Role of the Interventionist: Nonsurgical Management of the Spine Pain Patient
Joel M. Press
Mary E. Caldwell
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
Understand the role of interventional diagnostic and therapeutic techniques.
Understand the role of different medications and injections for back and neck problems.
Understand the expected recovery for different spinal surgeries.
Gradually reactivate postsurgical patients.
Recommend invasive pain management options for chronic pain patients.
“Take your victories, whatever they may be, cherish them, use them, but don’t settle for them.
MIA HAMM
Introduction
The purpose of this chapter is to discuss the nonoperative treatment options for patients with musculoskeletal spinal disorders who are not responding to the basic principles of spine rehabilitation such as reactivation advice, manipulation, or rehabilitative exercises. What, if any, contribution advanced imaging or interventional techniques such as spinal injections, medications, and invasive pain management procedures may make and their appropriate use will be presented. More important than the single benefit of any, or all, of the above treatments, is how they can be integrated into a treatment approach in a cost-effective, patient-oriented approach.1,2
Patients who have severe symptoms or complex pathology often require coordination of care and/or comanagement. Complementary to conservative procedures, there are a number of interventional techniques obtained through this multidisciplinary management.3 The key to improving quality of care and outcomes is the appropriate and timely recognition of the patient’s need for these services, for the purpose of controlling extreme symptoms, as well as diagnosing and improving the response for patients who have prolonged symptoms.
Interventional techniques in general offer two advantages for those patients who need them. First is the improvement of diagnostic specificity. Second is the promotion of symptom relief. Both may empower active coping, return to activity, and social participation.4 As is well known, diagnostic certainty is a rarity in musculoskeletal disease. The exact source of the patient’s pain and symptoms is often ambiguous. A number of different tissues are known to create overlapping pain patterns. For example, lumbosacral facet disease, sacroiliac (SI) disease and discogenic pain may have sclerotomal pain distribution patterns that overlap and can be confusing. Additionally, central sensitization can cause non-noxious stimuli to healthy tissue to be perceived as painful. In patients whose symptoms are severe or prolonged, introduction of appropriate interventional procedures can improve the patient’s compliance with functional restoration.1 They can promote greater confidence in the approach by successful identification of the source of pain and providing short-term, immediate, relief that can facilitate progress in rehabilitation and therapy.
This chapter will give an evidence-based approach to spine pain and discuss how some of these treatment options can be used to assist with difficult cases. Clinicians must make informed choices about how to facilitate recovery in both acute and chronic spine patients. Such choices should ideally be evidence based; however, much of the literature contains many limitations.3 Ultimately, the goal is treating the patient and doing the best we can with the information available.
Basic Principles
There is a demanding need for evidence-based and comprehensive spine care as soon as a patient presents (see Chapter 2). In the past decade, back pain was the number one cause of disability in the United States, followed by neck pain as the number four.5 Back pain was the sixth highest contributor to the global burden of disease.6 Further, a recent analysis of national data in the United States for spine-related health care expenditures from 1997 to 2006 demonstrated increasing total costs for inpatient hospitalization, prescription medications, and emergency department visits. Specifically, there was a 37% increase in hospitalizations, 139% increase in medications, and 84% increase in emergency visits. There was a 49% increase in the number of patient seeking spine-related care as outpatients (12.2 million in 1997 to 18.2 million in 2006).7 These numbers demonstrate the striking need for quality spine care in the United States.
First, when a patient presents for spine-related care, our job is to provide a diagnosis and then provide the therapeutic milieu, appropriate counseling, and home program for the patient. It is ultimately the patient’s responsibility to get better. Treatment needs to address stability and self-efficacy. It is important to remember that skillful rehabilitation is not a “recipe” approach. Each person has life factors that come into play and we must treat the entire person as a whole recognizing the effect of mind on body with recovery.
Secondly, treatment should be active, meaning that the patient participates and ultimately is independent within the program. There are key steps needed to ensure a patient fully understands the program given. This requires explanation of the rehabilitation course including timeframes, realistic expectations, as well as short-term and long-term goals. There must be precise prescription and explanation of limitations and progression. Our job as clinicians is to teach them motor reeducation and muscle activation, improve strength and flexibility, and ultimately spine-sparing activity modifications to help them handle their normal activities of daily living.8 The most effective way to know if a patient is compliant with the prescribed exercise is to ask them to demonstrate the program when you see them on follow-up. Only then can
adequate assessment of their report of usefulness be made. It is also important to stratify and recognize which patients will need a formal referral to physical therapy. For example, in a recent study when patients who reported poor coping, increased stress, and psychological changes underwent formal physical therapy, they had increased return to work and improved health care savings when compared with the nonphysical therapy group.9 In becoming active, patients should be encouraged to pace themselves. An athlete will need a more aggressive rehabilitation program whereas a sedentary person a less aggressive one, but all patients require sufficient functional capacity to meet or exceed their functional demands (Fig. 40.1).
adequate assessment of their report of usefulness be made. It is also important to stratify and recognize which patients will need a formal referral to physical therapy. For example, in a recent study when patients who reported poor coping, increased stress, and psychological changes underwent formal physical therapy, they had increased return to work and improved health care savings when compared with the nonphysical therapy group.9 In becoming active, patients should be encouraged to pace themselves. An athlete will need a more aggressive rehabilitation program whereas a sedentary person a less aggressive one, but all patients require sufficient functional capacity to meet or exceed their functional demands (Fig. 40.1).
Third, the more effective approach to musculoskeletal problems is eclectic. As complex as these disorders may be, no one clinical specialty can provide all the answers. Different health care providers offer separate skill sets that may be more or less appropriate for different types of problem. Especially important and to be discussed in this chapter, for both acute and chronic pain, there is evidence specific to a diagnosis on which spinal interventions have demonstrated success and to what degree.3 The value of understanding and coordinating integrated care across multiple disciplines for patients is crucial for the improvement of quality of life in complicated musculoskeletal disorders. For uncomplicated cases, the knowledge and skills set is presented in Table 40.1. For complicated cases, the knowledge and skill set is presented in Table 40.2.
 Figure 40.1 Relationship of functional capacity and external demand. From Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996. |
Table 40.1 Uncomplicated Spine Care Core Competencies | |
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Table 40.2 Complicated Spine Care Core Competencies | |
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Advanced Diagnostic Steps
In general, imaging is used to detect the 5% of the population with back pain who have undiagnosed systemic disease as the cause of their pain. In a patient with acute back pain, it is well established that there is limited role for imaging without the presence of “red flag” features. “Red flags” are defined as those with a history of trauma, recent weight loss, immunosuppression, fever, history of cancer, age greater than 70, history of intravenous drug abuse, or progressive neurologic deficits10,11 (see Chapter 6) on the line. For the most part, once a patient has failed conservative therapy it is then reasonable to consider imaging. In such cases, the physician should begin with the plain radiograph. If radiographs are not explanatory of the patient’s symptoms, advanced imaging such as computed tomography (CT), magnetic resonance imaging (MRI), or nuclear medicine studies can be considered.10 Often, negative imaging can be reassuring for the patient in a chronic situation. If imaging is controversial, electrodiagnostics can be considered as an extension to the physical examination. See Table 40.3 for a summary of advanced diagnostic steps and their recommended uses.
Imaging
Plain Radiograph Plain radiographs are used to detect specific underlying structural pathology. They are not for routine use in patients with nonspecific low back pain as there is no evidence that they improve patient outcomes.8,12 In general, without the presence of red flags, they should not be used in the first month of symptoms.3,8,13 The exception is in patients where vertebral compression fracture is suspected (history of osteoporosis or prolonged steroid use), in young patients where excessive extension activities can result in fracture of the pars interarticularis,3,8 or in patients where seronegative spondyloarthropathy is a concern.10
Magnetic Resonance Imaging MRI should be used in patients with acute low back pain where the clinician identifies “red flags.”8 It is also useful if the patient has symptoms of radiculopathy or spinal stenosis and is a potential surgical or injection candidate, with the idea that imaging correlates with the symptoms.14 MRI is preferred over CT for nerve impingement because of better visualization of soft tissue, vertebral marrow, and the spinal canal.3 Ordering an MRI should be done with caution, as while it is a highly sensitive diagnostic tool, it is also highly nonspecific and may not correlate with symptoms.15,16 For instance, one study found that 20% of nonsymptomatic individuals less than 60 years old had a herniated nucleus pulposus (HNP) via MRI. While in those greater than 60 years old, 36% had a HNP and 21% had spinal stenosis without symptoms.15 MRI will also rarely change the patient’s outcome, as the natural course of both nonspecific low back pain and radicular pain is that it will resolve spontaneously within the first 4 to 6 weeks after onset.17 Early MRI has also shown to result in higher disability and medical costs compared to patients without early MRI.18 Further, improved resolution of MRI has led an increase in the diagnosis of abnormalities,19 which has led to more specialist referrals, an increase in surgical procedures, and an increase in health care costs without apparent improvement in patient outcomes.18,20,21,22
Computed Tomography CT is useful to evaluate for abnormal boney architecture such as in fractures or bone tumors.8,10 Similar to MRI, there is high rate of abnormal findings (such as herniated discs, facet arthropathy, and spinal stenosis) in asymptomatic individuals23 and CT findings should be interpreted with caution. CT is useful to assess for disc herniation and nerve impingement if MRI is not available.10
Nuclear Studies Technetium bone scans can be used to detect noninfectious inflammatory disease, subtle fractures, or tumor. When a bone scan is combined with single-photon emission CT capability, spatial resolution is improved and the diagnosis of spondylosis or assessing the burden of metastatic disease is easily done.10 Bone scan is useful in assessing pediatric patients with back pain to rule out serious etiologies and diagnose benign etiologies.24 It is highly sensitive for detecting stress-induced changes in bone and is especially useful to detect subtle defects, like that seen in the pars interarticularis in spondylolysis.25
Myelography Myelography (myelogram) requires an injection of contrast material into the subarachnoid space and is used in order to visualize the spinal cord, nerve roots, and meninges. It is typically performed with CT (CT myelogram), and is indicated in the MRI-incompatible patient, in assessing for root compressive lesions or pre-op to assess the spinal osseous elements.10 It is generally not used in acute low back pain, unless MRI and electrodiagnostics are unremarkable and there are still neurologic deficits on examination without clear cause.8
Serology
Spondyloarthropathy (noninfectious inflammatory joint disease of the vertebral column) is quite
common, and includes both rheumatoid arthritis (positive rheumatoid factor [RF] via a blood test/laboratory analysis) and seronegative spondyloarthropathies (defined by a blood test with a negative RF).10 Seronegative spondyloarthropathy can include ankylosing spondylitis, reactive arthritis, enteropathic spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis. These disorders are typically accompanied
by enthesitis and axial arthritis.26 When these disorders are suspected, blood tests should be performed including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), RF, and antinuclear antibodies. Human leukocyte antigen testing is often not performed because of a high false-negative rate. Referral to rheumatology should also be considered as there are specific diagnosis criteria, imaging, and treatment regimens that should be managed by a specialist.27 In general, if there is concern for active inflammation in any patient, ESR and CRP should be performed.14
common, and includes both rheumatoid arthritis (positive rheumatoid factor [RF] via a blood test/laboratory analysis) and seronegative spondyloarthropathies (defined by a blood test with a negative RF).10 Seronegative spondyloarthropathy can include ankylosing spondylitis, reactive arthritis, enteropathic spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis. These disorders are typically accompanied
by enthesitis and axial arthritis.26 When these disorders are suspected, blood tests should be performed including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), RF, and antinuclear antibodies. Human leukocyte antigen testing is often not performed because of a high false-negative rate. Referral to rheumatology should also be considered as there are specific diagnosis criteria, imaging, and treatment regimens that should be managed by a specialist.27 In general, if there is concern for active inflammation in any patient, ESR and CRP should be performed.14
Table 40.3 Summary of Advanced Diagnostic Steps | ||||||||||||||||||||||||||||||
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Electrodiagnostics
Electrodiagnostics can be useful to differentiate or exclude isolated lower extremity pathology versus pathology in the lower extremities from a spine etiology.8 They are often used as an extension of the physical examination and to determine if radiculopathy is present when advanced imaging or the physical examination demonstrates no obvious neurologic changes.28 They can also be considered for use before considering surgical referral for radiculopathy. A recent study showed that radiculopathy detected by electrodiagnostics, when there is no correlation with imaging or weakness on clinical examination, resulted in significantly unsuccessful surgical outcomes.29 Electrodiagnostics can also be useful to evaluate spinal stenosis—specifically by utilizing H-reflexes and F-waves, in which prolonged latency of F-waves or absence of H-reflexes correlates with specific anatomical changes on MRI and helps to identify the symptomatic levels in spinal stenosis patients.30
Diagnostic Needling Procedures
Five primary diagnostic techniques are utilized within interventional procedures. They include:
Facet and costovertebral joint blocks
Nerve blocks
Epidural injections
Sacroiliac joint blocks
Discography (see Note below)
Most of these methods provide both diagnostic and therapeutic benefits by identifying the site symptomatically relieved or provoked by the injected material and by providing a vehicle to transport mediation locally to be directly applied to the tissue. Except for discography, the diagnostic application will be discussed along with the therapeutic procedure in the section on the role of therapeutic injections below. In order to ensure proper interpretation of the results, under no circumstances should diagnostic or therapeutic injection procedures be performed without the use of video fluoroscopy for direct visualization of the placement of the needle, visualization of contrast at the targeted site, and visualization of successful injection into the joint.
Note: In general use, discography is not employed, because of its extreme invasive nature, until and/or unless the patient has had 6 months of therapy without adequate recover and all other probable symptom sources have been ruled out. The North American Spine Society (NASS) issued guidelines for its use in a patient with persistent back pain, negative imaging findings, suspected intervertebral disc abnormalities, and being considered for spinal fusion surgery. Discography is often used in patients who have MRIs showing multiple areas of pathology including the possibility of multiple level disc bulge/protrusion and/or degenerative disease and where surgery (e.g., arthroplasty disc replacement and/or fusion procedures) is being contemplated.
Discography is a controversial procedure. Carragee et al showed that discography and MRI (i.e., annular disruption) are not good predictors of future back pain, disability, or medical care compared to psychosocial risk factors.2,31 Carragee et al have also shown that discography is positive on similar percentages (40%) of asymptomatic patients and symptomatic patients.32 Patients with abnormal psychological profiles have significantly higher positive findings with discography than either asymptomatic volunteers or symptomatic subjects with normal psychological screening.
A positive test is one that shows reproduction of the patient’s symptoms (concordance) with morphologic change within the injected disc.33 Many complications have been reported from discography. Both acute lumbar disc herniation and discitis have been reported,34,35 and much rarer cases of spinal cord injury in cervical discography.36
The Role of Medication
There is not a single medication, nor one class of medication, that works best for all spine pain patients. In order to understand when a medicine or nutraceutical may contribute to case management, some knowledge of the indications, contraindications, mechanism of action, side effect profile, and interactions with other medications is essential. Although rare, severe reactions can occur with the combined use of herbal and prescription medications.
A rational pharmacologic approach for severe acute or chronic spine pain may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), oral steroids, and opioids. Over time, should simple pharmacologic management fail, or levels of analgesia and function reach a plateau, a more comprehensive medication pain management along with other interventional strategies may be necessary. A mechanistic approach to rational pharmacology is an important component of the spine practitioner’s armamentarium for managing acute and chronic pain. Understanding the type of pain, whether neuropathic, mechanical, or central, is key to success. In certain cases of neuropathic pain, using antidepressants and anticonvulsants may be helpful, whereas in other, carefully selected cases, chronic opioid therapy may be indicated. The mechanistic approach requires an understanding of basic physiologic and neurotransmitter function that helps to target the use of single or a combination of agents to reduce inflammation, alter excitability, and block pain peripherally or centrally.
Goals for pharmacotherapy should focus on decreasing pain, maximizing independent physical function (activity level), and improving psychosocial or emotional state (social participation). This section will review current updates in pharmacotherapy as it applies to a broad range of spine-related conditions including neuropathic pain (a model for treatment of radiculopathy) and manifestations of chronic pain conditions (pain, affective distress, and sleep disturbance). The sections will include an overview related to controversies in the use of cyclooxygenase (COX)-2 inhibitors, pharmacologic use of opioids, traditional and novel antidepressants, anticonvulsant medications, and topical analgesics. A few simple, common questions should be included in the patient history to protect against iatrogenic medical complications (Table 40.4). Inclusion of this information when obtaining an interdisciplinary consultation will facilitate successful comanagement of the patient.
Table 40.4 Most Common Questions for Directing Interdisciplinary Consultation for Medication to Manage Back Pain | ||||||||||||||||||
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Analgesics
Non-narcotic (Acetaminophen) In general, for nonspecific low back or neck pain the first-line medication is acetaminophen (Tylenol).14,37 Acetaminophen is generally accepted as first line based on the assessment of its efficacy and safety and it reduced prostaglandin synthesis centrally with less peripheral action. It possibly plays a role in the COX-1 or COX-2 pathway14,38,39 (Fig. 40.2). Though prescribing acetaminophen as first line is typical practice, it is important to briefly review the literature with regard to the evidence. For nonspecific, acute low back pain, a systematic review in 2008 demonstrated that no trial had compared acetaminophen to placebo and only one compared it versus no treatment. The authors concluded there was insufficient evidence to assess the efficacy of acetaminophen in patients with low back pain.40 In 2015, a systematic review concluded that there is high quality evidence that acetaminophen is ineffective for reducing acute (<6 weeks), nonspecific low back pain or improving quality of life in patients at the 3-month follow-up.41 There have further been studies where NSAIDs have demonstrated clinically superior efficacy over acetaminophen, though the results are inconsistent. In one double-blind randomized study, patients with nonspecific, chronic low back pain received celecoxib
200 mg twice a day versus acetaminophen 500 mg twice a day; the NSAID group had significant improvement in both functional outcomes and pain scores compared to acetaminophen.42 Ultimately, acetaminophen is inexpensive, available over the counter, and has a good safety profile. Serious side effects including liver toxicity can occur with prolonged use of high doses, particularly in association with substantial alcohol intake.
200 mg twice a day versus acetaminophen 500 mg twice a day; the NSAID group had significant improvement in both functional outcomes and pain scores compared to acetaminophen.42 Ultimately, acetaminophen is inexpensive, available over the counter, and has a good safety profile. Serious side effects including liver toxicity can occur with prolonged use of high doses, particularly in association with substantial alcohol intake.
 Figure 40.2 Cyclooxygenase pathway. |
Indication: Front-line nonprescription medicine for pain relief.
Risk: Minimal with short-term use. Liver toxicity with long-term use.
Narcotic (Opioid Analgesics) Opioid analgesics act primarily by binding with opiate receptors (µ, δ, and κ) in the central nervous system. They are indicated for the treatment of acute and chronic moderate to severe pain. They are specifically well established for use in back pain related to cancer. Prolonged or repeated use of opioids is not necessary in most patients with acute, nonspecific low back pain. Opiates can lead to dose-dependent respiratory depression, constipation, and sedation. Long-term use may be associated with tolerance, toxicity, addiction, and illicit use.
For acute low back pain, the use of opioids is recommended either in collaboration with other interventions or if there are contraindications to other medications. Prescribing opioids in acute back pain has been associated with higher long-term disability in workers’ compensation claimants, increased rate of surgery, and long-term use of opioids.43,44 Foster et al demonstrated that if acute back pain patients are stratified into their risk of developing chronic pain based on perceived disability at evaluation, those at high risk who receive physical therapy, psychotherapy, and short-acting opioids (rather than nonnarcotics) require less time off work and report improved function compared to those without the combined intervention.9 Other studies have compared opioid use with other medications (without therapy as well) and demonstrated they may not be indicated in that sense. For example, a randomized double-blind study of 323 patients compared naproxen plus placebo versus naproxen plus oxycodone/acetaminophen and demonstrated that adding narcotics to the regimen did not improve pain or outcomes at follow-up.45
Related posts:
Active Care: An Evidence-Informed Approach to Self-Care for Patients with Spine Pain
Pain Mechanism Classification System Overview and Focus on the Motor/Autonomic Mechanism
Programming From Rehabilitation to Performance
Rotational Sports and the Spine
The Resilience Model
Dynamic Variable Resistance Training
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