Laxmaiah Manchikanti1, Nebojsa Nick Knezevic2, Annu Navani3, Paul J Christo4, Gerard Limerick5, Aaron K Calodney6, Jay Grider7, Michael E Harned7, Lynn Cintron8, Christopher G Gharibo9, Shalini Shah10, Devi E Nampiaparampil11, Kenneth D Candido12, Amol Soin13, Alan D Kaye14, Radomir Kosanovic15, Trevor R Magee16, Douglas P Beall17, Sairam Atluri18, Myank Gupta19, Standiford Helm Ii20, Bradley W Wargo21, Sudhir Diwan22, Steve M Aydin23, Mark V Boswell24, Bill W Haney25, Sheri L Albers26, Richard Latchaw26, Alaa Abd-Elsayed27, Ann Conn28, Hans Hansen29, Thomas T Simopoulos30, John R Swicegood31, David A Bryce32, Vijay Singh33, Salahadin Abdi34, Sanjay Bakshi35, Ricardo M Buenaventura36, Joseph A Cabaret37, Jessica Jameson38, Sunny Jha39, Adam M Kaye40, Ramarao Pasupuleti41, Kartic Rajput42, Mahendra R Sanapati43, Nalini Sehgal44, Andrea M Trescot45, Gabor B Racz, Sanjeeva Gupta46, Manohar Lal Sharma47, Vahid Grami48, Allan T Parr49, Emilija Knezevic50, Sukdeb Datta51, Kunj G Patel52, Deborah H Tracy53, Harold J Cordner54, Lee T Snook55, Ramsin M Benyamin56, Joshua A Hirsch57. 1. Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA. 2. Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL. 3. Comprehensive Pain Management Center, Campbell, CA. 4. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Blaustein Pain Treatment Center, Johns Hopkins Hospital, Baltimore MD. 5. Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 6. Precision Spine Care, Tyler, TX. 7. Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY. 8. Dept. of Anesthesiology and Perioperative Care, Adjunct Associate Clinical Professor, University of California, Irvine School of Medicine, Irvine, CA. 9. Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY. 10. University of California, Irvine, Department of Anesthesiology, Orange, CA. 11. New York University School of Medicine, New York, NY. 12. Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine. 13. Ohio Pain Clinic, Dayton, OH. 14. LSU Health Science Center, New Orleans. 15. Pain Management Centers of America, Paducah, KY. 16. Clinical Radiology of Oklahoma, Edmond, OK, USA. 17. Department of Radiology, Summit Medical Center, Edmond, OK. 18. Tri State Spine Care Institute. 19. Kansas Pain Management & Neuroscience Research Center, LLC, Overland Park, KS, and Adjunct Clinical Assistant Professor, Anesthesiology and Pain Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA. 20. The Helm Center for Pain Management. 21. Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center. 22. Advanced Spine on Park Avenue. 23. Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY. 24. Department of Anesthesiology and Perioperative Medicine, University of Louisville. 25. Pain Management Centers of America, Louisville, KY. 26. Radiology Research and Consultation. 27. Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI. 28. , Advanced Pain Institute, Covington, LA. 29. Pain Relief Centers, Conover, NC. 30. Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. 31. Advanced Interventional Pain and Diagnostics of Western Arkansas, Fort Smith, AR. 32. Advanced Pain Management, Madison, WI. 33. Spine Pain Diagnostics Associates, Niagara, WI. 34. University of Texas, MD Anderson Cancer Center, Houston, TX. 35. SurgiCare of Manhattan and Lenox Hill Hospital. 36. Pain Relief of Dayton, Centerville, OH, and Clinical Associate Professor, Department of Surgery, Wright State University School of Medicine, Dayton, OH. 37. Genesis Pain Specialist. 38. Axis Spine Center, Coeur d'Alene, ID. 39. Department of Anesthesiology, Houston Methodist Hospital, Houston, TX. 40. Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA. 41. Center for Pain Management. 42. Sutter Gould Medical Foundation, Stockton, CA. 43. Pain Management Centers of America, Evansville, IN. 44. Division of Rehabilitation Medicine, Vice Chair Department of Orthopedics & Rehabilitation and Program Director, Multidisciplinary Pain Medicine Fellowship, University of Wisconsin School of Medicine & Public Health, UW Health, Madison, WI. 45. Pain and Headache Center, Eagle River, Alaska. 46. Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK. 47. The Walton Centre NHS Foundation Trust. 48. Geisinger Medical Center Interventional Pain Center Woodbine, Danville, PA. 49. Premier Pain Center, Covington, LA. 50. University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL. 51. Datta Endoscopic Back Surgery and Pain Center and Professorial Lecturer, Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY. 52. Center for Regenerative and Interventional Spine and Sports Pain, St. Louis, MO. 53. HCA Oak Hill Hospital, Board Chair, Brooksville, FL. 54. Florida Pain Management Associates, Sebastian, FL; and Associate Clinical Professor Florida State University College of Medicine, Tallahassee, FL. 55. Metropolitan Pain Management Consultants, Inc., Sacramento, CA. 56. Millennium Pain Center, Bloomington, IL, Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL, Department of Psychology, Illinois Wesleyan University, and Stimgenics LLC, Bloomington, IL. 57. Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Abstract
BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
Authors: Ji Yeong Kim; Do-Hyeong Kim; Dong Woo Han; Young Chan Kim; Ji Young Lee; Young Kyung Park; Hue Jung Park Journal: Int J Med Sci Date: 2022-06-06 Impact factor: 3.642
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Authors: Laxmaiah Manchikanti; Emilija Knezevic; Nebojsa Nick Knezevic; Mahendra R Sanapati; Alan D Kaye; Srinivasa Thota; Joshua A Hirsch Journal: Korean J Pain Date: 2021-07-01
Authors: Xiaoqin Wang; Grace Martin; Behnam Sadeghirad; Andrea J Darzi; Rachel J Couban; Ivan D Florez; Holly N Crandon; Elena Kum; Yaping Chang; Meisam Abdar Esfahani; Laxsanaa Sivananthan; Fatemeh Mehrabi; Neil K Sengupta; Preksha Rathod; Rami Z Morsi; D Norman Buckley; Gordon H Guyatt; Y Raja Rampersaud; Christopher J Standaert; Thomas Agoritsas; Jason W Busse Journal: BMJ Open Date: 2021-07-09 Impact factor: 2.692