Management of chronic low back pain: rationales, principles, and targets of imaging-guided spinal injections.

If low back pain does not improve with conservative management, the cause of the pain must be determined before further therapy is initiated. Information obtained from the patient's medical history, physical examination, and imaging may suffice to rule out many common causes of chronic pain (eg, fracture, malignancy, visceral or metabolic abnormality, deformity, inflammation, and infection). However, in most cases, the initial clinical and imaging findings have a low predictive value for the identification of specific pain-producing spinal structures. Diagnostic spinal injections performed in conjunction with imaging may be necessary to test the hypothesis that a particular structure is the source of pain. To ensure a valid test result, diagnostic injection procedures should be monitored with fluoroscopy, computed tomography, or magnetic resonance imaging. The use of controlled and comparative injections helps maximize the reliability of the test results. After a symptomatic structure has been identified, therapeutic spinal injections may be administered as an adjunct to conservative management, especially in patients with inoperable conditions. Therapeutic injections also may help hasten the recovery of patients with persistent or recurrent pain after spinal surgery.

[1]  C. Aprill,et al.  Sacroiliac Joint: Pain Referral Maps Upon Applying a New Injection/Arthrography Technique Part I Asymptomatic Volunteers , 1994, Spine.

[2]  R. Deyo,et al.  What can the history and physical examination tell us about low back pain? , 1992, JAMA.

[3]  R. Herzog,et al.  The Value of Radionuclide Imaging in the Diagnosis of Sacroiliac Joint Syndrome , 1996, Spine.

[4]  A. Gangi,et al.  Interventional Musculoskeletal Procedures , 2001 .

[5]  R. Fraser,et al.  Interbody, Posterior, and Combined Lumbar Fusions , 1995, Spine.

[6]  J. Weinstein,et al.  The Role of Steroids and Their Effects on Phospholipase A2: An Animal Model of Radiculopathy , 1998, Spine.

[7]  C. Pfirrmann,et al.  Selective nerve root blocks for the treatment of sciatica: evaluation of injection site and effectiveness--a study with patients and cadavers. , 2001, Radiology.

[8]  N. Bogduk,et al.  The Ability of Computed Tomography to Identify a Painful Zygapophysial Joint in Patients With Chronic Low Back Pain , 1995, Spine.

[9]  M. Brant-Zawadzki,et al.  Low Back Pain1 , 2000 .

[10]  N. Bogduk,et al.  The Prevalence and Clinical Features of Internal Disc Disruption in Patients With Chronic Low Back Pain , 1995, Spine.

[11]  J. Stessman,et al.  Chronic Back Pain Among the Elderly: Prevalence, Associations, and Predictors , 2006, Spine.

[12]  N. Bogduk,et al.  The Value of Medical History and Physical Examination in Diagnosing Sacroiliac Joint Pain , 1996, Spine.

[13]  N. Bogduk,et al.  The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints , 1994, Pain.

[14]  A. Gangi,et al.  CT-guided interventional procedures for pain management in the lumbosacral spine. , 1998, Radiographics : a review publication of the Radiological Society of North America, Inc.

[15]  C. Slipman,et al.  Inciting events initiating injection-proven sacroiliac joint syndrome. , 2004, Pain medicine.

[16]  M. Osteaux,et al.  Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. , 1998, Radiology.

[17]  B. Mehta,et al.  Imaging-guided injection techniques with fluoroscopy and CT for spinal pain management. , 2001, Radiographics : a review publication of the Radiological Society of North America, Inc.

[18]  J. Schölmerich,et al.  No alterations of serum levels of adrenal and gonadal hormones in patients with ankylosing spondylitis. , 2002, Clinical and experimental rheumatology.

[19]  A. Nachemson,et al.  Newest knowledge of low back pain. A critical look. , 1992, Clinical orthopaedics and related research.

[20]  L. Gilula,et al.  Management of spinal pain with imaging-guided injection. , 2003, Radiographics : a review publication of the Radiological Society of North America, Inc.

[21]  D. Grob,et al.  Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. , 2006, Acta orthopaedica Belgica.

[22]  T. Thulbourne,et al.  Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain , 1992, Pain.

[23]  C. Pfirrmann,et al.  Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. , 2001, Radiology.

[24]  Y. Maugars,et al.  Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study. , 1996, British journal of rheumatology.

[25]  H. Genant,et al.  The normal sacroiliac joint: a CT study of asymptomatic patients. , 1984, Radiology.

[26]  F. Sturmans,et al.  Injection therapy for subacute and chronic benign low back pain. , 2001, Spine.

[27]  N. Bogduk.  Clinical Anatomy of the Lumbar Spine and Sacrum , 1997 .

[28]  Thomas J Errico,et al.  Paraplegia after lumbosacral nerve root block: report of three cases. , 2002, The spine journal : official journal of the North American Spine Society.

[29]  T. Videman,et al.  The Occurrence of Anular Tears and Their Relation to Lifetime Back Pain History: A Cadaveric Study Using Barium Sulfate Discography , 2004, Spine.

[30]  N. Bogduk,et al.  The value of the provocation response in lumbar zygapophyseal joint injections. , 1994, The Clinical journal of pain.

[31]  D. Brodke,et al.  Nonsurgical management of low back pain and lumbar disk degeneration. , 2005, Instructional course lectures.

[32]  J. Taylor,et al.  Facet joint injection for low back pain. A clinical study. , 1986, The Journal of bone and joint surgery. British volume.

[33]  N. Bogduk,et al.  The Sacroiliac Joint in Chronic Low Back Pain , 1995, Spine.

[34]  L. Manchikanti,et al.  Evaluation of the relative contributions of various structures in chronic low back pain. , 2001, Pain physician.

[35]  D. Schellinger,et al.  Facet joint disorders and their role in the production of back pain and sciatica. , 1987, Radiographics : a review publication of the Radiological Society of North America, Inc.

[36]  P. Wennerstrand,et al.  Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint. , 2002, Clinical and experimental rheumatology.

[37]  F. Falco,et al.  Three pathways between the sacroiliac joint and neural structures. , 1999, AJNR. American journal of neuroradiology.

[38]  L. Bouter,et al.  On the Accuracy of History, Physical Examination, and Erythrocyte Sedimentation Rate in Diagnosing Low Back Pain in General Practice: A Criteria‐Based Review of the Literature , 1995, Spine.

[39]  G. Groen,et al.  Diagnostic Lumbosacral Segmental Nerve Blocks With Local Anesthetics: A Prospective Double-Blind Study on the Variability and Interpretation of Segmental Effects , 2000, Regional Anesthesia & Pain Medicine.

[40]  L. Manchikanti,et al.  Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions , 2004, BMC musculoskeletal disorders.

[41]  E. Vresilovic,et al.  Sacroiliac joint pain referral zones. , 2000, Archives of physical medicine and rehabilitation.

[42]  L. Lenke,et al.  Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. , 2006, The Journal of bone and joint surgery. American volume.

[43]  S. Piantadosi,et al.  Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease , 1996, Pain.

[44]  P. D. Wall,et al.  Sensory afferent impulses originate from dorsal root ganglia as well as from the periphery in normal and nerve injured rats , 1983, Pain.

[45]  G. Lutz,et al.  Transforaminal Epidural Steroid Injections in Lumbosacral Radiculopathy: A Prospective Randomized Study , 2002, Spine.

[46]  Y. Toyama,et al.  Long-Term Outcomes of Standard Discectomy for Lumbar Disc Herniation: A Follow-Up Study of More Than 10 Years , 2001, Spine.

[47]  N. Bogduk,et al.  Specificity of Lumbar Medial Branch and L5 Dorsal Ramus Blocks: A Computed Tomography Study , 1997, Spine.

[48]  R. Moots,et al.  Is methotrexate effective in ankylosing spondylitis? , 2002, Rheumatology.

[49]  L. Manchikanti,et al.  Evaluation of the prevalence of facet joint pain in chronic thoracic pain. , 2002, Pain physician.

[50]  C. Claussen,et al.  Magnetresonanzgesteuerte kortikosteroid-infiltration der sakroiliakalgelenke: Schmerztherapie der sakroiliitis bei patienten mit spondylitis ankylosans , 2005 .

[51]  N Bogduk,et al.  Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. , 1996, The New England journal of medicine.

[52]  L. Bouter,et al.  The Prognosis of Low Back Pain in General Practice , 1997, Spine.

[53]  Marie E. Latulippe,et al.  A controlled trial of corticosteroid injections into facet joints for chronic low back pain. , 1991, The New England journal of medicine.

[54]  Ricardo Pietrobon,et al.  Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States , 2004, Spine.

[55]  N. Bogduk,et al.  Clinical Features of Patients with Pain Stemming from the Lumbar Zygapophysial Joints: Is the Lumbar Facet Syndrome a Clinical Entity? , 1994, Spine.

[56]  G. Andersson.  Epidemiological features of chronic low-back pain , 1999, The Lancet.

[57]  E. Vresilovic,et al.  Fluoroscopically Guided Therapeutic Sacroiliac Joint Injections for Sacroiliac Joint Syndrome , 2001, American journal of physical medicine & rehabilitation.

[58]  T. Takebayashi,et al.  Effects of Nucleus Pulposus on Nerve Root Neural Activity, Mechanosensitivity, Axonal Morphology, and Sodium Channel Expression , 2004, Spine.

[59]  N. Obuchowski,et al.  Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. , 2005, Radiology.

[60]  C HIRSCH,et al.  The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. , 1963, Acta orthopaedica Scandinavica.

[61]  R. Derby,et al.  Disc Stimulation and Patterns of Referred Pain , 2002, Spine.

[62]  L. Czervionke,et al.  Image-Guided Spine Intervention , 2002 .

[63]  N. Bogduk.  International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophysial joint blocks. , 1997, The Clinical journal of pain.

[64]  D. Quint,et al.  Computerized tomographic localization of clinically-guided sacroiliac joint injections. , 2000, The Clinical journal of pain.

[65]  John W. Frymoyer,et al.  Back pain and sciatica. , 1988, The New England journal of medicine.

[66]  Kuslich Sd,et al.  The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. , 1991 .

[67]  Jeffrey Jarvik,et al.  Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging , 2002, Annals of Internal Medicine.

[68]  Lasse Jyrkinen,et al.  MRI-guided periradicular nerve root infiltration therapy in low-field (0.23-T) MRI system using optical instrument tracking , 2002, European Radiology.

[69]  Roberto Blanco Sequeiros,et al.  Percutaneous MR‐guided discography in a low‐field system using optical instrument tracking: A feasibility study , 2003, Journal of magnetic resonance imaging : JMRI.

[70]  J. Maigne,et al.  Results of Sacroiliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain , 1996, Spine.

[71]  P. Goupille,et al.  Pathophysiology of disk-related sciatica. I.--Evidence supporting a chemical component. , 2006, Joint, bone, spine : revue du rhumatisme.

[72]  T. Takebayashi,et al.  Effect of Nucleus Pulposus on the Neural Activity of Dorsal Root Ganglion , 2001, Spine.

[73]  S. Nakamura,et al.  Innervation of the Lumbar Facet Joints: Origins and Functions , 1997, Spine.

[74]  Jonathan H Sunshine,et al.  Spinal injection procedures: volume, provider distribution, and reimbursement in the U.S. medicare population from 1993 to 1999. , 2002, Radiology.

[75]  R. E. Kinard,et al.  Diagnostic spinal injection procedures. , 1996, Neurosurgery clinics of North America.

[76]  N. Semmer,et al.  The Diagnostic Accuracy of Magnetic Resonance Imaging, Work Perception, and Psychosocial Factors in Identifying Symptomatic Disc Herniations , 1995, Spine.

[77]  P. Robertson,et al.  Prospective Assessment of Outcomes Improvement Following Fusion for Low Back Pain , 2004, Journal of spinal disorders & techniques.