Pain Medicine Demystified!

Evidence for Spinal Interventions

Dr Sanjeeva Gupta
MD; Dip NB; FRCA; FFPMRCA; FIPP
Consultant in Pain Medicine
Bradford Teaching Hospitals NHS
Foundation Trust
Educational Meetings Advisor : Faculty of
Pain Medicine

Precision Diagnosis and

Management of Pain
History
Physical Examination
Investigations
70 to 80% of spinal pain cannot be
diagnosed
With Precision diagnostic techniques
nearly 70% of spinal pain can be
diagnosed

Facet Joint Mediated Low Back Pain

Evaluation: Medial Branch Block
Facet Joint
Injections
Medial Branch
Block

L4

L5

High on the eye of the Scotty dog

C2
C3
C4
ap
C5

C6

ervical Facet Joint Pain

C4

C5

Manchikanti L, et al. A modified approach to grading of evidence.

Pain Physician 2014; 17:E319-E325 (174)
Level I

Evidence obtained from multiple relevant high quality

randomized controlled trials OR
Evidence obtained from multiple high quality diagnostic
accuracy studies
Level II Evidence obtained from at least one relevant high quality
randomized controlled trial or multiple relevant moderate
or low quality randomized controlled trials OR
Evidence obtained from at least one high quality
diagnostic accuracy study or multiple moderate or low
quality diagnostic accuracy studies
Level III Evidence obtained from at least one relevant moderate or
low quality randomized controlled trial study OR
Evidence obtained from at least one relevant high quality
non-randomized trial or observational study with multiple
moderate or low quality observational studies OR
Evidence obtained from at least one moderate quality
diagnostic accuracy study in addition to low quality
studies
Level IV Evidence obtained from multiple moderate or low quality
relevant observational studies OR
Evidence obtained from multiple relevant low quality
diagnostic accuracy studies

A Best-Evidence systematic appraisal of

the diagnostic accuracy and utility of facet
joint nerve injections in chronic spinal
pain. Pain Physician 2015; 18: E497-E533

Level I evidence for diagnostic

accuracy of lumbar facet joint nerve
blocks with at least 75% pain relief
as criterion standard
Level II evidence for
Cervical facet joint nerve blocks with at
least 80% pain relief as the criterion
standard

A systematic review of efficacy and best

evidence synthesis of therapeutic facet
joint interventions in managing chronic
spinal pain. Pain Physician 2015; 18: E535E582
Level II evidence for long term
improvement of FJ pain for
Lumbar and cervical radiofrequency
neurotomy
Therapeutic facet joint nerve blocks in
cervical, thoracic and lumbar spine

Prevalence and Diagnosis of SIJ

Pain
Prevalence of SIJ
pain was 10-20%

Schwarzer, Spine, 20:31,

1995, Maigne, Spine
21,1889, 1996

SIJ was found to be a

source of post-fusion
pain in 32% of
patients by single IA
block
Katz. J Spinal Disorders 16;9699, 2003, Maigne. Euro Spine

Evidence for SIJ Interventions

Meta-Analysis of the Prevalence, Diagnostic Accuracy &
Therapeutic Effectiveness of SIJ Interventions. Pain
Physician 2015: 18

11 diagnostic accuracy studies & 14

therapeutic studies
Level II Evidence for diagnostic accuracy
Level II to III Evidence for cooled
radiofrequency neurotomy in managing SIJ
pain

Radicular Pain

Dr Tim Maus, Mayo Clin

What Can You See?

Would You Inject Steroid?

S1

S1

DJ Kennedy, et al. Pain Medicine 2014; 15 (4): 548-55

Randomized, DB comparative effectiveness trial
60 mg Triamcinolone OR 15 mg Dexamethasone

2 Weeks

3 Months
Triam

6 Months

Dex

Triam

Dex

Dex

Triam

%
Surgery

2.7%

14.6% 16.2% 14.6% 18.9%

50 %
Pain
Relief

31.7% 43.2% 73.2% 73%

50 %
ODI
decreas
e

26.8% 35.1% 68.2% 67.6% 70.7% 64.9%

73.2% 75.7%

Dr Tim Maus, Mayo Clini

Spinal cord stimulation for chronic

neuropathic pain
NICE technology appraisal guidance
[TA159]
Spinal cord stimulation is recommended for
persistent chronic neuropathic of 6 months or
more duration

British Pain Society Pain Pathways

Low Back Pain Specialist Management

Copyright [2012] Map of Medicine Limited. All rights reserved

Good Practice Guidelines

of the FPM and BPS

https://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdf
https://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_ FINAL.pdf
http://www.rcoa.ac.uk/node/2206

Summary
There is good evidence for
Diagnostic spinal interventions
Radiofrequency denervation at lumbar
and cervical levels
Spinal cord stimulation
Transforaminal Epidural steroid injections
Less chance of complications with
Dexamethasone

Pain Pathways and the FPM and BPS

good practice guidelines can help raise
standards

Thank You