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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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outcomes in RFN.
Sacroiliac Joint Pain
The SI joint is the cause of chronic LBP in 15% to 30% of patients, with a
higher prevalence in older patients as well as in patients with a history of
lumbosacral fusion, spondyloarthropathy, and/or pain isolated below L5.
1
Although no single physical examination maneuver has a high predictive
value for diagnosing SI joint pain, the following criteria predict a positive
response to a diagnostic block in 70% to 80% of patients: maximal pain
below L5 and positive findings on at least three of these six provocation tests
—distraction; compression; thigh thrust; Gaenslen; flexion, abduction,
external rotation; and sacral thrust.40 Unless true sacroiliitis is present,
imaging is of limited use in diagnosing presumed SI joint pain. The preferred
method for diagnosing SI joint pain remains positive response to an imageguided intra-articular block with local anesthetic. As with facet joint
injections, false-positive rates are high with single blocks (20% to 40%).
5
After SI joint pain has been confirmed and physical rehabilitation has
been unsuccessful, interventional treatment may be performed. Treatment
options include intra-articular SI joint injection with corticosteroid (Figure
7), conventional RFN, and cooled RFN. All procedures should be performed
under image guidance. Intra-articular injections should be confirmed with
radiopaque contrast. Similar to the facet joint injection studies, most
therapeutic SI joint injection trials suffer from loose patient selection criteria.
The estimated therapeutic effectiveness of SI joint injection is shown in
Table 2.
RFN may be considered for patients who have confirmed SI joint pain
and who do not experience sustained improvement after intra-articular
injection. Because of the complex innervation of the SI joint, positive
response to diagnostic lateral branch blocks should be obtained before
proceeding to RFN, even in patients who have a positive response to the
intra-articular local anesthetic block. The most common protocol includes
anesthetic blockade of the L5 dorsal ramus and lateral branches from S1-S3
(blocked at the lateral aspects of the S1, S2, and S3 sacral foramina). The
ventral innervation of the joint is not accessible. Patients who experience a
positive intra-articular block but have a negative response to lateral branch
blocks may still have pain related to the SI joint ligament complex; however,
these patients are not good candidates for RFN. Placebo-controlled trials
using cooled RFN suggest NNT of 1.5 to 2 to achieve at least 50% pain relief
for 3 to 9 months, if patients are selected on the basis of having experienced
at least 50% to 75% relief from anesthetic blocks.
41,42
Further studies are
needed to evaluate the effectiveness of conventional RFN in the management
of SI joint pain.
Soft-Tissue Pain From Posterior Hardware
In a study that used a stringent diagnostic protocol, including the use of two
local anesthetic blocks and a saline injection, approximately 2.9% (95%
confidence interval, 1.3% to 6.7%) of patients with postfusion axial pain
were found to have hardware-mediated pain.1 There are currently no
literature-supported percutaneous treatments for hardware-mediated pain.
Pseudoarticular Pain
Pseudoarticular pain is a rare cause of LBP, occurring in fewer than 3% of
patients and may result from Baastrup disease or Bertolotti syndrome.
1
Diagnosis is easily confirmed on image-guided local anesthetic injection.
Although the use of corticosteroid injection or RFN in such patients has not
been rigorously studied, these modalities do provide pain relief in some
patients.
Contraindications to and Risks of Spine Interventions
Absolute contraindications to most percutaneous spine interventions include
bleeding disorder; infection; history of severe allergic reaction with any of
the injected materials; tumor in the location of the injection; pregnancy; and
inability to obtain informed consent, including reasonable patient
expectations. Guidelines should be used for periprocedural management of
anticoagulants and antiplatelet agents.50 Other relative contraindications
include uncontrolled diabetes mellitus; heart failure; mild pain that responds
to less invasive treatments; pain in multiple regions of the body; and/or
substantial preinjection anxiety, fear-avoidance, or catastrophizing.
Percutaneous procedural complications are rare, occurring in fewer than
1% of patients; however, complications can include infection (0.01% to 0.1%
of injections), epidural hematoma (<0.0001% of epidural injections),
anaphylaxis, air embolism, vasovagal syncope (1% to 2% for lumbar and 8%
for cervical injections), and temporary or permanent nerve injury.
5,7,51
Risks
particular to ESIs include dural puncture, spinal headache, nerve puncture,
intrathecal injection, and intravascular injection. Intrathecal injection of local
anesthetic can result in variable degrees of spinal block, which is potentially
catastrophic in the cervical spine. Intrathecal injection of any substance,
particularly corticosteroid, carries the risk for arachnoiditis. Intravenous
injection is rarely dangerous; however, intra-arterial injection can cause
catastrophic injury, with the potential for seizure, stroke, paralysis, or
death.31 Awareness of the risk for intra-arterial injection is particularly
pertinent when performing cervical transforaminal ESI (because the vertebral
and radicular arteries can reside in close proximity to the needle) and
transforaminal ESI in the lower thoracic spine (and, more rarely, the lumbar
spine) where the artery of Adamkiewicz is located. The artery of
Adamkiewicz provides the main blood supply to the anterior spinal artery and
typically enters the spinal canal between T9 and L2; however, this artery can
enter the spinal canal more caudally and on the right side. Inadvertent
injection of particulate corticosteroid into this artery during transforaminal
ESI has been linked to several cases of paraplegia.51 Negative aspiration is
inadequate for detecting intravascular penetration in 50% of epidural
injections.
5,51
Fluoroscopically guided contrast injection can reduce the risk
of intravascular injection, and use of digital subtraction angiography, if
available, is an even better option.
5,7,51
Risks of corticosteroid injection can be
substantial, including but not limited to osteoporosis, adrenal insufficiency,
Cushing syndrome, and hyperglycemia.
RFN carries additional unique risks, including post-RFN neuritis,
anesthesia dolorosa, and muscle injury/denervation. Risk to the dorsal and
ventral nerve roots is low when correct technique is used. Post-RFN neuritis
can occur even with perfect technique, and it typically involves painful
dysesthesias in the distribution of the targeted nerve lasting days to several
weeks. Segmental multifidus denervation occurs with successful RFN, but
this finding is not clinically significant in the lumbar spine.52 Cervical muscle
weakness and kyphosis have been reported after multilevel cervical RFN.
Added caution is needed when performing RFN at a site near posterior spinal
hardware, because hardware temperatures can potentially heat to dangerous
levels.
53
Investigational Technologies
Some surgeons believe that pulsed radiofrequency to the DRG may be an
alternative to ESI for managing refractory radicular pain. In pulsed
radiofrequency, a conventional RFN needle is heated to 42°C and the target
nerve is exposed to an electrical field in an attempt to suppress ectopic firing
of nociceptive fibers, without coagulating the nerve. Limited early studies
show small effect size compared with sham treatment, with an NNT of 6 to
achieve at least 50% improvement in pain.43 A large RCT is required to
investigate the efficacy of this technique.
The Minimally Invasive Lumbar Decompression (mild; Vertos Medical)
procedure involves percutaneous removal of redundant ligamentum flavum
under fluoroscopic guidance. Most studies are industry sponsored, with the
best study indicating stronger treatment effect than ESI through 12 weeks
postprocedure.54 The best systematic review indicates that the mild procedure
appears to be generally safe, with some positive treatment effects after up to
1-year follow-up based on low-quality evidence.
54
Plasma disk decompression involves percutaneous removal of nucleus
pulposus through a 17-gauge needle with the goal of decompressing an
intervertebral disk herniation. Industry-sponsored studies suggest a higher
rate of responders at 2-year follow-up after treatment with plasma disk
decompression compared with transforaminal ESI in patients in whom
physical therapy, medications, and one ESI have been unsuccessful.
Specifically, this study reported a 50% probability of needing a second
procedural intervention (such as repeat injection or surgery) within 2 years in
the group receiving plasma disk decompression versus an 80% probability in
the group receiving a transforaminal ESI.55 Level I trials are needed to
determine the efficacy of this technique.
Biologic regenerative treatments for degenerative spine conditions,
especially for discogenic pain, are of considerable interest currently.
Although animal and in vitro models have shown promise for both platelet-
rich plasma (PRP) and stem cells, published clinical trials are lacking and
treatments remain experimental. One recent double-blind, placebo-controlled
RCT reported positive mean outcomes of intradiscal PRP compared with
injection of contrast at 8-week follow-up.44 However, categorical data were
provided for patient satisfaction only, with satisfaction rates of 55% after
intradiscal PRP and 18% after contrast injection. Prospective case studies
have demonstrated positive effects of intradiscal PRP, intradiscal autologous
bone marrow aspirate for diskography-confirmed discogenic LBP, PRP
injection for SI joint pain, and hyaluronic acid injection for lumbar facet joint
pain.56 An FDA-monitored phase II RCT assessed the safety and efficacy of
allogeneic mesenchymal stem cells injected into a single mildly degenerative
disk.56 Preliminary results indicate a 69% response rate for at least 50%
improvement in LBP, compared with a 33% response rate in the control
group (NNT = 2.8). A phase III study is in development.
Missing Evidence
Currently, there is no evidence to support the widespread use of injections to
manage thoracic pain, axial pain resulting from stenosis, or spondylolisthesis.
No evidence exists that any interventional treatment, whether percutaneous or
surgical, is better than therapeutic exercise for managing chronic nonspecific
axial LBP.
Summary
In the current healthcare environment, procedural interventions are
increasingly being judged on their ability to provide measurable populationbased benefits. In other words, to add value to the system, therapeutic spine
interventions must be effective in more than a small proportion of patients
treated, facilitate restoration of function and increased return-to-work rates,
decrease healthcare utilization, be cost-effective, and be better than placebo.
The importance of accurate diagnosis and patient selection cannot be
overstated. When used in the appropriate patient and with precise technique,
percutaneous spine interventions remain a valuable part of a comprehensive
treatment approach.
Key Study Points
Of all percutaneous therapeutic spine interventions, the only grade A
recommendation is for lumbar transforaminal ESI to manage radicular
pain resulting from disk herniation.
In carefully selected patients, RFN has proved to be effective for
maintaining long-term improvement in chronic facet joint pain.
Although some patients with spinal stenosis benefit from ESI, it remains
unclear if corticosteroid is better than epidural injection of local anesthetic.
No percutaneous intradiscal procedures have proved to be consistently
effective in a majority of patients with axial discogenic pain.
Annotated References
1. DePalma MJ, Ketchum JM, Saullo T: What is the source of chronic low back pain and
does age play a role? Pain Med 2011;12(2):224-233.
The intervertebral disk is the most common cause of chronic low back pain in adults.
Spinal facet pain and sacroiliac joint pain become more common with increased age.
2. Yin W, Bogduk N: The nature of neck pain in a private pain clinic in the United States.
Pain Med 2008;9(2):196-203.
3. DePalma M, Laplant B: Interventional spine care, in Rao RD, Smuck M, eds:
Orthopaedic Knowledge Update: Spine, ed 4. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2012, pp 121-146.
Interventional spine procedures can reveal the source of chronic spinal pain in 80% to
90% of patients. Procedures aimed at the appropriate pain generator can reduce pain
and disability.
4. Brinjikji W, Luetmer PH, Comstock B, et al: Systematic literature review of imaging
features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol
2015;36(4):811-816.
Imaging findings of spine degeneration are present in high proportions of asymptomatic
individuals, and these findings increase with age. Many imaging-based degenerative
features likely are part of the normal aging process and are unassociated with pain.
5. Bogduk N, ed: Practice Guidelines for Spinal Diagnostic and Treatment Procedures,
ed 2. San Francisco, CA, International Spine Intervention Society, 2013.
Diagnostic and therapeutic spine interventions continue to evolve. Technical guidelines
exist to optimize patient selection and performance.
6. Woolf CJ: Central sensitization: Implications for the diagnosis and treatment of pain.
Pain 2011;152(3 suppl):S2-S15.
Nociceptive input from a disk, joint, or nerve can increase excitability and synaptic
efficacy in central nociceptive pathways, which is representative of the neuroplasticity
of the pain processing system.
7. Friedrich JM, Harrast MA: Lumbar epidural steroid injections: Indications,
contraindications, risks, and benefits. Curr Sports Med Rep 2010;9(1):43-49.
8. Bogduk N, Aprill C, Derby R: Lumbar discogenic pain: State-of-the-art review. Pain
Med 2013;14(6):813-836.
This evidence-based review supports the pathophysiology of discogenic pain. Correctly
performed diskography remains the standard for diagnosis.
9. Barham G, Hilton A: Caudal epidurals: The accuracy of blind needle placement and the
value of a confirmatory epidurogram. Eur Spine J 2010;19(9):1479-1483.
syndrome”: Is fluoroscopy really necessary? Anesth Analg 1999;88(2):367-372.
branch radiofrequency neurotomy in New Zealand. Pain Med 2013;14(5):639-645.
This prospective outcome study of 106 patients reported that lumbar RFN can be
effective when performed in a rigorous manner in appropriately selected patients. Level
of evidence: IV.
sacroiliac joint pain: A meta-analysis. PM R 2010;2(9):842-851.
warn of rare but serious neurologic problems after epidural corticosteroid injections for
pain. April 23, 2014. Available at:
https://www.fda.gov/Drugs/DrugSafety/ucm394280.htm. Accessed February 15, 2017.
2016. Available at: http://packageinserts.bms.com/pi/pi_kenalog-40.pdf. Accessed
February 15, 2017.
Injections: Review and Recommendation Statement. Burr Ridge, IL, North American
Spine Society, 2013. Available at:
www.spine.org/Portals/0/Documents/ResearchClinicalCare/LTFESIReviewRecStatement.pdf
Accessed January 25, 2017.
Grade A evidence from level I trials supports the use of transforaminal epidural steroid
injections in the management of radicular pain. Evidence is limited for other
indications.
steroids in spinal epidurals: A systematic review and meta-analysis. Eur Spine J 2016;
Feb 12 [Epub ahead of print].
Particulate steroids are not demonstrably better for relieving pain compared with their
nonparticulate steroid preparations in spinal epidural injections. Nonparticulate steroids
may be safer than particulate steroids. Level of evidence: II.
transforaminal epidural steroid injections with particulate versus nonparticulate
corticosteroids for lumbar radicular pain due to intervertebral disc herniation: A
prospective, randomized, double-blind trial. Pain Med 2014;15(4):548-555.
There is no significant difference between nonparticulate and particulate steroids in
outcomes after transforaminal epidural steroid injections to manage radicular pain. A
small number of patients receiving nonparticulate steroids require an additional
injection to obtain optimal benefit. Level of evidence: II.
outcomes between epidural injections with particulate versus non-particulate steroids?
Eur Radiol 2016;Jul 19 [Epub ahead of print].
The authors of this retrospective analysis of 597 patients who were treated with an
interlaminar epidural steroid injection to manage radicular pain reported more favorable
outcomes in patients who received particulate steroid injection compared with patients
who received nonparticulate steroid injections. Level of evidence: III.
transforaminal injection of steroids: A comprehensive review with systematic analysis
of the published data. Pain Med 2013;14(1):14-28.
In most patients with lumbar radicular pain resulting from disk herniation,
transforaminal injection of corticosteroids is effective in reducing pain, restoring
function, reducing the need for other health care, and avoiding surgery. Level of
evidence: II.
epidural steroid injection affect infection risk after ACDF or posterior cervical fusion?
Spine (Phila Pa 1976) 2016;Apr 23 [Epub ahead of print].
Preoperative cervical epidural steroid injection within 3 to 6 months of cervical surgery
is independently associated with an increased rate of postoperative infection. Level of
evidence: III.
associated with increased risk of infection after single level lumbar decompression: A
nationwide database analysis of 62,241 cases. Spine J 2015;15(10):S126 Available at:
http://www.thespinejournalonline.com/article/S1529-9430(15)00791-3/abstract.
Accessed January 18, 2017.
Lumbar decompression within 3 months after epidural steroid injection may be
associated with an increased rate of postoperative infection, although the incidence of
infection remains low.
less improvement in patients with lumbar spinal stenosis: A subgroup analysis of the
Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2013;38(4):279-291.
Epidural steroid injections are associated with significantly less improvement at 4-year
follow-up among all patients with spinal stenosis in SPORT. Such injections are also
associated with longer surgical time and hospital stays.
steroid injection on postoperative outcome in patients from the Lumbar Spinal Stenosis
Outcome Study. Spine (Phila Pa 1976) 2015;40(16):1303-1310.
Epidural steroid injections had no significant effect on surgical or nonsurgical outcomes
in a cohort of 281 patients with lumbar stenosis. Level of evidence: III.
Clin N Am 2016;27(3):673-686.
Most spine procedures for managing pain can be performed under ultrasonographic
guidance; however, clinical trials are lacking, and bone may obscure the surgeon’s
ability to detect intravascular injection when performing transforaminal epidural steroid
injection.
for the treatment of lumbar radicular pain. Pain Med 2010;11(8):1149-1168.
considered for epidural steroid injections. PM R 2013;5(5suppl):S96-S99.
Positive electrodiagnostic evaluation for radiculopathy is associated with increased odds
of positive response to epidural steroid injection.
efficacy of epidural steroid injections for structural lumbar degenerative pathology.
Spine J 2016;16(8):928-934.
Attributes associated with substantial positive functional outcomes after epidural steroid
injection include a diagnosis of disk herniation, central stenosis, and increased initial
disability. Negative responses were predicted by prior surgery, longstanding symptoms,
and preinjection anxiety.
glucocorticoid injections for spinal stenosis. N Engl J Med 2014;371(1):11-21.
For management of lumbar spinal stenosis, epidural injection of corticosteroid plus
lidocaine offered minimal or no short-term benefit compared with epidural injection of
lidocaine alone. Level of evidence: II.
stenosis with neurogenic claudication. Cochrane Database Syst Rev
2013;8(8):CD010712.
The authors of this study present low-quality evidence that epidural steroid injections
provide short-term benefit compared with exercise. Moderate- and high-quality
evidence for nonsurgical management of spinal stenosis is lacking.
and Recommendation Statement. Burr Ridge, IL, North American Spine Society, 2011.
Available at:
https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/CESIReviewRecStatement.pdf
Accessed January 18, 2017.
Grade C recommendation state that transforaminal and interlaminar epidural steroid
injections can provide short- and long-term relief in patients who have cervical
radiculitis. Grade B recommendation state that better outcomes are predicted by
cervical disk herniation as well as central or foraminal stenosis.
Intervention Society: The effectiveness and risks of fluoroscopically guided cervical
transforaminal injections of steroids: A systematic review with comprehensive analysis
of the published data. Pain Med 2014;15(3):386-402.
This study reports low-quality evidence suggesting that 50% of patients experience 50%
relief of radicular pain with cervical transforaminal epidural steroid injection and that
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