Prescriptive clinical prediction rules in back pain research: a systematic review.

J Man Manip Ther. 2009;17(1):36-45

Authors: May S, Rosedale R

Prescriptive clinical prediction rules (CPRs) are a way of using a small selection of clinical findings to match patients to optimal interventions. A number of CPRs have been developed for use with back pain patients, but these have not been systematically reviewed. The purpose of this review was to evaluate existing CPRs against established criteria to determine the quality of the studies and the overall development of the CPR against a set number of stages. Medline was searched up until June 2008, and 16 studies were reviewed that related to 9 different CPRs. These studies investigated and attempted to find clinical characteristics for responders to manipulation, stabilization exercise, physical therapy, chiropractic, traction, rehabilitation, usual care, and zygapophyseal joint injections. Eleven of these studies related to the derivation stage and five to the validation stage. The manipulation and stabilization CPRs had been the most studied. The derivation studies were mostly high quality, whereas none of the validation studies were. Some of the validation studies did not provide evidence that validated the CPR. Most of these CPRs need further evaluation before they can be applied clinically; most did not pass the lowest level of evidence hierarchy. As regards the manipulation CPR, evidence to date for its clinical utility is limited and contradictory. For the stabilization CPR, there was limited evidence that it may be considered but only with caution and in similar patients. Overall, there is limited evidence to support the general application of spinal CPRs.

PMID: 20046564 [PubMed]

Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.

Pain Physician. 2009 Jul-Aug;12(4):699-802

Authors: Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJ, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA,

Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians.

PMID: 19644537 [PubMed – indexed for MEDLINE]

Cervical facet joint dysfunction: a review.

Arch Phys Med Rehabil. 2008 Apr;89(4):770-4

Authors: Kirpalani D, Mitra R

To review the relevant literature on cervical facet joint dysfunction and determine findings regarding its anatomy, etiology, prevalence, clinical features, diagnosis, and treatment.

PMID: 18374011 [PubMed – indexed for MEDLINE]

Lidocaine cytotoxicity to the zygapophysial joints in rabbits: changes in cell viability and proteoglycan metabolism in vitro.

Spine (Phila Pa 1976). 2009 Dec 15;34(26):E945-51

Authors: Takeno K, Kobayashi S, Miyazaki T, Shimada S, Kubota M, Meir A, Urban J, Baba H

STUDY DESIGN.: To examine whether lidocaine cytotoxicity to chondrocytes has been implicated in the development of osteoarthritis of the zygapophysial joints. OBJECTIVE.: This study was performed to determine the effects of varying concentrations and exposure times of lidocaine on the viability and proteoglycan metabolism of rabbit zygapophysial chondrocytes in vitro. SUMMARY OF BACKGROUND DATA.: Zygapophysial joint injections are commonly administered with lidocaine for chronic spinal pain in orthopedic treatment. A lot of studies on the effect of zygapophysial joint injections are clinical, but many questions on the effect of lidocaine to zygapophysial chondrocytes remain unanswered. METHODS.: Cartilage was obtained from zygapophysial joints of adult rabbits. Chondrocytes in alginate beads were cultured in medium containing 6% fetal calf serum at 370 mOsmol at cell densities of 4 million cells/mL. They were then cultured for 24 hours under 21% oxygen with 0.125%, 0.25%, 0.5%, and 1% lidocaine, and without lidocaine as control. The cell viability profile across intact beads was determined by manual counting using fluorescent probes (LIVE/DEAD assay) and transmission electron microscopy. Lactate production was measured enzymatically as a marker of energy metabolism. Glycosaminoglycan (GAG) accumulation was measured using a modified dimethylmethylene blue assay. RESULTS.: Cell viability decreased in a time- and dose-dependent manner in the concentration range of 0.125% to 1.0% lidocaine under the confocal microscope. Under the electron microscope, apoptosis increased as the concentration of lidocaine increased. GAG accumulation/tissue volume decreases as the concentration of lidocaine increased. However, GAG produced per million cells and the rate of lactate production per live cell was significantly higher for cells cultured at 0.5% and 1% lidocaine than the control group. CONCLUSION.: While these in vitro results cannot be directly extrapolated to the clinical setting, this data suggestcaution in prolonged exposure of zygapophysial cartilage to high concentration lidocaine.

PMID: 20010383 [PubMed – indexed for MEDLINE]

Single photon emission computerized tomography (SPECT) scan-positive facet joints and other spinal structures in a hospital-wide population with spinal pain.

Spine J. 2010 Jan;10(1):58-62

Authors: Makki D, Khazim R, Zaidan AA, Ravi K, Toma T

The current criterion standard for zygapophyseal (facet) joint pain diagnosis is placebo-controlled triple comparative local anesthetic facet joint or medial branch blocks. Single photon emission computerized tomography (SPECT) scanning is a less invasive modality that has been widely used in patients with spinal pain for the diagnosis of facet joint arthritis. Previous studies have shown that SPECT results correlate well with response to facet joints steroid injections.

PMID: 19643679 [PubMed – indexed for MEDLINE]

Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914.

Pain Physician. 2008 Mar-Apr;11(2):121-32

Authors: Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V

Lumbar facet joints have been implicated as the source of chronic pain in 15% to 45% of patients with chronic low back pain. Various therapeutic techniques including intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin.

PMID: 18354721 [PubMed – indexed for MEDLINE]

A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome: a randomized, equivalence controlled trial.

Pain Physician. 2009 Nov-Dec;12(6):E355-68

Authors: Manchikanti L, Singh V, Cash KA, Pampati V, Datta S

Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, and facet joint pain among other causes. Even though fluoroscopically directed caudal epidural injections and facet joint interventions are effective in some patients, others continue to suffer with chronic persistent pain. Percutaneous adhesiolysis with target delivery of medications has been demonstrated to be effective in these patients. However, the evidence for percutaneous adhesiolysis in managing post surgery syndrome has been questioned, coupled with a paucity of controlled trials.

PMID: 19935992 [PubMed – indexed for MEDLINE]

The pathophysiology and nonsurgical treatment of lumbar spinal stenosis.

Instr Course Lect. 2009;58:657-68

Authors: Daffner SD, Wang JC

Lumbar spinal stenosis, which affects an ever-increasing number of patients, is best defined as a collection of clinical symptoms that includes low back pain, bilateral lower extremity pain, paresthesias, and other neurologic deficits that occur concomitantly with anatomic narrowing of the neural pathway through the spine. The narrowing may be centrally located in the spinal canal or more laterally in the lateral recesses or neuroforamina. Lumbar spinal stenosis can have a congenital or acquired etiology, and the origin of acquired lumbar stenosis is classified as degenerative, posttraumatic, or iatrogenic. In degenerative lumbar stenosis, the anatomic changes result from a cascade of events that includes intervertebral disk degeneration, facet joint arthrosis, and hypertrophy of the ligamentum flavum. The altered biomechanical characteristics of the spinal segment perpetuate a cycle of degenerative changes, and the resulting stenosis produces radicular pain through a combination of direct mechanical compression of nerve roots, restriction of microvascular circulation and axoplasmic flow, and inflammatory mediators. The initial treatment of lumbar spinal stenosis is nonsurgical. The most effective nonsurgical treatment is a comprehensive combination of oral anti-inflammatory drugs, physical therapy and conditioning, and epidural steroid injections. A significant number of patients improve after nonsurgical treatment, although most studies have found that patients treated surgically have better clinical results. Delaying surgical treatment until after a trial of nonsurgical treatment does not affect the outcome. Surgical intervention should be considered only if a comprehensive program of nonsurgical measures fails to improve the patient’s quality of life.

PMID: 19385575 [PubMed – indexed for MEDLINE]

Real-time MR fluoroscopy-navigated lumbar facet joint injections: feasibility and technical properties.

Eur Radiol. 2008 Jul;18(7):1513-8

Authors: Fritz J, Clasen S, Boss A, Thomas C, König CW, Claussen CD, Pereira PL

We prospectively evaluated the feasibility and technical properties of a dedicated interventional magnetic resonance (MR) imaging protocol for near-real-time MR fluoroscopy-guided bilateral lumbar facet joint injections. A total of 44 facet joint injections were performed in 22 patients using a C-shaped open 0.2-T MR imaging system (Magnetom Concerto, Siemens Medical Solutions, Erlangen, Germany). A T1/T2-weighted fast-imaging-with-steady-precession (FISP) sequence with an end-to-end latency of 1.2 s facilitated sufficient near real-time MR imaging guidance in all cases. A T1-weighted two dimensional fast-low-angle-shot (FLASH2D) MR sequence identified final needle tip location. Different angles of the needle path had only minimal influence on the appearance of the needle artifact produced by both sequences, resulting in a symmetrical needle tip artifact. The joint cavity was successfully punctured in 79.5% (35/44) of joints, which was followed by intra-articular fluid accumulation in 75% (33/44). Inaccessible joints demonstrated a significantly (p=0.044) higher number of posterior osteophytes (66.7%, 6/9 joints) compared to accessible joints (26%, 9/35 joints). No complications occurred. Table time showed significant shortening over time with average table time of 33 (21-68.5) min. We conclude that MR fluoroscopy-navigated lumbar facet joint injections are feasible and safe.

PMID: 18299836 [PubMed – indexed for MEDLINE]

Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports.

Pain Med. 2009 Nov;10(8):1389-94

Authors: Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N

To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases.

PMID: 19863744 [PubMed – indexed for MEDLINE]

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