult to manage chronic back pain.
Epidural Decompressive Neuroplasty
The relevant anatomy is the same for epidural catheter placement.
The procedure is indicated when adhesions of the epidural space are suspected, which can restrict movement or cause traction on the neural elements. Adhesions are thought to underlie some intractable chronic back pain. Previous surgery, trauma, or infection is thought to cause adhesions that are amenable to this procedure.
This procedure requires radiographic guidance, a specialized wire-wound epidural catheter, and contrast. With the patient typically under conscious sedation, the catheter is inserted into the epidural space at a location several vertebral bodies below the area of suspected disease. For lumbar procedures, the caudal canal is used. Corticosteroids, local anesthetics, and mild neurolytic solutions (such as hypertonic saline) have been advocated for this procedure.
Complications are similar to those described for epidural catheters. Neurolytic solutions and aggressive technique can damage the spinal cord and nerve roots.
Large case series have reported improvement.
Sacroiliac Joint Injections
The SI joint is a synovial joint that forms the articular surface of the sacrum and ilium on either sides of the sacrum. This joint is irregular in contour and is matched on the ilium side with reciprocal irregularities. An articular capsule covers the joint and attaches to the periphery of the articular surfaces.
Injections are indicated for SI joint pain that is determined on physical examination. This procedure is also indicated as a diagnostic procedure for surgical intervention. The incidence of SI joint pain may be as high as 30% in patients reporting chronic low back pain.
Using radiographic guidance, the SI joint is identified. A 22-gauge needle is introduced about 2 cm medial at an angle into the joint. Placement can be confirmed by the use of contrast and anteroposterior and lateral views. Alternatively, CT scan can be used for confirmation of needle placement.
An increase in local pain is not uncommon. Local anesthetic can leak through the joint and anesthetize both sacral and lumbar somatic nerves.
Numerous case series have confirmed short-term efficacy for the corticosteroid injection procedure. Radiofrequency lesioning of the joint has shown prolonged improvement in one case series.
Spinal Cord Stimulation
The bounds of the epidural space have been described above. Location of involved spinal nerves determines location of the stimulating electrodes in the epidural space.
Electrical stimulation of the central nervous system has long been used for analgesia in neuropathic pain states. Although many theories exist as to the mechanism of
analgesia, frequency modulation of the central nervous system masking the neuropathic sensation is the leading explanation. Epidural placement of multielectrode arrays can be effective for a variety of conditions and are helpful for a diverse number of neuropathic pain conditions, including failed spinal surgery. Screening trials showing at least 50% efficacy is a very important prognostic factor for long-term efficacy. Preprocedure psychological evaluation is also considered to be helpful in screening of potential candidates.
Epidural placement of the electrode is similar to the placement of epidural catheters. Trial stimulation determines efficacy prior to implantation of the system. Fastidious attention to the fixation of the electrode is important to avoid movement and to achieve long-term efficacy. Two types of pulse generators exist: an external system that relies on radiofrequency current for power and a battery-operated implantable pulse generator (IPG). The IPG portion of the device can be implanted either in the buttock (over the greater trochanter) or in the abdominal wall (most common).
Complications are very similar to epidural catheter placement. In addition, because of the presence of a foreign body, surgical infections commonly lead to explantation of the device. MRI imaging is contraindicated in patients with spinal cord stimulation. The battery life of an IPG is limited and requires replacement on exhaustion. Battery life depends on the current use, number of active electrodes, and both rate and pulse width settings of each patient. Superficial skin irritation can limit therapy in patients with radiofrequency devices. Other complications unique to this procedure include electrode migration or fracture with consequent loss of analgesia. Patients walking through some theft detectors have reported IPG interference.
Patients who are candidates for this procedure often have not responded to other therapies. The increased sophistication of these devices with multiple electrode arrays and patient-programming options have continued to improve efficacy in well-selected patients who have realistic treatment goals.
Neuroaxial Infusion Systems
Epidural infusion systems are generally used only for short-term relief. Intrathecal catheters and fully implanted pumps are generally used for long-term therapy. Intrathecal catheters can be directed toward the appropriate level within the spinal canal. Care must be taken to avoid damage to the spinal cord. Commonly these catheters are inserted using a modified epidural needle that should be placed below the level of termination of the spinal cord, which is at L1. Special circumstances can exist when this is not feasible, such as previous fusion surgery or other anatomic abnormalities.
Neuroaxial infusion systems are indicated for chronic intractable pain, which cannot be managed by more conventional means in a patient who is not a candidate for a surgical approach and who has responded poorly to oral medications. For noncancer pain, the most common indication is failed spinal surgery. As with spinal cord stimulation, patient selection is the key to long-term efficacy. Patients should have both a psychological screening test and neuroaxial medication trial. No clear consensus exists whether this trial should be an epidural or intrathecal catheter trial. Single shot trials are also considered predictive of success, although most experienced clinicians believe that catheter trials are a better predictor of success. Various medications and combinations are used to provide analgesia. These include opioids, local anesthetic solutions, baclofen, and clonidine.
The procedure is similar to that for epidural placement, except the needle is advanced into the intrathecal space. The presence of cerebrospinal fluid confirms placement. The intrathecal catheter is then advanced to the desired level. For back and leg pain, the catheter is typically advanced to the T12-T10 level. For the pump implantation, an incision and dissection is used to create a pocket sufficient in size to hold the pump. This pocket is usually located in the anterior abdominal wall; care must be taken so that the pump does not rub against the ribs and that its placement is away from a belt and elastic waistbands of a patient's undergarments. After the creation of the subcutaneous pocket, the spinal catheter is then tunneled from the posterior incision site to the pump pocket and attached to the pump.
There are two types of pumps: fixed flow and programmable. Fixed flow pumps are usually less costly and can hold more drug volume, but dosing changes require pump refills, which can become expensive with higher cost drugs and multiple dose changes. Programmable pumps can provide various programming options including complex infusion programs. Dosing changes are easily done, with programmed increase in the pumps infusion rate. Intrathecal administration is preferred over epidural for long-term therapy because of the greater potency of medications infused into the cerebrospinal fluid and the epidural fibrosis that is often found in patients with spinal surgery.
There is a 1 to 5% reported risk of infection. Other complications are nerve injury, persistent paresthesias, and even paraplegia. Minor complications include pocket seromas, hygromas, and spinal headaches from cerebrospinal fluid leaks. Complications associated with refilling the pump include inadvertent side port injections especially in older pumps which lack safety screens. This mistake may deliver an intrathecal injection of months' worth of medication and provoke respiratory and cardiovascular collapse, even death. Programming errors are also potential complications, which can lead to death from drug overdoses.
Complications from spinal opioids include nausea and vomiting, urinary retention, and respiratory depression. Respiratory depression is unlikely in patients who are already tolerant to the effects of systemic opioids except when other systemic problems, such as pneumonia, occur; the respiratory depressant effects of opioids may become addictive with the development of such systemic problems.
Spinal opioid therapy can apparently be continued for years without significant complications. Recently, concerns about catheter granulomas have been raised. The mechanism of development is still being debated, but a noninfectious inflammatory response to the intraspinal opioid may be the cause. Severe neurologic compromise can occur when these granulomas enlarge and remain undiagnosed.
In most situations, no single medication can be effective for both neuropathic and nociceptive pain. Because of this observation, most experienced clinicians who implant neuroaxial systems choose medication combinations to provide optimal analgesia while diminishing side effects. There is substantial literature documenting case series and expert experience suggesting long-term efficacy in well-selected patients.
Trigger Point Injections
Trigger points are characterized by areas of tender nodules or distinct bands of muscle, palpation of which can reliably refer pain to consistent locations on the trunk or extremities. Trigger points are identified by applying pressure over the presumed location until the patient's pain is replicated.
Injection of trigger points may improve both the range of motion and the function of the affected area. This procedure may play a useful role in conjunction with a rehabilitation program.
A trigger point can be injected either with a dry acupuncture needle or a needle filled with saline or local anesthetic with or without a corticosteroid. This procedure is often repeated during the rehabilitation program in order to treat recurrences. Recently, botulism toxin has been advocated for use during trigger point injections in order to treat resistant myofascial pain secondary to recurrent trigger points.
Following the procedure, the pain elicited from the trigger point area may temporarily worsen. Misdirected needles may puncture adjacent organs and blood vessels. Inadvertent intravascular injection of local anesthetic may precipitate seizures or systemic toxicity. Botulism toxin injections can lead to systemic effects, such as widespread muscle weakness or even anaphylaxis in allergic patients.
Well-controlled outcome studies are limited, in part due to the lack of consistent criteria for the diagnosis of trigger points. Case series and small controlled studies have demonstrated short-term improvement. Case series suggest that botulinum toxin is efficacious. Multiple and repeated trigger point injections do not have any support for efficacy. Trigger point injections without rehabilitation are often ineffective as well.
Psoas Muscle Injection
The psoas muscle lies deep to the transverse process of the lumbar spine. It originates at multiple levels from the transverse processes of each lumbar vertebra and typically courses below the inguinal ligament to insert with the iliacus muscle as a conjoint tendon onto the lesser trochanter.
Treatment of deep, ill-defined back pain with occasional coincident groin pain may indicate psoas muscle spasm.
With the patient prone, using either fluoroscopy with contrast or CT scan for radiographic guidance, two needles are inserted using a “loss of resistance” technique into the psoas compartment.
Following injection of local anesthetic, the branches of the lumbar plexus, which traverse the psoas muscle, may be temporarily affected. Poor aseptic technique has led to infection of the psoas compartment.
Table 13-14. Low Back Pain and Diagnosis and Treatment Approaches.
Several cohort series suggest efficacy. Injection of botulinum toxin into the psoas muscle has been reported to decrease the duration of pain originating from persistent muscle spasm.
Piriformis Muscle Injection
This muscle arises from the pelvic surface of the sacrum, the sacrotuberous ligament and the posterior portion of the ilium. The muscle then courses through the sciatic foramen to insert into the upper border of the greater trochanter.
Injection of this muscle is indicated for assessment and treatment of piriformis syndrome. Patients presenting with this syndrome often complain of radiculopathy-like symptoms, which can be confused with lumbar radiculopathy.
The muscle in thin persons can often be palpated; pressure on the muscle reproduces the symptoms. The muscle is approached in a similar fashion as the posterior approach to the sciatic nerve. A nerve stimulator or electromyography can be used to increase accuracy.
With the sciatic nerve in the immediate vicinity, anesthesia and paresthesia can occur. Local pain and irritation is the most frequent complication.
Piriformis syndrome is a well-known syndrome and several case series have shown improvement with this procedure.
Table 13-14 divides the causes of low back pain into nine categories:
Figure 13-1 shows the diagnostic approach to mechanical pain. There are six treatment algorithms that demonstrate the approach to managing the various types of mechanical back pain, including discogenic spinal pain, facet joint pain, spinal stenosis, spondylolysis or spondylolisthesis, and SI joint pain. Other treatment algorithms outline the approach to managing spinal infection, metabolic bone disease, and failed spinal surgery.
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Figure 13-2. Treatment of discogenic spinal pain. Spinal pain due to torn annulus, internal disruption, or prolapsed intervertebral disk. IDET, intradiscal electrothermoplasty. A and B = Go to corresponding letter within algorithm.
Figure 13-3. Treatment of facet joint pain. Pain, with or without referred pain, stemming from one or more facet joints; pain due to sprains or other injuries to the capsule of facet joints or arthritic changes. A = Go to corresponding letter within algorithm.
Figure 13-4. Treatment of spinal stenosis pain. Pain due to narrowing of the vertebral canal at multiple levels, usually of the cervical or lumbar vertebrae. A = Go to corresponding letter within algorithm.
Figure 13-5. Treatment of spondylolysis or spondylolisthesis.
Figure 13-6. Treatment of sacroiliac (SI) joint pain. A = Go to corresponding letter within algorithm. NSAIDs, nonsteroidal anti-inflammatory drugs; TENS, transcutaneous electrical nerve stimulation.
Figure 13-7. Treatment of spinal infection. Spinal pain in the context of specified infection or likely infection. A and B = Go to corresponding letter within algorithm.
Figure 13-8. Treatment of metabolic bone disease. A and B = Go to corresponding letter within algorithm.
Figure 13-9. Treatment of failed spinal surgery. A and B and C = Go to corresponding letter within algorithm.