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      The potential impact of various diagnostic strategies in cases of chronic pain syndromes associated with lumbar spine degeneration

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          Abstract

          Purpose

          To study the possible effects of various diagnostic strategies and the relative contribution of various structures in order to determine the optimal diagnostic strategy in treating patients with noncompressive pain syndromes.

          Study design

          Prospective, nonrandomized cohort study of 83 consecutive patients with noncompressive pain syndromes resistant to repeated courses of conservative treatment. The follow-up period was 18 months.

          Results

          Nucleoplasty was effective in cases of discogenic pain; the consequences related to false positive results of the discography were significant. The most specific criterion was 80% pain relief after facet joint blocks, whereas 50% pain relief and any subjective pain relief were not associated with a significant increase in the success rate. A considerable rate of false negative results was associated with 80% pain relief, whereas 50% pain relief after facet joint blocks showed the optimal ratio of sensitivity and specificity. Facet joint pain was detected in 50.6% of cases (95% confidence interval 44.1%–66.3%), discogenic pain in 16.9% cases (95% confidence interval 9.5%–26.7%), and sacroiliac joint pain in 7.2% cases (95% confidence interval 2.7%–15%). It was impossible to differentiate the main source of pain in 25.3% of cases.

          Conclusion

          It is rational to adjust the diagnostic algorithm to the probability of detecting a particular pain source and, in doing so, reduce the number of invasive diagnostic measures to evaluate a pain source. False positive results of diagnostic measures can negatively affect the overall efficacy of a particular technology; therefore, all reasons for the failure should be studied in order to reach an unbiased conclusion. In choosing diagnostic criteria, not only should the success rate of a particular technology be taken into consideration but also the rate of false negative results. Acceptable diagnostic criteria should be based on a rational balance of sensitivity and specificity.

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          Most cited references 52

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          Comprehensive review of epidemiology, scope, and impact of spinal pain.

          Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, "pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur." In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.
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            Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.

            This prospective study consisted of the evaluation of a double sacroiliac block in patients with low back pain. To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain, and to assess certain pain provocation tests. Previous studies have implicated the sacroliac joint as a potential etiology of back and leg pain, but none has tested double anesthetic blocks in a prospective fashion. Fifty-four patients with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the sacroiliac joint, and no obvious source of pain in the lumbar spine were selected for a double anesthetic block. The procedure consisted of a through clinical examination with a visual analog scale, testing of sacroiliac pain provocation tests followed by a first screening block with a short-acting anesthetic. A second examination consisting of the same tests assessed the efficacy of the first block. If results were positive, a confirmatory block was performed. All blocks were performed under fluoroscopic guidance. Nineteen patients had a positive response to the first block. Among them, 10 (18.5%) were temporarily relieved by the confirmatory block. No pain provocation test reached statistical significance. The present study suggests the sacroiliac joint is an uncommon but real source of low back pain. The accuracy of some of the presumed "sacroiliac pain provocations tests" is questioned.
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              Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.

              Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians. To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Systematic assessment of the literature. Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term. The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2. The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations. The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. 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. Further, these guidelines also do not represent "standard of care."
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2013
                17 April 2013
                : 6
                : 289-296
                Affiliations
                Scientific Research Institute of Traumatology and Orthopedics, Nizhniy Novgorod, Russian Federation
                Author notes
                Correspondence: Andrey Bokov, Scientific Research Institute of Traumatology and Orthopedics, Verkhnyaya Volzhskaya Naberezhnaya – 18, Nizhniy Novgorod 603155, Russian Federation, Tel +7 910 798 5159, Fax +7 831 278 7901, Email andrei_bokov@ 123456mail.ru
                Article
                jpr-6-289
                10.2147/JPR.S42646
                3636805
                23637553
                © 2013 Bokov et al, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

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