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then and now: A historical and scientific perspective. PM R 2015;7(7):746-761.
A narrative review of myofascial trigger points is presented.
visualize and characterize myofascial trigger points and surrounding soft tissue. Arch
Phys Med Rehabil 2009;90(11):1829-1838.
using in vivo microdialysis: An application of muscle pain concepts to myofascial pain
syndrome. J Bodyw Mov Ther 2008;12(4):371-384.
and nociceptive sensitivity in low back pain patient responders versus non-responders
after dry needling treatment. Man Ther 2015;20(6):769-776.
A quasi-experimental study involving 66 volunteers with mechanical low back pain
showed that patients who responded to a single dry needling treatment of the lumbar
multifidus muscle with improved disability 1 week after treatment exhibited larger
improvements in lumbar multifidi muscle contraction and nociceptive sensitivity 1
week after dry needling.
with clinical improvement after dry needling in individuals with low back pain. J
Orthop Sports Phys Ther 2015;45(8):604-612.
A quasi-experimental study involving 72 volunteers with mechanical low back pain
showed that increased low back pain with the multifidus lift test on physical
examination was the strongest predictor of improved disability 1 week after a single dry
needling treatment of the lumbar multifidus.
compared to progressive muscle relaxation in patients with chronic neck pain: A
randomized controlled trial. PLoS One 2013;8(6):e65378.
A randomized controlled trial of 61 patients with nonspecific neck pain showed that
cupping massage was no more effective than progressive muscle relaxation for
improving pain but may be better in improving well-being and decreasing pressure pain
sensitivity. Level of evidence: I.
pain and low back pain: A systematic review and meta-analysis. PLoS One
2015;10(2):e0117146.
A systematic review and meta-analysis of traditional Chinese medicine treatments for
neck pain and low back pain identified 75 randomized controlled trials involving 11,077
patients. Results showed moderate evidence that acupuncture was more effective than
sham acupuncture in reducing pain immediately posttreatment for chronic neck pain,
chronic low back pain, and acute low back pain. Level of evidence: II.
terminal (VDT) users: A randomized controlled pilot trial. J Occup Health
2012;54(6):416-426.
A randomized controlled pilot trial of 40 individuals with neck pain who used video
display terminals showed that cupping was more effective than a heating pad in
improving pain and function. Level of evidence: II.
complementary health approaches among adults: United States, 2002-2012. Natl Health
Stat Report 2015;79:1-16.
This article, based on results from the National Health Interview Survey, provides
statistical trends regarding the use of complementary and alternative medicine in the
United States. It is a helpful review of the various other treatments that are sought
outside the realm of traditional Western medicine.
2002;112(7):566-571.
manipulative therapy practice. Man Ther 2016;21:2-9.
Cervical arterial dissections and association with cervical manipulative therapy: A
statement for healthcare professionals from the American heart association/American
stroke association. Stroke 2014;45(10):3155-3174.
Guidelines for cervical manipulative therapy were provided in a joint manner by the
American Heart Association and American Stroke Association, specifically in regard to
the risk for arterial dissection. This landmark article provides helpful recommendations
for manual medicine practitioners and physicians who see patients treated with manual
medicine techniques.
contrasted against an inactive control or another active treatment. Cochrane Database
Syst Rev 2015;9:CD004249.
The authors provide a systematic review of cervical and thoracic manipulation versus
active and inactive controls. Their review included 51 trials with 2,920 total
participants. Their data include outcome measures for pain, function, and quality of life.
Level of evidence: II.
effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for
older adults with chronic neck pain. Spine J 2016;16(11):1292-1304.
The authors provide estimates on cost-effectiveness of common therapies for older
patients with chronic neck pain, using data collected from a randomized controlled trial.
This study provides helpful information about the cost-effectiveness and clinical
outcomes for selected therapies after 1 year. Level of evidence: I.
chiropractic interventions for low-back pain. Spine (Phila Pa 1976) 2011;36(3):230-
242.
The authors provide a systematic review of lumbar chiropractic manipulations versus an
active or inactive control. This review included 12 trials with 2,887 total participants.
Their data include outcome measures for pain and disability. Level of evidence: II.
Ther 2013;17(3):269-270.
An editorial from a leader in the field of bodywork and movement therapies is
presented.
thoracolumbar fascia in rats and humans. Neuroscience 2011;194:302-308.
A basic science rat and human study showed that the thoracolumbar fascia in both is a
densely innervated tissue with marked differences in the distribution of nerve endings
over the fascial layers and presumably contains nociceptive fibers.
treatment. PM R 2016;8(2):161-168.
A narrative review of fascia research and treatment is presented.
solution. Biomacromolecules 2005;6(1):61-67.
repetitive motion injury and myofascial release. J Bodyw Mov Ther 2010;14(2):162-
171.
Evaluatory and Treatment Approach. Laurel, MD, Rehabilitation Services, 1990.
neck pain: Randomized clinical trial for diagnosis and follow-up. Surg Radiol Anat
2014;36(3):243-253.
A study of 25 healthy patients and 28 patients with chronic neck pain found a difference
in the thickness of the sternocleidomastoid fascia and the scalene fascia as measured
using ultrasound between the two groups, with neck pain patients having thicker fascia.
Level of evidence: III.
thoracolumbar fascia in chronic mechanical back pain: A microscopic study. Spine
(Phila Pa 1976) 1995;20(10):1161-1164.
human chronic low back pain. BMC Musculoskelet Disord 2011;12:203.
A study involving 50 patients without low back pain and 71 patients with chronic low
back pain showed that thoracolumbar fascia shear strain, as measured with ultrasound
cine-recording and a motorized hinge table, was reduced in approximately 20% in the
low back pain group. Level of evidence: III.
Cochrane Database Syst Rev 2015;9:CD001929.
A Cochrane review of massage therapy for low back pain included 25 trials and 3,096
participants. Little evidence was found that massage is an effective treatment for low
back pain. Patients with acute, subacute, and chronic low back pain had improvements
in pain outcomes from massage in the short term. Level of evidence: III.
Manipulation® for chronic aspecific low back pain: A single blinded randomized
controlled trial. F1000Res 2015;4:1208.
This single-blinded randomized controlled trial of 24 patients with chronic a specific
low back pain showed that those receiving fascial manipulation and physiotherapy had
statistically and clinically significant short- and medium-term improvements in pain and
function compared with those receiving physiotherapy alone. Level of evidence: I.
technique in patients with subacute whiplash associated disorders: A pilot study. Eur J
Phys Rehabil Med 2011;47(4):561-568.
A pilot randomized clinical trial of 18 patients with subacute whiplash-associated
disorder found that fascial manipulation resulted in a statistically significant
improvement in neck flexion immediately after treatment compared with conventional
neck exercises and mobilization. Level of evidence: II.
cervical or lumbar pain. J Bodyw Mov Ther 2011;15(4):405-416.
In a study of 60 patients with nonspecific neck pain or low back pain evaluated before
and after fascial techniques and compared with 30 control subjects given sham
treatments, it was found that dynamic ultrasound topographic anatomy evaluation can
be a valid instrument to assess effective sliding of fascial layers in vivo. Level of
evidence: III.
R, Fuentes-Boquete IM: Myofascial release therapy in the treatment of occupational
mechanical neck pain: A randomized parallel group study. Am J Phys Med Rehabil
2016;95(7):507-515.
A randomized, single-blinded parallel group study of 59 patients with occupational
neck pain showed that after five sessions, myofascial release therapy seemed to be more
effective than manual therapy for correcting advanced position of the head, recovering
range of motion in side bending and rotation, and improving quality of life. Level of
evidence: I.
management of chronic low back pain in nursing professionals. J Bodyw Mov Ther
2014;18(2):273-281.
A randomized, controlled, single-blinded trial involving 80 nursing professionals with
chronic low back pain showed that myofascial release as an adjunct to specific back
exercises is more effective than sham myofascial release and specific back exercises in
terms of reduction in pain and functional disability. Level of evidence: I.
Herbal medicine for low back pain: A Cochrane review. Spine (Phila Pa 1976)
2016;41(2):116-133.
This Cochrane review to determine the effectiveness of herbal medicines for
nonspecific low back pain analyzed 14 randomized controlled trials involving 2,050
participants. Results showed that Capsicum frutescens reduced pain more than placebo.
Several other compounds also may reduce pain, but quality of evidence was less for
those compounds compared with that of Capsicum frutescens.
cannabinoids in chronic pain associated with rheumatic diseases (fibromyalgia
syndrome, back pain, osteoarthritis, rheumatoid arthritis): A systematic review of
randomized controlled trials. Schmerz 2016;30(1):47-61.
A systematic review of cannabinoids in chronic pain returned three studies after
screening, two of which were randomized controlled trials. The findings of superiority
of cannabinoids over controls were not consistent. Level of evidence: III.
2011;24(4):452-462.
The authors presented patient scenarios and suggested treatments for the use of
cannabis and its derivatives, detailed the harms and challenges of using cannabis, and
reviewed clinical studies of patients using cannabis and its derivatives for Tourette
syndrome, glaucoma, and pain. Good results were reported in patients with HIV and
multiple sclerosis.
https://www.yogajournal.com/yoga-101/the-roots-of-yoga. Accessed May 5, 2017.
health approaches among children aged 4-17 years in the United States: National Health
Interview Survey, 2007-2012. Natl Health Stat Report 2015;78:1-19.
This article, based on results from the National Health Interview Survey, provides
statistical trends regarding the use of complementary and alternative medicine in the
United States. It is a helpful review of a variety of other treatments for pediatric patients
that are outside of the realm of traditional Western medicine.
predictors of yoga use: Results of a U.S. nationally representative survey. Am J Prev
Med 2016;50(2):230-235.
This article, based on results from the National Health Interview Survey, provides
information regarding the use of yoga in the United States in 2012.
pain: A systematic review of the literature. J Orthop Rheumatol 2016;3(1):1-8.
The authors present a systematic review of randomized controlled trials addressing yoga
as a treatment for chronic low back pain. This article provided strong support for the
use of yoga in reducing pain and disability. Level of evidence: II.
once- versus twice-weekly yoga classes for chronic low back pain in predominantly low
income minorities: A randomized dosing trial. Evid Based Complement Alternat Med
2013;2013:658030.
This randomized controlled trial demonstrates that once-weekly yoga classes are
equally as effective in reducing pain and improving function as twice-weekly classes.
For all patients, but especially those with limited resources, this is important to consider
when creating a therapeutic exercise program for those with chronic low back pain.
controlled trials. J Phys Ther Sci 2016;28(7):2171-2174.
This systematic review of three randomized controlled trials suggests a potential benefit
for practicing yoga to manage chronic neck pain in regard to pain and functional
disability. Level of evidence: II.
Best Pract Res Clin Rheumatol 2012;26(3):387-398.
This descriptive review provides a summarized overview of the historical treatment of
rheumatoid arthritis and osteoarthritis with yoga and tai chi. This article may be helpful
for providing a cultural reference and the benefits of these exercises for rheumatoid
arthritis and osteoarthritis.
2012;46(10):713-718.
The authors of this article critically evaluate prior systematic reviews that evaluated the
potential health benefits from participating in tai chi. Their findings support the use of
tai chi for fall prevention and psychological health improvement.
treatment of chronic nonspecific neck pain: A randomized controlled trial. J Pain
2016;17(9):1013-1027.
The authors present a randomized controlled trial evaluating the effectiveness of three
treatments: tai chi, conventional neck exercises, and waitlist controls. Both tai chi and
conventional neck exercises produced similar improvements in pain and quality of life
when compared with no treatment.
pain and disability in people with persistent low back pain: A randomized controlled
trial. Arthritis Care Res (Hoboken) 2011;63(11):1576-1583.
This randomized controlled trial demonstrates the increased effectiveness of tai chi on
pain interference, pain severity, and disability when compared with outcomes in a
waitlist control group. Level of evidence: II.
Chapter 14
Nonsurgical Care of the Spine:
Procedures
Jason Friedrich, MD Benjamin Marshall, DO
Abstract
In appropriately selected patients, percutaneous spine interventions can
effectively reduce pain and disability resulting from a variety of painful
spine conditions. Research supports the efficacy of transforaminal epidural
steroid injections to manage lumbar radicular pain resulting from disk
herniation and the efficacy of radiofrequency neurotomy to manage chronic
pain in the spinal facet joint. Other spine interventions remain controversial
because of inadequate or conflicting research. Meticulous diagnosis, patient
selection, and technique are required to achieve optimal outcomes with the
use of spine interventions.
Keywords: epidural steroid injection; percutaneous spine
intervention; radiofrequency neurotomy; spine
Neither of the following authors nor any immediate family member has received
anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this chapter: Dr. Friedrich
and Dr. Marshall.
Introduction
Most spine-related pain is effectively managed nonsurgically. When included
in a comprehensive treatment regimen, percutaneous spine interventions can
reduce pain, facilitate rehabilitation, reduce the need for surgery, and help
predict surgical outcome. Whether spine interventional procedures are useful
for certain conditions, such as discogenic low back pain (LBP) and spinal
stenosis, remains controversial. Despite the limitations of the available
literature, it is important to provide a rational, evidence-informed approach to
the use of spine interventions.
Optimizing Interventional Spine Care
Most surgeons agree that spine interventional procedures can relieve pain in
well-selected patients who have back and neck pain and that these procedures
will not be effective in all such patients. The importance of establishing the
correct pathoanatomic diagnosis before proceeding with a therapeutic
interventional procedure cannot be overemphasized.
The three most common sources of axial LBP among adults are the
intervertebral disk, lumbar facet joint, and sacroiliac (SI) joint, with incidence
rates of approximately 40%, 15% to 30%, and 20%, respectively.
1
Intervertebral disk involvement consists of internal disk disruption or
nonhealing annular fissure. Insufficiency fracture, ankylosing spondylitis,
Baastrup syndrome, painful lumbosacral junction pseudarthrosis, and pain
related to surgical hardware each account for fewer than 5% of instances of
LBP. Malignancy, spinal infection, and cauda equina syndrome contribute a
combined 1%. After age 55 years, the risk for discogenic pain decreases, but
the risk for spinal facet joint pain rises, especially in the absence of midline
pain.1 Compared with the lumbar spine, the spinal facet joint accounts for a
greater percentage of cervical pain (55%).2 Prevalence of SI joint pain
increases in patients with lumbosacral fusion and pain below L5.
1,3
Mechanical spine pain is often multifactorial; thus, a comprehensive
approach to diagnosis should be used to account for biomechanical factors
that should be targeted with appropriate physical rehabilitation. Such
biomechanical factors include head-forward position, anterior sagittal
imbalance, hip abductor weakness, altered gait pattern, muscular
deconditioning, poor motor control, midrange segmental motion instability,
hip flexion contracture, hamstring tightness, and poor ergonomics. A
comprehensive musculoskeletal and neuromuscular examination is needed to
evaluate for competing diagnoses such as hip or shoulder disorders and
peripheral neuropathies. A multidisciplinary approach must be used to treat
patients in whom psychosocial factors or central sensitization are involved.
Proceeding with interventional treatments while neglecting the
biomechanical, neurophysiologic, and psychosocial aspects of spine pain will
be a low-value endeavor and may cause harm.
Even after thorough analysis of the patient history, detailed physical
examination, and diligent inspection of all pertinent diagnostic testing, the
precise etiology of spine pain often remains unknown. Although imaging
evaluation is critical in diagnosis, degenerative findings are nonspecific and
can be misleading.4 In patients in whom clinical and radiologic information
yield at least a moderate or high pretest probability for chronic spine pain,
carefully performed diagnostic procedures confirm the source of the pain in
at least 80% of patients.
2,3
False-positive diagnostic injection occurs in up to
40% of patients after a single injection, so in patients in whom accurate
diagnosis is imperative, the surgeon should take steps to reduce the risk for
false-positive diagnostic injection.5 To reduce the risk for false-positive
results, the surgeon can perform a second block with an anesthetic of
different duration of action and classify the patient’s response by both
percentage and duration of improvement. A concordantly positive response
would be one in which the patient attains a predetermined level of pain relief
for the expected duration of the anesthetic used.5 After the pathoanatomic
diagnosis is established, targeted interventional treatments can be used to
reduce pain and disability. In some patients, targeted interventional treatment
obviates the need for spinal surgery.
Rationale for Use of Spine Interventional Procedures
Understanding of the pathophysiology of the various causes of spine pain
continues to evolve. Radicular pain can occur as a result of mechanical
compression or a chemoinflammatory response, as occurs in the setting of an
intervertebral disk herniation. An annular fissure exposes the highly antigenic
nucleus pulposus, triggering an inflammatory cascade that contributes to
local neural edema, altered nerve function, and sensitization.
6-8
Sensitizing
chemicals and inflammatory mediators have been identified at the site of disk
injury, along with upregulation of neuropeptide receptors in local pain
generators, including the dorsal root ganglion (DRG), anulus fibrosus, and
ligaments.7 Placement of autologous nucleus pulposus around the DRG
triggers sustained neural discharges that are consistent with nociception.
7
Neurogenic inflammation associated with spinal facet joint arthritis similarly
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