Reliability and Safety of Contra-Lateral Oblique View for Interlaminar Epidural Needle Placement.

Cord trauma is a risk with a cervical and thoracic interlaminar epidural approach to the epidural space. Intermittent lateral fluoroscopic imaging to detect needle depth is often cumbersome and may be difficult to interpret. In comparison, the contra-lateral oblique (CLO) fluoroscopic view is efficient and easy to interpret. However, the in vivo reliability and safety of this technique has not been formally investigated.The senior author collected fluoroscopic images on 278 consecutive patients undergoing an interlaminar epidural block at the T1-T2 level performed using a 17 gauge Tuohy needle. Before catheter placement, anterior-posterior (AP) and CLO fluoroscopic images were saved with the needle at the ligamentum flavum and the needle just through the ligamentum flavum.We randomly selected the images of 40 cases that included the paired CLO images (total 80 images) documenting the views at and through the ligamentum flavum. Three interventionalists were asked to review, in a blinded fashion, the randomly selected, paired CLO images and to score each image, recording whether the 17 gauge needle was in or out of the epidural space to determine the accuracy and reliability of this technique.There was a 97.5%, 95%, and 93.8% agreement between each reviewing physician and the senior author resulting in a correlation using the Kappa statistic value of 0.950, 0.875, and 0.874, respectively (P < 0.001). The 3 reviewing physicians disagreed with the senior author's correct answer in 2.5%, 5%, and 6.2%, respectively, however, the disagreement occurred primarily because of poor image quality. Agreement between the 3 reviewing physicians was 93.8%, 96.3%, and 90%, with a Kappa value of 0.875, 0.924, and 0.799, respectively (P < 0.001). There was 100% technical success in the 278 case series without "wet taps," provocation of pain during entry, or any other immediate post procedural complication.We conclude the CLO view provides an efficient and reliable method to visualize needle tip depth in relation to the epidural space. The close inter-observer agreement was possible with minimal physician instruction.Key words: Cervical interlaminar, cervical epidural, contra-lateral oblique, fluoroscopic imaging.

Effectiveness of a new navigable percutaneous disc decompression device (L'DISQ) in patients with lumbar discogenic pain.

OBJECTIVE: This study is a pilot study to assess the clinical outcomes of percutaneous disc decompression using the L'DISQ in patients with lumbar discogenic pain. STUDY DESIGN: An institutional, prospective clinical data analysis. METHODS: We ablated the torn annulus using L'DISQ on 20 patients with axial low back pain for at least 3 months (average 29 months) unresponsive to conservative management. Before the therapeutic procedure, all the patients had been diagnosed with lumbar discogenic pain through provocation discography, which had confirmed the level of painful discs. The torn annulus was identified through lumbosacral magnetic resonance image and computed tomographic discogram. Baseline data were prospectively gathered before the procedure and at 1, 4, 12, 24, and 48 weeks post-procedure. Data included pain intensity (visual analog scale [VAS]), measure of disability (Oswestry Disability Index [ODI] and Rolando-Morris Disability Questionnaire [RM]), and health-related quality of life (Bodily Pain Scale of Short Form-36 version 2 [SF-36 BP]). RESULTS: At 48 weeks, the VAS fell from 7.55 ± 1.28 to 3.60 ± 2.28 scores, the ODI and RM had decreased significantly, and the SF-36 BP showed significant improvement (P < 0.05). The success rates of procedure were 55.0% at 48 weeks. There were no complications with the exception of a minor venous bleeding at the site of needle puncture. CONCLUSIONS: The L'DISQ device is specifically designed to ablate adjacent disc tissue using a wand that can be navigated into a torn annulus. Following ablation, we measured clinically significant pain improvement and decreased disability for patients with axial low back pain.

Indications for repeat diagnostic medial branch nerve blocks following a failed first medial branch nerve block.

No studies have directly measured the false negative rate of medial branch block (MBB) with correlation to medial branch neurotomy (MBN) outcome. We investigated the potential false negative MBB rate and the subsequent MBN outcome on a consecutive audit of all patients undergoing a double MBB protocol. We prospectively collected audit data and retrospectively collected data by phone on 229 consecutive patients undergoing diagnostic MBB. One-hundred-twenty-two patients reporting greater than 50% of subjective pain relief subsequently underwent either MBN or a confirmatory block followed by MBN. A total of 55 patients underwent a second confirmatory MBB and within that group 27.3% (15/55) reported less than 50% relief post initial MBB and 30.9% (17/55) between 50% and 69% relief. We performed an in-depth analysis of these 2 subgroups focusing on the reason a second MBB was performed despite a "negative" or "indeterminant" first MBB. We divided the "negative" responders to the first MBB into those reporting < 50% relief (Group 1) and those reporting between 50% and 69% relief (Group 2). We calculated a potential 46.7% false negative rate in Group 1 and 47.1% false negative in Group 2; however, the false negative results in Group 1 were predominately in those patients reporting delayed relief of pain and those re-blocked greater than 2 years after the first MBB. The success rate in all patients undergoing MBN was 87% compared to the 75% relief in the false negative groups with no statistically significant difference. In summary, the false negative rate for patients reporting less than 50% relief post MBB is probably less than 20% although there is a high "apparent negative" responds in patients reporting delayed relief or in those who had a second block 2 or more years post initial MBB. Patients reporting between 50 and 69% pain relief have a false negative response rate of 47.1% and should be considered for a confirmatory block.

Lumbar discogenic pain: state-of-the-art review.

OBJECTIVE: To test the null hypotheses that: lumbar intervertebral discs cannot be a source of pain; discs are not a source of pain; painful lumbar discs cannot be diagnosed; and there is no pathology that causes discogenic pain. METHODS: Philosophical essay and discourse with reference to the literature. RESULTS: Anatomic and physiologic evidence denies the proposition that disc cannot be a source of pain. In patients with back pain, discs can be source of pain. No studies have refuted the ability of disc stimulation to diagnose discogenic pain. Studies warn only that disc stimulation may have a false-positive rate of 10% or less. Internal disc disruption is the leading cause of discogenic pain. Discogenic pain correlates with altered morphology on computerized tomography scan, with changes on magnetic resonance imaging, and with internal biophysical features of the disc. The morphological and biophysical features of discogenic pain have been produced in biomechanics studies and in laboratory animals. CONCLUSIONS: All of the null hypotheses that have been raised against the concept of discogenic pain and its diagnosis have each been refuted by one or more studies. Although studies have raised concerns, none has sustained any null hypothesis. Discogenic pain can occur and can be diagnosed if strict operational criteria are used to reduce the likelihood of false-positive results.

An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain.

BACKGROUND: The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool. STUDY DESIGN: A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature. OBJECTIVE: To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography. METHODS: The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. 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. RESULTS: Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%. CONCLUSION: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain.

Cost comparisons of various diagnostic medial branch block protocols and medial branch neurotomy in a private practice setting.

OBJECTIVE: We calculated the average total facility and professional cost of medial branch neurotomy (MBN) procedure and diagnostic medial branch blocks (MBBs), based on increments of MBB results (50-100% cutoff values), to determine the most cost-effective protocol that correlates with positive MBN outcome. DESIGN/METHODS: We evaluated both actual cost and the theoretical cost of procedures in three groups: 0, single and double MBB. We calculated costs assuming MBB success rates at incrementally higher levels by incrementally raising the cutoff values for a successful diagnostic MBB by 10% increments (from 50% to 100%). We analyzed each cutoff value using the preposition that all patients meeting the cutoff value would proceed to MBN. Those not meeting the cutoff value would not have the cost of MBN added to the cost calculations. A cost per successful procedure was also analyzed. RESULTS: Cost savings were noted when ≥70% cutoff MBB values were utilized and additionally when patients declined MBN for reasons other than their MBB outcome, although these dropouts lowered the cost-effectiveness of MBB when analyzed as cost per successful procedure. Costs over 5 years per successful procedure using 0, 1 and 2 diagnostic MBB protocol (x) and MBB protocol (o) were, however, similar at all MBB cutoff values. CONCLUSIONS: Diagnostic MBB using progressively stringent MBB cutoff values incrementally excluded patients without posterior element pain as evidenced by incremental increase in positive outcomes following MBN. The exclusion of patients from MBN due to failure to report 70% or greater pain relief following MBB resulted in cost savings in favor of performing diagnostic MBB.

Comparison of four different analgesic discogram protocols comparing the incidence of reported pain relief following local anesthetic injection into concordantly painful lumbar intervertebral discs.

OBJECTIVE: To compare the incidence of pain relief following injection of local anesthetic (LA) into lumbar discs that caused concordant pain during provocation testing. DESIGN: Prospective collected data review from two centers and compare with published results. OUTCOME MEASURES: We compared subjective reported pain relief following provocative testing using the following protocols at three separate facilities: 23 patients undergoing routine provocative discography using contrast alone (PD); 47 patients undergoing provocative discography performed using an equal combination of LA and contrast (CPD); 120 patients injected with LA following routine PD (ADPD); 33 patients undergoing stand-alone analgesic discography (SAAD); and 28 patients injected with LA through a catheter (FAD) placed during provocative discogaphy testing. RESULTS: Pressure-controlled PD showed a positive response rate of 34% per disc in patients with a clinical diagnosis of discogenic pain. None of the PD group without LA had pain relief and less than 10% of the CPD group reported pain relief. Forty percent of the SAAD group with positive pain reproduction reported ≥50% relief and 20% reporting ≥80% relief. Forty-six percent of the ADPD group reported ≥50% relief and 30% reporting ≥80% relief. The FAD group had a greater 80% patients reporting ≥50% pain relief although fewer 26% reporting more convincing ≥80% relief. CONCLUSIONS: If the criterion standard to confirm painful annular tears is concordant pain provocation and 80% or greater pain relief following LA injected into lumbar discs, the SAAD, ADPD, and FAD protocols show statistically similar 20% to 30% prevelance.

Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome.

OBJECTIVE: We sought an optimal medial branch block (MBB) cutoff value for both single and double MBB protocols that would best correlate with a positive outcome of medial branch neurotomy (MBN). OUTCOME MEASURES: We analyzed the percentage of subjective pain relief following MBB, confirmed by numerical rating scale (NRS) in aggravating positions before and 45 minutes after MBB. The percentage of overall pain relief following MBB was plotted against the following outcome variables: degree of subjective pain relief, duration of relief, patient satisfaction and activity level, no other doctor's visits, and reduction in medications use. RESULTS: Using the percent of pain relief post-MBB plotted in 10% increments in the double-MBB group, patients reporting 70% or greater pain relief following MBB showed statistically favorable outcome for the following four criteria: percentage of pain relief, duration of relief, patient satisfaction, and pain medications reduction. In the single MBB group, patients reporting 80% or greater pain relief following MBB had favorable outcomes for improvement in activity level and patient satisfaction. CONCLUSIONS: The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.

An assessment of a new navigatable percutaneous disc decompression device (l'DISQ) through histologic evaluation and thermo-mapping in human cadaveric discs.

STUDY DESIGN: This is an in vitro experimental study of the technical capability and safety study of a navigable percutaneous disc decompression device named L'DISQ. OBJECTIVES: The objectives of this study were to determine if L'DISQ could adequately reach certain target zones in the disc and to measure the distribution of rises in temperature in the surrounding tissue when the device was used to ablate the disc. METHODS: Placement of the wand of L'DISQ was attempted into the posterior annulus of the discs of four fresh human cadavers. During disc ablation, thermocouple probes were used to measure the temperature within the nucleus pulposus and annulus fibrosus, on the surface of the annulus, and on the posterior longitudinal ligament. Tissues harvested from around the disc were examined histologically. RESULTS: The tip of the wand could be successfully navigated to the posterolateral or posterocentral annulus at all levels above L5-S1 using a lateral approach. Rises in temperature did not exceed 13.25 ± 0.84°C within the disc, and did not exceed 1°C on the surface of the disc. Histology demonstrated no thermal damage to the surrounding neural tissues. CONCLUSION: L'DISQ can be successfully navigated to the target zones, and disc tissue ablated without thermal or structural damage to the adjacent neural tissues.

Improving the safety of transforaminal epidural steroid injections in the treatment of cervical radiculopathy.

BACKGROUND: Unplanned vascular trespass occurs in 20% of cervical transforaminal epidural steroid injections (CTFESI) and rarely results in devastating neurologic complications. The Trucath Spinal Injection System is a novel integrated catheter and needle device that is specifically designed to minimize vascular trespass risk. OBJECTIVE: To compare the vascular trespass incidence with the Trucath Spinal Injection System versus standard spinal needles during CTFESI treatment in patients with cervical radiculopathy. STUDY DESIGN: Prospective, multicenter, nonrandomized safety trial. SETTING: Six tertiary spinal pain management centers in the United States. METHODS: We treated 290 patients (411 levels) with recalcitrant cervical radiculopathy using CTFESI; 129 patients (180 levels) were treated with the Trucath Spinal Injection System (Test group) and 161 patients (231 levels) were treated with standard spinal needles (Control group). All injections were administered via a transforaminal approach. Each site attained IRB approval for this study before any research was performed. The primary study endpoint was vascular trespass per treated level. Secondary endpoints included nerve pain or paresthesia, injection accuracy, device performance measures, and procedural adverse events. RESULTS: Vascular trespass occurred more often (odds ratio (OR): 3.1, 95% Confidence Interval (CI): 1.8-5.4, P < 0.001) in Controls (26.8%, 62/231 levels) versus Test patients (10.6%, 19/180 levels). Radicular pain or paresthesia from device positioning was more frequent (OR: 21.1, 95% CI: 6.9-64.5, P < 0.001) in Controls (26.4%, 61/231) versus Test participants (1.7%, 3/179). Inadequate epiradicular flow was observed in 3.0% (7/231) of Controls and 5.6% (10/179) of Test participants (OR: 0.5, 95% CI: 0.2-1.4, P = 0.22). Based on subjective physician judgment (scale: 1-10), there were no differences between the Test and Control groups, respectively, for ease of use (mean 8.9 vs. 9.0), visualization under fluoroscopy (mean 9.2 vs. 9.0), and overall performance (mean 9.0 vs. 8.6). No additional adverse effects were reported in either treatment group in this clinical study. LIMITATIONS: The study did not randomly allocate the type of injection procedure to participants and no clinical outcomes beyond the initial treatment were collected. CONCLUSIONS: The Trucath Spinal Injection System demonstrated a statistically significant reduction in the rate of intravenous and intra-arterial trespass, procedural pain, and paresthesia, and has similar accuracy and performance versus standard spinal needles for CTFESI treatment of cervical radiculopathy.

Efficacy of a new navigable percutaneous disc decompression device (L'DISQ) in patients with herniated nucleus pulposus related to radicular pain.

STUDY DESIGN: An institutional, prospective clinical data analysis. OBJECTIVE: To evaluate the safety and efficacy of a new navigable percutaneous disc decompression device (L'DISQ) in patients with lumbar disc herniation with radicular pain. METHODS AND OUTCOME MEASURES: We performed disc decompressions using L'DISQ on 27 patients with persistent disabling back and leg pain for 1 month or longer (average 6.48 months) due to a herniated lumbar intervertebral disc. Baseline data were prospectively gathered before the index procedure and at 1, 4, 12, and 24 weeks post-procedure. Data included pain intensity (visual analog scale [VAS]), measure of disability (Oswestry Disability Index [ODI] and Rolando-Morris Questionnaire [RM]), health-related quality of life (Bodily Pain Scale of Short Form-36 version 2 [SF-36 BP]), and passive straight leg raising test (SLR). RESULTS: The VAS fell from 7.08±1.22 to 1.84±0.99 scores at 24 weeks post-procedure. At 24 weeks, the ODI had fallen from 41.88±10.61 to 16.66±8.55% and the RM from 11.52±3.91 to 2.68±1.97 points. The SF-36 BP dropped significant improvement from 32.89±5.83 to 49.57±4.96 scales. In the SLR test, the angular change of 24 weeks showed considerable improvement from 60.20±20.02 to 83.00±14.29 degrees. No major complication occurred, although two cases developed a disc reherniation 1 month post-procedure. CONCLUSIONS: The L'DISQ device is specifically designed to remove herniated disc using a wand that can be navigated into a disc protrusion or extrusion. Following decompression, we measured clinically significant pain improvement and decreased disability for patients with both radicular and axial pain caused by protruded and extruded discs.

Novel treatment of onychomycosis using over-the-counter mentholated ointment: a clinical case series.

BACKGROUND: current medication treatments for onychomycosis have less than full cure-rate efficacy and have the potential for adverse side effects. Vicks VapoRub (The Proctor & Gamble Company, Cincinnati, OH) has been advocated in the lay literature as an effective treatment for onychomycosis. This pilot study tested Vicks VapoRub as a safe, cost-effective alternative for treating toenail onychomycosis. METHODS: eighteen participants were recruited to use Vicks VapoRub as treatment for onychomycosis. Participants were followed at intervals of 4, 8, 12, 24, 36, and 48 weeks; digital photographs were obtained during initial and follow-up visits. Primary outcome measures were mycological cure at 48 weeks and clinical cure through subjective assessment of appearance and quantifiable change in the area of affected nail by digital photography analysis. Patient satisfaction was a secondary outcome, measured using a single-item questionnaire scored by a 5-point Likert scale. RESULTS: fifteen of the 18 participants (83%) showed a positive treatment effect; 5 (27.8%) had a mycological and clinical cure at 48 weeks; 10 (55.6%) had partial clearance, and 3 (16.7%) showed no change. All 18 participants rated their satisfaction with the nail appearance at the end of the study as "satisfied" (n = 9) or "very satisfied" (n = 9). CONCLUSIONS: Vicks VapoRub seems to have a positive clinical effect in the treatment onychomycosis.

Toward more useful pressure-controlled discography: in vitro evaluation of injection speed, sensor location, and tube length.

OBJECTIVE: Pressure-controlled manometric discography is used by clinicians to evaluate discogenic pain. However, some would improve diagnostic accuracy. The goal of this study was to investigate potential confounding factors that might affect discographic results. Pressure differences depending on different speed of injection, lengths of connecting tubing and locations of sensors were evaluated using an in vitro model system. METHODS: Two sets of automated discography devices were arranged to record post-syringeal pressure pressures (PSPs) and intradiscal pressures (IDPs) in an "air chamber disk model" representing intradiscal pressure. PSPs and IDPs were measured simultaneously while varying injection speeds, and using intrasyringeal and extrasyringeal pressure sensors and contrast medium-filled tubing of different lengths. All pressure/volume curves were collected and viewed dynamically, and stored for further analysis. RESULTS: At injection speed of 0.1 cc/second, the mean pressure difference (mean ΔP) between PSP and IDP was 38.1 psi. As injection speed was reduced, mean ΔP was proportionally decreased. Mean ΔP was 5.3 psi at injection speed of 0.01 cc/second and 0.7 psi at 0.005 cc/second. Mean ΔP values were significantly higher when pressures were recorded using intrasyringeal sensor: at injection speed of 0.1 cc/second, PSP and IDP values were 82.9 and 30.1 psi, respectively, compared with 50.6 and 12.5 psi measured by extrasyringeal sensor. Mean ΔP due to increased length of tubing was not significant. CONCLUSION: Discography can be better performed with low speed injection (≤0.01 cc/second), using an extrasyringeal sensor. Difference of length of connecting tubings did not cause significant pressure differences. These data suggest that automated discography is a helpful adjunct to improve diagnostic accuracy, due to extrasyringeal location of pressure sensor and greater control of injection speed.

Comparison of pressure-controlled provocation discography using automated versus manual syringe pump manometry in patients with chronic low back pain.

PURPOSE: The study compares the rate of positive discograms using an automated versus a manual pressure-controlled injection devise and compares the pressure and volume values at various pressures and initial evoked pain and 6/10 or greater evoked pain. STUDY DESIGN: A retrospective study prospectively collected patient study data used in a prior prospective study and with prospectively collected data which is routinely collected per our institutional standardized audit protocol. Two custom-built disc manometers (automated injection speed control; manual injection speed control) were sequentially employed during provocation discography in 510 discs of 151 consecutive patients. Two hundred thirty-seven discs of 67 patients with chronic low back pain were evaluated using the automated manometer (automated group) and 273 discs of 84 patients were evaluated with a manual manometer (manual group). RESULT: No significant differences in positive discogram rates were found between the automated and manual groups (32.1% vs 32.6% per disc, respectively, P>0.05). No significant differences in low-pressure positive discogram rates were found (16.0% vs 15.0% per disc, automated group versus manual group, respectively, P>0.05). However, there were significantly increased volumes and lower pressures at initial and "bad" pain provocation. CONCLUSION: The study results found equivalent positive discogram rates following a series of pressure-controlled discography using either an automated or manual pressure devise. There were, however significant increases in volume at both initial onset of evoked pain and at 6/10 pain when using the automated injection devise that may have caused the observed lower opening pressure and lower pressure values at initial evoked pain. Assuming increased volumes are innocuous, automated injection is inherently more controlled and may better reduce unintended and often unrecorded spurious high dynamic pressure peaks thereby reducing conscious and unconscious operator bias.

Intradiscal electrothermal therapy treatment for back pain.

The intradiscal electrothermal therapy (IDET) procedure is a minimally invasive technique designed to treat discogenic chronic low back pain. The debate surrounding IDET ranges from the concept of the procedure, the technique and patient selection, to its effectiveness. The procedure provides modest improvement; however, it is considered less invasive and destructive than other modalities of treatments available at the present time, and has lower cost. The effectiveness evidence is limited at the present time, but based on the results of six recently published positive single-arm studies, it appears that patients experienced a perceptible clinical benefit from the IDET procedure. Thus, IDET is recommended in patients with moderate functional impairment, relatively well-maintained disc heights and discogenic pain caused by annular tears or protrusions less than 3-4 mm after the failure of less invasive procedures.

15. Discogenic low back pain.

An estimated 40% of chronic lumbosacral spinal pain is attributed to the discus intervertebralis. Degenerative changes following loss of hydration of the nucleus pulposus lead to circumferential or radial tears within the annulus fibrosus. Annular tears within the outer annulus stimulate the ingrowth of blood vessels and accompanying nociceptors into the outer and occasionally inner annulus. Sensitization of these nociceptors by various inflammatory repair mechanisms may lead to chronic discogenic pain. The current criterion standard for diagnosing discogenic pain is pressure-controlled provocative discography using strict criteria and at least one negative control level. The strictness of criteria and the adherence to technical detail will allow an acceptable low false positive response rate. The most important determinants are the standardization of pressure stimulus by using a validated pressure monitoring device and avoiding overly high dynamic pressures by the slow injection rate of 0.05 mL/s. A positive discogram requires the reproduction of the patient's typical pain at an intensity of > 6/10 at a pressure of < 15 psi above opening pressure and at a volume less than 3.0 mL. Perhaps the most important and defendable response is the failure to confirm the discus is symptomatic by not meeting this strict criteria. Various interventional treatment strategies for chronic discogenic low back pain unresponsive to conservative care include reduction of inflammation, ablation of intradiscal nociceptors, lowering intranuclear pressure, removal of herniated nucleus, and radiofrequency ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal criteria for a positive treatment advice. In particular, single-needle radiofrequency thermocoagulation of the discus is not recommended for patients with discogenic pain (2 B-). Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans, does meet the (2 B+) level for endorsement. There is currently insufficient proof to recommend intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a study protocol. Future studies should include more strict inclusion criteria.

Analgesic discography: effect of adding a local anesthetic to routine lumbar provocation discography.

INTRODUCTION: There is a renewed interest in analgesic testing, influenced by several studies reporting robust surgical results when the diagnosis of discogenic pain is confirmed by relief of pain post-provocative discography after injecting local anesthetic into painful discs. OBJECTIVE: We anticipated and sought to confirm that injecting local anesthetic in intervertebral discs would provide convincing pain relief and that the degree of pain relief would help confirm or refute the findings of provocative discography. METHODS: There were 23 patients in the nonanalgesic group, and 47 patients in the analgesic group. The analgesic patient discs were injected with an equal volume of local anesthetic and nonionic contrast media. Lumbar discography was performed using an automated pressure-controlled provocative discographic (APCPD) technique. Subjects reported global subjective relief at 15 and 45 minutes after APCPD. Pre- and post-procedure pain was rated using a numerical rating scale (NRS) using standardized pain provoking positions. In addition, we further compared the numbers of patients reporting a decrease in NRS scores (≥2) in standardized pain provoking positions. RESULTS: The addition of local anesthetic to APCPD did not affect the number of positive APCPD results that averaged ∼30% positive discs in both groups. The addition of local anesthetic to contrast significantly reduced pain NRS scores by 2/10 or greater during forward flexion and sitting compared with patients whose discs were injected with contrast without local anesthetic. The average pain improvement using standardized pain provocation positions and average subjective relief were not, however, significantly different in the two groups. Only two patients reported overall pain relief equal or greater to 50%. CONCLUSIONS: Using an equal mixtures of injected local anesthetic and contrast during provocative discography in a cohort of patients did not provide significant overall subjective pain relief compared to using contrast alone in a comparative separate cohort.

A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions.

BACKGROUND: Clinical guidelines are defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The clinical guideline industry has been erupting even faster than innovation in health care, constantly adding unhealthy perspectives with broad and complex mandates to health care interventions. Clinical guidelines are based on evidence-based medicine (EBM) and comparative effectiveness research (CER). Multiple issues related to the development of clinical guidelines are based on conflicts of interest, controversies, and limitations of the guideline process. Recently, the American Pain Society (APS) developed and published multiple guidelines in managing low back pain resulting in multiple publications. However, these guidelines have been questioned regarding their development process, their implementation, and their impact on various specialties. OBJECTIVES: To reassess the APS guidelines' evidence synthesis for low back pain diagnostic interventions using the same methodology utilized by the APS authors. The interventions examined were diagnostic techniques for managing low back pain of facet joint origin, discogenic origin, and sacroiliac joint origin. METHODS: A literature search by two authors was carried out utilizing appropriate databases from 1966 through July 2008. Methodologic quality assessment was also performed by at least 2 authors utilizing the same criteria applied in APS guidelines. The guideline reassessment process included the evaluation of individual studies and systematic reviews and the translation into practice recommendations. RESULTS: Our reassessment of Chou et al's evaluation, utilizing Chou et al's criteria, showed good evidence for lumbar facet joint nerve blocks, fair evidence for lumbar provocation discography, and fair to poor evidence for sacroiliac joint blocks to diagnose sacroiliac joint pain. The reassessment illustrates that Chou et al have utilized multiple studies inappropriately and have excluded appropriate studies. Also, Chou et al failed to eliminate their bias in their study evaluations. CONCLUSION: The reassessment, using appropriate methodology and including high quality studies, shows evidence that differs from published APS guidelines.