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Minimally-interventional therapeutic procedures in the spine:an evidence-based review Ioannis Karnezis FRCS(Orth)Orthopaedic and Spinal Surgeon,Director, Back Care network (Athens) invasive interventional techniques for the clinical trials al articles were categorised practicing clinician from the principles of clinical practice) as all clinical decisions The aim of the present article is to study the peer-reviewed medical literature andevaluate the current evidence oncommon minimally-interventionaltherapeutic spinal procedures.
Table I: The minimally-invasive therapeutic interventional spinal procedures considered in thepresent study 2. Selective nerve root injections3. Epidural adhesiolysis4. Zygapophyseal (facet) joint injections5. Zygapophyseal (facet) joint denervation6. Sacroiliac joint injections7. Intradiscal Electrothermal Therapy (IDET)8. Percutaneous lumbar endoscopic discectomy9. Vertebroplasty and Kyphoplasty Table II: ‘Levels of Evidence’ of published studies High-quality randomized controlled trial with statistical y significantdifference or no statistical y significant difference but narrow confidenceintervals,orSystematic review of Level-I randomized controlled trials (and studyresults were homogeneous).
Lesser-quality randomized controlled trial (e.g., <80% follow-up, no blinding,or improper randomization),orProspective comparative study,orSystematic review of Level-II studies or Level-I studies with inconsistentresults.
Case-control study,orRetrospective comparative study,orSystematic review of Level-III studies.
(Centre for Evidence-Based Medicine, Headington, Oxford OX3 7LF, United Kingdom) Table III: ‘Grades of Recommendation’ of treatment methods consistent level 2 or 3 studies or extrapolations from level 1 studies level 4 studies or extrapolations from level 2 or 3 studies level 5 evidence or troublingly inconsistent or inconclusive studies of anylevel (Centre for Evidence-Based Medicine, Headington, Oxford, OX3 7LF, United Kingdom) corticosteroid close to the site ofsymptomatic pathology which is followed in clinical practice, namely (a) (either the caudal epidural injection, when interlaminar epidural injection, when the (one year) pain relief in cases of cervical nerve root block) which involves delivery of corticosteroid selectively to the level syndrome (grade of recommendation: A).
for their use include acute radicular pain, further evaluation by level-I studies.
post-lumbar laminectomy (‘failed back’)syndrome (1). However, there is ongoing corticosteroid close to the site of origin pain of short-term duration only (2,3) or no significant reduction in pain relief and injection was also found to be inferior to (therapeutic injection) is performed.
Although the role of diagnostic selective nerve root injections in the differential there is significant controversy about the in the latter pathology a short-lived (one caudal epidural injections without steroid to acute disc prolapse rather in cases of symptomatic lumbar spinal stenosis (8).
Table IV: Level of Evidence of studies on therapeutic nerve root injections no statistical differences in primary outcome variables (pain, function); reduction in the need for spinal surgery (‘surrogate end point’) discectomy) syndrome (grade ofrecommendation: A).
However, two level-I studies (randomizedcontrolled trials) addressing the in studies of case series without control steroid injection) and control (localanesthetic only injection) groups for chronic lumbar radicular pain (17) and the Postoperative epidural fibrosis is said to ‘failed back surgery’ syndrome (18).
nerve root injections also failed to show cervical nerve root steroid injections (19).
selective steroid nerve root injections for statistically significant effect of steroid tissue believed to be responsible for the selective) interspinous epidural injections endoscopy (‘myeloscopy’) to allow three- dimensional visualization of the contents selective caudal epidural steroid injection root injections of corticosteroids have no effect on the long-term natural history of literature (Table V) reveals four level-I radiculopathy or the 'failed back’ (post- symptomatic postoperative epiduralfibrosis epidural adhesiolysis is significantly more effective than placebo be the result of repeated procedures, the effects of a single procedure lasting for an average of around 3 to 4 months (24).
from 80-97% at 3 months to 47-72% at 12months (21-23). However, this appears to Table V: Level of Evidence of studies on epidural adhesiolysis successful results with repeated procedures ranges from 80-97% (3 months) to 47-72% (12 months);effects of a single procedure last for average 3 to 4 monthssuccessful results with both non-endoscopic and endoscopic adhesiolysis also shows similar successful results forsymptomatic postoperative epidural endoscopic adhesiolysis (25-27). Final y, there is one level-IV study (28) reporting contrast material before injection usually months is an effective minimally-invasive bilaterally usually at multiple levels of Comment: as the majority (five out of the results of facet joint injections for lower back pain of facet origin. The first trial between three patient groups havingintra-articular and peri-articular injection neck pain (‘facet joint syndrome’).
Research into the role of facet joints in spinal pain has shown that cervical facet groups having intra-articular injection of recent, trial (n=200 randomized patients) having intra-articular injections with or of 12 months from the procedure (34).
joints of an affected motion segment.
literature (Table VI) shows that there are relief following facet injections that has controlled trials) on the results of medial response after facet block injections.
The two largest of these randomized Facet joints are innervated by the medial neurotomy’ or simply ‘facet neurotomy’, is the nerve supply to a painful facet joint improvement in functional disability. The base of the transverse processes alongthe course of the medial branch before Table VI: Level of Evidence of studies on medial branch (facet) neurotomy no difference in level of pain, physical activities and analgesic intake;short-term improvement in function but no further difference in level of pain and functional disability;significant al eviation of pain and functional disability for 12 months aftertreatmentLumbar: pain relief for average 4-12 months in 60-87% of patients; Cervical: pain relief for average 7-9 months in 80% of patients;Thoracic: pain relief form 76% at 1 year to 69% at 3 years (one study) the published data on the results offacet neurotomy for back pain of facet what has been described as ‘facet joint synovitis’ in younger athletic patients (41).
lasting effectiveness (up to three years) secondary to facet joint involvement (44).
and related disability for two years after Conclusion: there is limited evidence that sacroiliac joint injection of steroids can has been attributed to the ‘sacroiliac joint an effective treatment for back pain offacet joint origin.
Intradiscal Electrothermal Therapy (IDET) can be at least temporarily (average 9 to cervical or thoracic pain of facet origin by nociceptive nerve fibers that havebeen shown to grow into the annulus of the affected disc. During the procedure a energy are transferred to a broad section spondylarthropathic origin (‘sacroiliac joint syndrome’). Sacroiliac joint injections of nociceptive fibers. This is believed to annular fissures, reduction of disc bulge and desensitization of the pain receptors material to confirm intra-articular position of the needle before injection usual y of steroid (therapeutic procedure). If helpful, The value of sacroiliac joint injection of anaesthesia and light sedation. The latter literature shows that there are no level-I studies (randomized controlled trials) on structures. With the patient in the prone the results of sacroiliac joint injection patients with low back pain attributed to the ‘sacroiliac joint syndrome’. There is contact with the posterior annular wal .
strictly defined patients. Interestingly, the single available level-II (prospective non- literature (Table VII) shows that there are only two level-I studies (randomizedcontrolled trials) on the results of IDETfor discogenic lower back pain. The firststudy (52) showed no significant changein outcome measures in the IDET or thecontrol group at 6 months and ittherefore no significant benefit from IDET Table VII: Level of Evidence of studies on Intradiscal Electrothermal Therapy No significant benefit from IDET over placebo; IDET appears to provide worthwhile relief in a smal proportion ofstrictly defined patientsPain reduced by half in 54% of patients; Pain relieved completely in 20% of patients;Long-term results enduringSuperior to conventional conservative care in pain reduction in substantial proportion of carefully selected cases published data on the results of IDET for discogenic lower back pain representlevel-IV evidence (case series studies practical y limited to level-IV (case series regarding the effect of IDET treatment of ranged from half of the patients beingdissatisfied with the outcome (58), early surgical method for the treatment ofsymptomatic disc prolapse (herniation). It literature (Table VIII) shows that the vast resolution of neurological deficit) in 77% Table VIII: Level of Evidence of studies on percutaneous endoscopic lumbar discectomy higher (not statistical y significant) rate of symptom resolution compared to open microsurgical discectomyno difference in clinical outcome between percutaneous endoscopic lumbar discectomy and open microdiscectomyexcel ent / good clinical outcome (pain relief and resolution of neurological deficit) in 77% to 94% of cases studies that fall into the level-III evidencecategory (retrospective comparative open microdiscectomy (68-69). Thesingle published randomized controlled higher rate of resolution of sciatica, low- height and often prolonged disability.
from compression osteoporotic fractures.
of studied cases. Of note is that no other since the time of publication of the latter position by insertion of a special cannula through the pedicle of the vertebra or via persistent segmental instability and pain, operative (surgical morbidity) methods of trauma, short hospitalization, accelerated literature (Table IX) shows that there is Vertebroplasty and bal oon Kyphoplasty.
appreciation of the limitations of thetraditional non-operative (poor restoration Table IX: Level of Evidence of studies on Vertebroplasty and balloon Kyphoplasty useful for early pain relief assisting rehabilitation; no difference with nonoperative management beyond 12 months(or less)rapid, significant, sustained improvement in back pain, function and published data on the results ofVertebroplasty and bal oon Kyphoplasty persist beyond 12 months (77-80). Final y, a level-II (prospective comparative) study (71-74). This also holds true for cases of Review of the level-II evidence (deriving epidural corticosteroid injection in themanagement of sciatica. Br JRheumatol 1988;27(4):295-9.
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