Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy.

Chronic non-cancer pain (CNCP) is a disabling chronic condition with a high prevalence rate around the world. Opioids are routinely prescribed for treatment of chronic pain (CP). In the past two decades there has been a massive increase in the number of opioid prescriptions, prescribed daily opioid doses and overall opioid availability. Many more patients with CNCP receive high doses of long-acting opioids on a long-term basis. Yet CP and related disability rates remain high, and majority of the patients with CNCP are dissatisfied with their treatments. Intersecting with the upward trajectory in opioid use are the increasing trends in opioid related adverse effects, especially prescription drug abuse, addiction and overdose deaths. This complex situation raises questions on the relevance of opioid therapy in the treatment of CNCP. This article reviews current evidence on opioid effectiveness, the benefits and harms of long-term therapy in CNCP.

An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations.

OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. METHODOLOGY: Systematic assessment of the literature. EVIDENCE: I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. • The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for 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 evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic epidural injections in managing thoracic pain. • The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections. IV. Implantables • The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. • There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox). • There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events. CONCLUSIONS: Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed. DISCLAIMER: The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."

Spinal endoscopic adhesiolysis in post lumbar surgery syndrome: an update of assessment of the evidence.

BACKGROUND: Post lumbar surgery syndrome refers to pain occurring or present after lumbar surgery. While the causes of pain after lumbar surgery are multi-factorial, scarring is a significant source of that pain. Low back and/or leg pain after lumbar surgery can persist despite appropriate conservative therapy. Spinal endoscopy allows direct visual evaluation of the epidural space, along with mechanical lysis of any adhesions present. STUDY DESIGN: A systematic review of the effectiveness of spinal endoscopic adhesiolysis in post lumbar surgery syndrome. OBJECTIVE: To evaluate and update the effectiveness of spinal endoscopic adhesiolysis in treating post lumbar surgery syndrome. METHODS:   The available literature on spinal endoscopic adhesiolysis in treating post lumbar surgery syndrome was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies.The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES: Pain relief and functional improvement were the primary outcome measures. Other outcome measures were improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as improvement of 12 months or less; whereas, long-term effectiveness was defined 12 months or longer. RESULTS: For this systematic review, 21 studies were identified. Of these, one randomized controlled trial (RCT) and 5 observational studies met the inclusion criteria. Two of the observational studies were excluded because of other methodological issues, despite showing positive outcomes.Using current criteria for successful outcomes, these studies indicate that there is fair evidence for the effectiveness of spinal endoscopy in the treatment of persistent low back and/or leg pain in post lumbar surgery syndrome. LIMITATIONS:   The limitations of this systematic review include the paucity of literature. CONCLUSIONS: The evidence is fair that spinal endoscopy is effective in the treatment of post lumbar surgery syndrome.

An update of evaluation of intravenous sedation on diagnostic spinal injection procedures.

BACKGROUND: Intravenous (IV) sedation analgesia is often employed in patients with chronic spinal pain undergoing diagnostic spinal injection procedures. The drugs used for intravenous sedation analgesia produce varying degrees of sedation, amnesia, anxiolysis, muscle relaxation, and analgesia. The very nature of these pharmacologic effects in altering the patient's level of consciousness, awareness, or response to a particular diagnostic stimulus invokes a sense of uncertainty about the results or response obtained from the diagnostic procedure. There is an ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity, specificity, and accuracy. Moreover, there is no consensus with regards to the use of sedation analgesic measures prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis. OBJECTIVE: To assess and update the clinically significant effects sedation analgesia procedures have on the diagnostic accuracy and validity of interventional spinal techniques. METHODS: A comprehensive literature search using PubMed, EMBASE, and Cochrane Library review databases up to September 2012 was performed. The search included systematic and narrative review articles, prospective and retrospective studies, as well as cross-referencing of bibliographies from notable primary and review articles and abstracts from scientific meetings and peer-reviewed non-indexed journals. The search emphasized the effects of sedation analgesia on diagnostic spinal interventions. CONCLUSION: Based on a review of the available evidence, it appears that the administration of mild to moderate sedation does not confound the results or diagnostic validity of spinal injection procedures. Specifically, immediate pain relief after cervical and lumbar facet joint controlled nerve blocks is not enhanced by IV sedation with midazolam or fentanyl. This is especially true if stringent outcome criteria are employed, such as at least 75% pain relief combined with an increase in range of motion for pain limited movements.

Office-based opioid dependence treatment.

BACKGROUND: Opioid misuse and abuse occurring in association with the treatment of chronic non-cancer pain are not new phenomena, but their increasing prevalence in recent years is unprecedented. Advancements in pharmaceutical technologies have provided opioid-related drugs, which lack the pure mu agonist activity characteristic of the typical opioid congeners. This absent or altered mu receptor activity imparts an opioid receptor antagonistic or partial agonistic pharmacologic action, which serves to modulate the development of opioid-induced tolerance and physical dependence and facilitate detoxification and withdrawal from opioids. Opioid antagonists and partial agonists are being used in abuse deterrent strategy regimens to prevent opioid tolerance and the development of dependence, as well as in the management of opioid detoxification and treatment of withdrawal. The specific opioid antagonists and partial agonists used in these various therapeutic modalities will be the focus of this review. OBJECTIVES: Evaluate the comparative therapeutic utility of opioid antagonists and partial agonists in preventing the development of opioid tolerance and treating opioid dependence, detoxification, and withdrawal. A primary focus is the use of opioid antagonists and partial agonists within an office-based practice. METHODS: A narrative review of the current literature involving the therapeutic use of opioid antagonists and partial agonists in the management of opioid tolerance, dependence, detoxification, and withdrawal. A computerized literature search in the PubMed, EMBASE, BioMed, and Cochrane Library review databases from 2008 through 2010 was performed. This search included systematic and narrative reviews, prospective and retrospective studies, as well as cross-references from bibliographies of notable primary and review articles and abstracts from scientific meetings. US Food and Drug Administration records and pharmaceutical manufacturers' product literature were also used in the search. CONCLUSION: Opioid dependency, whether it results from the misuse or abuse of prescription or street drugs, continues to be a significant public health issue. Passage of DATA 2000 and US Food and Drug Administration approval of buprenorphine and buprenorphine/ naloxone has revolutionized opioid dependence therapy. The traditional addiction medicine therapy regimen of methadone maintenance, with its inherent legal limitations and restrictions, has been challenged by an office-based dependence practice with buprenorphine serving as a prominent therapeutic tool.

Cervicofacial subcutaneous emphysema and pneumomediastinum after retinal detachment surgery: just another monitored anesthesia eye case.

Repair of a retinal detachment was performed during a retrobulbar block with monitored anesthesia care and intravenous conscious sedation. Following the procedure and after removal of the sterile drapes, the patient exhibited significant swelling of the bilateral orbits, face, neck, and chest. Subcutaneous emphysema and pneumomediastinum were confirmed on postoperative chest radiographs and computed tomographic scans. Possible mechanisms and potential sequelae of this intraoperative event are discussed.

Urine drug testing in chronic pain.

Therapeutic use, overuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain continue to be an issue for physicians and patients. The challenge is to eliminate or significantly curtail abuse of controlled prescription drugs while still assuring the proper treatment of those patients. Some physicians are apprehensive regarding the use of chronic opioid therapy in chronic non-cancer pain due to a perceived lack of proven evidence, the misuse of opioids, tolerance, dependence, and hyperalgesia. However, others have criticized the underuse of opioids, resulting in the undertreatment of pain. It has been the convention that federal, state, and local governments; professional associations; as well as pharmaceutical companies, physicians, accrediting bodies, medical licensure boards, and the public all share responsibility for preventing abuse of controlled prescription drugs. To overcome the critical challenge of eliminating or significantly curtailing abuse of controlled prescription drugs and at the same time assuring the appropriate treatment for those patients who can be helped by these medications, it is crucial to practice adherence or compliance monitoring of opioid therapy. Compliance monitoring has been shown to be crucial in delivering proper opioid therapy and preserving this therapy for the future. Urine drug testing (UDT) is considered one of the mainstays of adherence monitoring in conjunction with prescription monitoring programs and other screening tools, however, UDT is associated with multiple limitations secondary to potential pitfalls related to drug metabolism, reliability of the tests, and the knowledge of the pain physician. UDT is a widely available and familiar method for monitoring opioid use in chronic pain patients. UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient's predisposition to, and patterns of, drug misuse/abuse--a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. This comprehensive review provides the role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse.

A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain.

BACKGROUND: The prevalence of cancer-related pain and residual pain in cancer survivors is high. Opioids serve as the gold standard for treating moderate to severe cancer pain. The evaluation of the effectiveness of opioids in chronic non-cancer pain has shown a lack of effectiveness, or rather weak evidence for some of the drugs. In contrast, in cancer pain, opioids are expected to be very effective. Due to the nature of the disease, there is evidence of a paucity of randomized trials investigating opioid effectiveness in cancer pain on a long-term basis. Consequently, the effectiveness of opioids in managing cancer-related pain warrants further evidence-based review beyond randomized trials, including observational studies and case reports. METHODS: The comprehensive literature search was conducted for the period 1996 through June 2010. Databases for the search included PubMed, EMBASE, Cochrane Reviews, and clinicaltrials.gov, along with reviews and cross references. Methodologic quality assessment of the observational studies managing chronic cancer pain with opioids was conducted utilizing the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. Analysis of evidence included 5 levels of evidence developed by the United States Preventive Services Task Force (USPSTF) ranging from Level I to III with 3 subcategories in Level II. Grading recommendations were based on Guyatt et al's recommendations with 6 levels: 3 in the strong category and 3 in the weak category. RESULTS: This evaluation is of 18 manuscripts considered for inclusion; 7 manuscripts met the inclusion criteria based on AHRQ quality assessment. Level of evidence for opioid therapy in cancer pain was Level II-3, and recommendations were 1C/strong recommendation based on observational studies, which could change based on future evidence. CONCLUSION: This systematic review of observational studies indicates Level II-3 evidence for effectiveness of opioids in cancer pain therapy, with 1C/strong recommendation based on observational studies, which could change based on future evidence.

Ultrasonographic evaluation of neck hematoma and block salvage after failed neurostimulation-guided interscalene block.

Ultrasound-guided regional anesthetic techniques have shown some advantages over conventional paresthesia and neurostimulation techniques. We report the case of a neurostimulation-guided continuous interscalene block that would have ended in complication were it not for experience with ultrasound-guided regional anesthesia. Familiarity with ultrasound-guided block techniques permitted assessment of a neck hematoma during interscalene block and ultimately allowed successful peripheral nerve block.

Opioid antagonists, partial agonists, and agonists/antagonists: the role of office-based detoxification.

BACKGROUND: The opioid receptor antagonists naloxone and naltrexone are competitive antagonists at the mu, kappa, and sigma receptors with a higher affinity for the mu receptor and lacking any mu receptor efficacy. Buprenorphine is classified as a partial agonist. It has a high affinity, but low efficacy at the mu receptor where it yields a partial effect upon binding. It also, however, possesses kappa receptor antagonist activity making it useful not only as an analgesic, but also in opioid abuse deterrence, detoxification, and maintenance therapies. Naloxone is added to sublingual buprenorphine (Suboxone) to prevent the intravenous abuse of buprenorphine. The same product (sublingual buprenorphine) when used alone (i.e. without naloxone) is marketed as Subutex. OBJECTIVE: To evaluate and update the available evidence regarding the use of agonist/antagonists to provide office-based opioid treatment for addiction. METHODS: A review using databases of EMBASE and MEDLINE (1992 to December 2007). These included systematic reviews, narrative reviews, prospective and retrospective studies, as well as cross-references from other articles. OUTCOME MEASURES: The primary outcome measure was treatment retention. Other outcome measures included opioid-free urine drug testing, opioid craving, intensity of withdrawal, pain reduction, adverse effects, addiction severity index, and HIV risk behavior. RESULTS: The results found 17 studies, 1 systematic review, 12 RCTs, and 4 observational series, which document the efficacy and safety of buprenorphine alone and in combination with naloxone in detoxifying and maintaining abstinence from illicit drugs in patients with opioid addiction. CONCLUSION: Based on the present evaluation, it appears that opioid antagonists, partial agonists, and antagonists are useful in office-based opioid treatment for addiction.

Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain.

BACKGROUND: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. DESIGN: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. METHODS: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). RESULTS: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. CONCLUSION: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."

Sacroiliac joint interventions: a systematic review.

BACKGROUND: The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. OBJECTIVE: To evaluate and update the available evidence regarding diagnostic and therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. STUDY DESIGN: A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria for therapeutic interventions and AHRQ, and Quality Assessment for Diagnostic Accuracy Studies (QUADAS) for diagnostic studies. METHODS: The databases of EMBASE and MEDLINE (1966 to December 2006), and Cochrane Reviews were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. RESULTS: The results of this systematic evaluation revealed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain is estimated to range between 10% and 27% using a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections is around 20%. The evidence for provocative testing to diagnose sacroiliac joint pain is limited. For therapeutic purposes, intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there is limited evidence for short-term and long-term relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis. CONCLUSIONS: The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.

Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update.

BACKGROUND: A 2-year review of literature from October 2004 to December 2006 was completed to update current scientific evidence on diagnostic utility of facet joint injections. Diagnostic injections are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. There is no physical examination technique, laboratory test, or imaging modality that can precisely identify the spinal structure causing pain, distinguish the culprit from a variety of potential targets, and predict response to a therapeutic intervention. Zygapophysial joint injections, commonly called facet injections (intraarticular joint injections and medial branch blocks) are local anesthetic injections of the facet joint or its nerve supply. These are diagnostic procedures used to determine if pain is arising from facet joints, distinguish painful from nonpainful joints and prognosticate response to therapeutic facet joint interventions. Diagnostic injections must meet the cardinal features of a diagnostic test i.e., accuracy, safety, and reproducibility. Accuracy is based on comparison with a "gold standard" to confirm presence or absence of a disease. There is, however, no available gold standard to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. OBJECTIVES: Evaluate and update available evidence (2004 to 2006) relating to clinical utility of facet joint injections (intraarticular and medial branch blocks) in diagnosing chronic spinal pain of facet joint origin. STUDY DESIGN: Review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing facet joint pain according to Agency for Healthcare Research and Quality (AHRQ) and Quality Assessment Studies of Diagnostic Accuracy (QUADAS) criteria. The level of evidence was classified as conclusive (Level I), strong (Level II), moderate (Level III), or limited (Level IV). METHODS: Computerized database search (2004 to 2006) of PUBMED, EMBASE, CINAHL, and Web of Knowledge was conducted to identify studies on facet joint pain and diagnostic interventions. Abstracts, reviews, book chapters, case reports, studies based on single blocks or blocks without radiologic control, and studies describing techniques were excluded. Prospective studies were given priority over retrospective studies. RESULTS: There is no change in the strength of evidence for facet joint diagnostic injections. There is strong evidence for controlled comparative local anesthetic facet joint injections or medial branch blocks in the diagnosis of neck and low back pain and moderate evidence in the diagnosis of pain arising from thoracic facet joints. CONCLUSION: The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.

A systematic review of therapeutic facet joint interventions in chronic spinal pain.

BACKGROUND: Facet joints are considered to be a common source of chronic spinal pain. Facet joint interventions, including intraarticular injections, medial branch nerve blocks, and neurotomy (radiofrequency and cryoneurolysis) are used to manage chronic facet-mediated spinal pain. A systematic review of therapeutic facet interventions published in January 2005, concluded that facet interventions were variably effective for short-term and long-term relief of facet joint pain. OBJECTIVE: To provide an updated evaluation of the effectiveness of 3 types of facet joint interventions in managing chronic spinal pain. STUDY DESIGN: A systematic review utilizing criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and the Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (November 2004 to December 2006) and manual searches of bibliographies of known primary and review articles within the last 2 years. Results of the analyses were performed for the different modes of facet joint interventions for the cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with these procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For intraarticular facet joint injections and medial branch blocks, short-term pain relief was defined as relief lasting less than 6 weeks and long-term relief as 6 weeks or longer. For medial branch blocks, repeated injections at defined intervals provided long-term pain relief. For medial branch radiofrequency neurotomy, short-term pain relief was defined as relief lasting less than 3 months and long-term relief as lasting 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For cervical intraarticular facet joint injections, the evidence is limited for short- and long-term pain relief. For lumbar intraarticular facet joint injections, the evidence is moderate for short- and long-term pain relief. For cervical, thoracic, and lumbar medial branch nerve blocks with local anesthetics (with or without steroids), the evidence is moderate for short- and long-term pain relief with repeat interventions. The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. CONCLUSION: With intraarticular facet joint injections, the evidence for short- and long-term pain relief is limited for cervical pain and moderate for lumbar pain. For medial branch blocks, the evidence is moderate for short- and long-term pain relief. For medial branch neurotomy, the evidence is moderate for short- and long-term pain relief.

Policy for therapeutic acupuncture in an academic health center: a model for standard policy development.

Acupuncture as a therapeutic modality offers multiple applications. Its effectiveness coupled with its general acceptance by conventional health care professionals makes it one of the first complementary and alternative medicine (CAM) modalities to be incorporated in an integrative approach to care. However, few centers that offer acupuncture have written standard policies to regulate its use. This lack of standard policies may impede provision of quality care, serve as a barrier to cross-institutional data collection and clinical application of that data, and may put health care professionals and institutions at risk when credentialing or malpractice liability has not been clearly addressed. Here we present a policy for acupuncture, created by a diverse group of health care professionals at the University of Michigan Health System. It may function as a generalizable template for standard policy development by institutions incorporating acupuncture.

Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines.

BACKGROUND: The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. DESIGN: A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventions and outcomes. METHODS: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Methodologic quality evaluation criteria utilized included AHRQ criteria, QUADAS criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). RESULTS: The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thoracic facet joint pain. The evidence was strong for lumbar discography, whereas, the evidence was limited for cervical and thoracic discography. The evidence was moderate for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anesthetics and steroids was moderate for short-term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections was strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis was strong. For spinal endoscopic adhesiolysis, the evidence was strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain was indeterminate. The evidence for intradiscal electrothermal therapy was strong for short-term relief and moderate for long-term relief in managing chronic discogenic low back pain, whereas, for nucleoplasty, the evidence was limited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems was moderate to strong. CONCLUSION: These guidelines included the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines do not represent "a standard of care".

Therapeutic facet joint interventions in chronic spinal pain: a systematic review of effectiveness and complications.

BACKGROUND: Facet joint interventions are used frequently for managing chronic spinal pain. Evidence continues to accumulate supporting the clinical effectiveness of these procedures and defining potential complications. OBJECTIVE: To evaluate the effectiveness of three types of facet joint interventions (facet joint injections, medial branch blocks and facet joint neurotomy) in managing spinal pain. STUDY DESIGN: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years. Analyses were performed for the different modes of facet joint interventions of cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with the procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For facet joint injections and medial branch blocks, short-term pain relief was defined as relief less than 6 weeks, and long-term as 6 weeks or longer. For medial branch radiofrequency neurotomy, short-term relief was defined as pain relief of less than 3 months, and long-term as 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For lumbar intraarticular facet joint injections, there was moderate evidence for short-term improvement, and limited evidence for long-term improvement. The evidence was negative for cervical intraarticular facet joint injections. For cervical and lumbar medial branch blocks with local anesthetics and steroids, the evidence was moderate. The evidence for pain relief with radiofrequency neurotomy of medial branch nerves was moderate to strong. CONCLUSION: The evidence for facet joint interventions ranged from negative to strong.

The pharmacology of sedation.

Sedation is commonly provided for patients undergoing interventional pain management procedures. Although many pain management interventionalists have trained in anesthesiology, the use of sedatives, analgesics and hypnotics, as well as monitoring techniques, may vary considerably between practices. This review provides an update on recent advances in the pharmacology of drugs commonly used for sedation, anxiolysis and analgesia. The information should also be useful for non-anesthesiologists who provide sedation for their patients. In addition to providing the right drug for the procedure, patient monitoring must be appropriate for the patient and the clinical circumstances. Undertaking a sedation analgesic course of therapy in support of an interventional procedure will require that patients are monitored appropriately during the course of treatment. Guidelines for monitoring patients during sedation are available.