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What Do the Experts Have to Say About Invasive Treatment for Chronic Back Pain?
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Posted on: 01/14/2010
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The United States leads the world in diagnostic technology yet for many patients, doctors can't accurately diagnose their back pain. Relying on MRIs and/or surgery to help identify the problem isn't working either. Half the patients with abnormal MRIs feel perfectly normal -- no back pain at all. And for those with chronic back pain who have surgery the expected pain relief never comes. In fact, they may end up with worse pain than before. Why is that?
Well, diagnosis of back pain is complex and challenging. Studies done so far show that in many cases, there isn't just one single pain generator. The discs, ligaments, muscles, bone, nerve roots, and even the coverings and linings of these structures can all turn on a pain signal. When more than one area is affected, the pain messages can overlap, creating back pain that may not respond to one single treatment technique.
What can physicians do to help sort out the causes of back pain and select the most effective treatment plan for each patient? Let's go back to the issue of the diagnosis. MRIs may not answer the question of what's really triggering pain messages but fluoroscopy-guided injections can.
Fluoroscopy is a type of real-time X-ray that allows the physician to see the location and pathway of the needle being used to inject the spine. Injecting the nerve, joint, disc, or other likely cause of the pain with a numbing and antiinflammatory agent helps confirm the diagnosis and treat the problem all at the same time.
Fluoroscopy has also made it possible to cut or heat the small sensory nerves that transmit pain signals in order to turn those signals off. The procedure is called a neurotomy. Other fluoroscopic-guided pain procedures include epidurals, adhesiolysis, nerve blocks, and intradiscal electrotherapy. These treatment methods all fall into a category called interventional pain procedures.
And there's more! Sacroiliac injections, radiofrequency ablations (using radio waves to heat up and destroy tissue), vertebroplasty and kyphoplasty for vertebral compression fractures, and implantable therapies (electric stimulators inside the spine to override pain messages to the brain) are all examples of interventional pain procedures used to help alleviate chronic back pain.
You can see there are many possible surgical interventions to choose from. How does the surgeon decide? Right now, doctors are using available evidence from research studies that report the results of these procedures. A key factor in the process is choosing the right patient for the procedure. These same studies help determine who is (and who isn't) a good candidate for one procedure over another.
The American Society of Interventional Pain Physicians (ASIPP) is assisting in determining treatment pathways for patients with chronic low back pain. They say that the best person to perform any of these specialized interventional pain procedures is a physician who has advanced training in the area of interventional pain treatment. Likewise, members of the ASIPP say these physicians are better able to conduct the necessary research needed to formulate treatment guidelines.
By reviewing currently available evidence, the ASIPP has published a summary of evidence-based guidelines for each of these interventional pain procedures. They systematically reviewed recent studies and offered their own ASIPP treatment guidelines for each of these therapies. Here's a brief summary of what they offer:
Studies that suggest epidural steroid injections (ESI) don't really work may have some design flaws of their own. Before tossing ESIs out the window, it's important to separate out the different types of injections based on location (e.g., around the nerve root versus inside the spinal canal) and take a closer look at the results.
When epidural injections are used in treatment, they should be limited to now more than four to six a year with at least two months (or more) in between injections. Repeated injections are only advised when patients get at least 50 per cent improvement that lasts six to eight weeks.
Adhesiolysis (breaking up fibrous scarring called adhesions) is used when patients develop pain-producing scar tissue following back surgery. The procedure hasn't been proven successful when used for other problems like spinal stenosis (narrowing of the spinal canal) or disc herniation.
There is good evidence that nerve blocks can be used to diagnose and treat pain coming from spinal joints. Once the involved area has been identified, injections using a local anesthetic (numbing agent) can be given every two months for up to six months. Similar injections using steroid medication (antiinflammatory) can be given every two months for up to a year.
Sacroiliac joint injections have become very popular in the last 10 years. There's no doubt now that the sacroiliac joint generates pain signals that can become chronic. Injecting the joint with a local anesthetic and/or steroid or using radiofrequency to stop nerve messages may work for a short time. Evidence for the effectiveness of these treatments over a long period is very limited right now.
Based on the evidence available, the ASIPP suggests interventional procedures for the sacroiliac (SI) joint should be limited by medical necessity. When used, both SI joints should be treated at the same time in the same way.
The ASIPP goes on to say that treating disc problems is a special challenge. It seems that some people just have more sensitive intervertebral discs than others. It just isn't working to do surgery on everyone with a disc problem. MRIs and CT scans don't really give the kind of information needed to decide whether surgery is indicated.
The surgeon must rely on the patient's history, signs and symptoms, and response to specific tests to diagnose the problem. It's possible to test the disc by poking it or tapping it -- much like the dentist pokes and taps a tooth to see if the pressure reproduces the pain.
A heating wire is threaded through the skin to the suspected discal area. Once the problem disc has been identified, it's possible to use heat to destroy the protruding tissue. The idea behind intradiscal therapies of this type is to avoid open and/or invasive back surgeries for disc problems.
In this article, the ASIPP offers guidelines for each area of the interventional pain procedures mentioned. Photographs taken during fluoroscopy from each procedure are included. Evidence presented is based on short-term, moderate-, and long-term pain relief.
Even with the evidence available today, there just aren't clear-cut guidelines to help surgeons plan the most effective care for each patient. There are incredible differences in the human pain experience. For example, people with the same problem experience and respond to their pain differently. And scientists can't offer a placebo without injecting the patient and that in itself is a treatment. There's also the ethical dilemma of not treating someone in pain when an effective treatment is available.
All of this leads experts in the area of pain control to say that there is much yet that needs to be done in terms of research, data collection, and analysis. Understanding what causes pain and finding ways to treat that pain with as little disruption as possible is everyone's goal. New knowledge gained will help shape and reshape future guidelines offered by the ASIPP.
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References:
Andrea Trescot, MD. Interventional Approaches to the Management of Spinal Pain. A Summary of ASIPP's Evidence-Based Guidelines. In Pain Medicine News Special Edition. December 2009. Vol. 7. No. 12. Pp. 85-95.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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