Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain.
BACKGROUND
Understanding the neurophysiological basis of chronic spinal pain and diagnostic interventional techniques is crucial in the proper diagnosis and management of chronic spinal pain. Central to the understanding of the structural basis of chronic spinal pain is the provision of physical diagnosis and validation of patient symptomatology. It has been shown that history, physical examination, imaging, and nerve conduction studies in non-radicular or discogenic pain are unable to diagnose the precise cause in 85% of the patients. In contrast, controlled diagnostic blocks have been shown to determine the cause of pain in as many as 85% of the patients.


OBJECTIVE
To provide evidence-based clinical practice guidelines for diagnostic interventional techniques.


METHODS
Best evidence synthesis.


METHODS
Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.
Diagnostic criteria established by systematic reviews were utilized with controlled diagnostic blocks. Diagnostic criteria included at least 80% pain relief with controlled local anesthetic blocks with the ability to perform multiple maneuvers which were painful prior to the diagnostic blocks for facet joint and sacroiliac joint blocks, whereas for provocation discography, the criteria included concordant pain upon stimulation of the target disc with 2 adjacent discs producing no pain at all.


RESULTS
The indicated level of evidence for diagnostic lumbar, cervical, and thoracic facet joint nerve blocks is Level I or II-1. The indicated evidence is Level II-2 for lumbar and cervical discography, whereas it is Level II-3 for thoracic provocation discography. The evidence for diagnostic sacroiliac joint nerve blocks is Level II-2. Level of evidence for selective nerve root blocks for diagnostic purposes is Level II-3.


CONCLUSIONS
Limitations of this guideline preparation include a continued paucity of literature and conflicts in preparation of systematic reviews and guidelines.


CONCLUSIONS
These guidelines include the evaluation of evidence for diagnostic interventional procedures in managing chronic spinal pain and recommendations. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."
Manchikanti
Laxmaiah
L
Pain Management Center of Paducah, Paducah, KY, USA. drlm@thepainmd.com
Boswell
Mark V
MV
Singh
Vijay
V
Derby
Richard
R
Fellows
Bert
B
Falco
Frank J E
FJ
Datta
Sukdeb
S
Smith
Howard S
HS
Hirsch
Joshua A
JA
D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D006801:Humans; D009407:Nerve Block / Q000379:methods; D009482:Neurophysiology; D010146:Pain / Q000150:complications / Q000175:diagnosis; D059408:Pain Management; D010147:Pain Measurement; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D012720:Severity of Illness Index; D013119:Spinal Cord Injuries / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D013131:Spine / Q000473:pathology; D016896:Treatment Outcome; D021801:Zygapophyseal Joint / Q000473:pathology / Q000503:physiopathology