Low Back Pain and Sciatica(eMedicine.com) Overview
Like a modern skyscraper, the human spine defies gravity, and
defines us as vertical bipeds. It forms the infrastructure of a
biological machine that anchors the kinetic chain and transfers
biomechanical forces into coordinated functional activities. The
spine acts as a conduit for precious neural structures and
possesses the physiological capacity to act as a crane for lifting
and a crankshaft for walking.
Subjected to aging, the spine adjusts to the wear and tear of
gravity and biomechanical loading through compensatory structural
and neurochemical changes, some of which can be maladaptive and
cause pain, functional disability, and altered neurophysiologic
circuitry. Some compensatory reactions are benign; however, some
are destructive and interfere with the organisms capacity to
function and cope. Spinal pain is multifaceted, involving
structural, biomechanical, biochemical, medical, and psychosocial
influences that result in dilemmas of such complexity that
treatment is often difficult or ineffective.[1]Low back pain (LBP)
is defined as chronic after 3 months because most normal connective
tissues heal within 6-12 weeks, unless pathoanatomic instability
persists. A slower rate of tissue repair in the relatively
avascular intervertebral disk may impair the resolution of some
persistent painful cases of chronic LBP (cLBP). An estimated 15-20%
develop protracted pain, and approximately 2-8% have chronic pain.
Of those individuals who remain disabled for more than 6 months,
fewer than half return to work, and after 2 years of LBP
disability, a return to work is even more unlikely.[2]Recent
studies suggest that one third to one fourth of patients in a
primary care setting may still have problems after 1 year.[3,
4]cLBP is the most common cause of disability in Americans younger
than 45 years.[5, 6]Each year, 3-4% of the US population is
temporarily disabled, and 1% of the working-age population is
totally and permanently disabled.[7, 3, 8]LBP has been cited as the
second most frequent reason to visit a physician for a chronic
condition[3, 8, 9, 10], the fifth most common cause for
hospitalization[3, 11, 12, 13], and the third most frequent reason
for a surgical procedure.[3, 11, 12, 13]The socioeconomic impact of
cLBP is massive. Ironically, a minority of patients with cLBP and
disability due to cLBP account for the majority of the economic
burden.[14, 15, 16]Most commonly, diagnoses of acute painful spinal
conditions are nonspecific, such as neck or back strain, although
injuries may affect any of several pain-sensitive structures, which
include the disk, facet joints, spinal musculature, and ligamentous
support.[17, 18]The origin of chronic back pain is often assumed to
be degenerative conditions of the spine; however, controlled
studies have indicated that any correlation between clinical
symptoms and radiological signs of degeneration is minimal or
nonexistent.[6, 17, 18, 19, 20, 21]Inflammatory arthropathy,
metabolic bone conditions, and fibromyalgia are cited in others as
the cause of chronic spine-related pain conditions.[17, 18]Although
disk herniation has been popularized as a cause of spinal and
radicular pain, asymptomatic disk herniations on computed
tomography (CT) and magnetic resonance imaging (MRI) scans are
common.[21, 22, 23, 24]Furthermore, there is no clear relationship
between the extent of disk protrusion and the degree of clinical
symptoms.[25]Degenerative change and injury to spinal structures
produce lower back and leg pain that vary proportionally. A
strictly mechanical or pathoanatomical explanation for LBP and
sciatica has proved inadequate; therefore, the role of biochemical
and inflammatory factors remains under investigation. In fact, this
failure of the pathological model to predict back pain often leads
to an ironic predicament for the patient with LBP.
Sciatica describes leg pain that is localized in the
distribution of one or more lumbosacral nerve roots, typically
L4-S2, with or without neurological deficit.[17, 18]However,
physicians often refer to leg pain from any lumbosacral segment as
sciatica. When the dermatomal distribution is unclear, the
descriptive phrasenonspecific radicular pattern" has been
advocated. When initially evaluating a patient with lower back and
leg pain, the physician must first determine that pain symptoms are
consistent with common activity-related disorders of the spine
resulting from the wear and tear of excessive biomechanical and
gravitational loading that some traditionally describe as
mechanical.[18, 26]Mechanical lumbar syndromes are typically
aggravated by static loading of the spine (eg, prolonged sitting or
standing), by long lever activities (eg, vacuuming or working with
the arms elevated and away from the body), or by levered postures
(eg, bending forward).[18, 26]Pain is reduced when the spine is
balanced by multidirectional forces (eg, walking or constantly
changing positions) or when the spine is unloaded (eg, reclining).
Mechanical conditions of the spine, including disk disease,
spondylosis, spinal stenosis, and fractures, account for up to 98%
of LBP cases, with the remaining ones due to systemic, visceral, or
inflammatory disorders.[1]Mechanical versus nonmechanical spinal
disorders
Mechanical syndromes
Diskal and facet motion segment degeneration
Muscular pain disorders (eg, myofascial pain syndrome)
Diskogenic pain with or without radicular symptoms
Radiculopathy due to structural impingement
Axial or radicular pain due to a biochemical or inflammatory
reaction to spinal injury
Motion segment or vertebral osseous fractures
Spondylosis with or without central or lateral canal
stenosis
Macroinstability or microinstability of the spine with or
without radiographic hypermobility or evidence of subluxation
Nonmechanical syndromes
Neurologic syndromes
Myelopathy or myelitis from intrinsic/extrinsic structural or
vascular processes
Lumbosacral plexopathy (eg, diabetes, vasculitis,
malignancy)
Acute, subacute, or chronic polyneuropathy (eg, chronic
inflammatory demyelinating polyneuropathy, Guillain-Barre syndrome,
diabetes)
Mononeuropathy, including causalgia (eg, trauma, diabetes)
Myopathy, including myositis and various metabolic
conditions
Spinal segmental, lumbopelvic, or generalized dystonia
Systemic disorders
Primary or metastatic neoplasms
Osseous, diskal, or epidural infections
Inflammatory spondyloarthropathy
Metabolic bone diseases, including osteoporosis
Vascular disorders (eg, atherosclerosis, vasculitis)
Referred pain
Gastrointestinal disorders (eg, pancreatitis, pancreatic cancer,
cholecystitis)
Cardiorespiratory disorders (eg, pericarditis, pleuritis,
pneumonia)
Disorders of the ribs or sternum
Genitourinary disorders (eg, nephrolithiasis, prostatitis,
pyelonephritis)
Thoracic or abdominal aortic aneurysms
Hip disorders (eg, injury, inflammation, or end-stage
degeneration of the joint and associated soft tissues [tendons,
bursae, ligaments])
Although acute LBP has a favorable prognosis, the effect of cLBP
and its attendant disability on society is tremendous. Unlike acute
LBP, cLBP serves no biological purpose. It is a disorder that
evolves in a complex milieu influenced by endogenous and exogenous
factors that alter the individual's productivity more than the
initiating pathological dysfunction would have.
If diagnostic studies do not reveal a structural cause,
physicians and patients alike question whether the pain has a
psychological, rather than physical, cause. Physical and
nonphysical factors, interwoven in a complex fashion, influence the
transition from acute to chronic LBP. The identification of all
contributing physical and nonphysical factors enables the treating
physician to adopt a comprehensive approach with the greatest
likelihood of success.
Epidemiology
LBP is the most expensive, benign condition in industrialized
countries.[7]Experts have estimated that approximately 80% of
Americans will experience LBP during their lifetimes.[7, 27, 28]The
annual prevalence of LBP is 15-45% with a point prevalence of
approximately 30%.[2]Sixty percent of those who suffer from acute
LBP recover in 6 weeks and up to 80-90% recover within 12 weeks;
however, the recovery of the remaining patients with LBP is less
certain.[2]About 2% of American workers suffer compensable back
injuries each yeara staggering 500,000 cases. LBP accounts for 19%
of all workers' compensation claims in the United States. According
to the Bureau of Labor and Statistics, metal workers generate 76%
of all claims of back strain and/or sprains. Jobs that require
heavy manual labor and material-handling activities account for
more than half of all back pain reports. Injuries to the back are
highest among truck drivers, operators of heavy equipment, and
construction workers. From 1971-1981, the number of Americans
disabled by LBP grew 14 times faster than the general population.
The resultant disability in Western society has reached epidemic
proportions, with enormous socioeconomic consequences.
An estimated 4.1 million Americans had symptoms of an
intervertebral disk disorder between 1985 and 1988, with an annual
prevalence of about 2% in men and 1.5% in women. A study of 295
Finnish concrete workers aged 15-64 years revealed that 42% of men,
and as many as 60% of the men aged 45 years or older, reported
having sciatica. When interviewed approximately 5 years later, the
lifetime prevalence had increased from 42% to 59%.
Sciatica due to lumbar intervertebral disk herniations usually
resolves with conservative treatment. However, it leads to surgery
more often than back pain alone. In a published review of more than
15,000 disk operations, the most common surgical level was L4-5
(49.8%), followed by L5-S1 (46.9%); only 3.4% were performed at
levels higher than these. Surgical treatment for lumbar diskogenic
syndromes is most common in the United States, where the estimated
rate is at least 40% higher than that in other countries and more
than 5 times higher than rates in Scotland and England.
Risk Factors
LBP is most prevalent in industrialized societies. Genetic
factors that predispose persons of specific ethnicity or race to
this disorder have not been clearly identified with respect to
mechanical, diskogenic, or degenerative causes. Men and women are
affected equally, but in those older than 60 years, women report
LBP symptoms more often than men. The incidence of LBP peaks in
middle age and declines in old age when degenerative changes of the
spine are universal. Sciatica usually occurs in patients during the
fourth and fifth decades of life; the average age of patients who
undergo lumbar diskectomy is 42 years.
Epidemiological data suggest that risk factors, including
extreme height, cigarette smoking, and morbid obesity, may
predispose an individual to back pain. However, research studies
have not clearly demonstrated that height, weight, or body build
are directly related to the risk of back injury. Weakness of the
trunk extensor muscles, compared with flexor strength, may be a
risk factor for sciatica. Fitness may be correlated with the time
to recovery and return to work after LBP; however, in prospective
studies controlled for age, isometric lifting strength and the
degree of cardiovascular fitness were not predictive of back
injury.
Occupational risk factors are difficult to define because
exposures to specific causative influences are unclear, mechanisms
of injury may be confusing, and the research supporting these
findings is variable and conflicting for most environmental risks.
Furthermore, job dissatisfaction, work conditions, legal and social
factors, financial stressors, and emotional circumstances heavily
influence back disability. Although many experts agree that heavy
physical work, lifting, prolonged static work postures,
simultaneous bending and twisting, and exposure to vibration may
contribute to back injuries, the medical literature provides
conflicting support for most of these proposed risk factors.
Pathophysiology
Degenerative cascade
The lumbar spine forms the caudal flexible portion of an axial
structure that supports the head, upper extremities, and internal
organs over a bipedal stance. The sacrum forms the foundation of
the spine through which it articulates with the sacroiliac joints
to the pelvis. The lumbar spine can support heavy loads in
relationship to its cross-sectional area. It resists anterior
gravitational movement by maintaining lordosis in a neutral
posture.
Unlike the thoracic spine, the lumbar spine is unsupported
laterally and has considerable mobility in both the sagittal and
coronal planes. The bony vertebrae act as specialized structures to
transmit loads through the spine. Parallel lamellae of highly
vascularized cancellous bone form trabeculae, which are oriented
along lines of biomechanical stress and encapsulated in a cortical
shell. Vertebral bodies progressively enlarge going down because
gravitational loads increase from the cephalic to the caudal
segments. Bony projections from the lumbar vertebrae, including the
transverse processes and spinous processes, maintain ligamentous
and muscular connections to the segments above and below them.
The intervertebral disk is composed of the outer annulus
fibrosis and the inner nucleus pulposus. The outer portion of the
annulus inserts into the vertebral body and accommodates
nociceptors and proprioceptive nerve endings. The inner portion of
the annulus encapsulates the nucleus, providing the disk with extra
strength during compression. The nucleus pulposus of a healthy
intervertebral disk constitutes two thirds of the surface area of
the disk and supports more than 70% of the compressive load.
The nucleus is composed of proteoglycan megamolecules that can
imbibe water to a capacity approximately 250% of their weight.
Until the third decade of life, the gel of the inner nucleus
pulposus is composed of approximately 90% water; however, the water
content gradually diminishes over the next 4 decades to
approximately 65%. Nutrition to the inner annulus fibrosis and
nucleus pulposus depends on the diffusion of water and small
molecular substances across the vertebral endplates because only
the outer third of the annulus receives blood supply from the
epidural space.
Repeated eccentric and torsional loading and recurrent
microtrauma result in circumferential and radial tears in the
annular fibers. Some annular tears may cause endplate separation,
which results in additional loss of nuclear nutrition and
hydration. The coalescence of circumferential tears into radial
tears may allow nuclear material to migrate out of the annular
containment into the epidural space and cause nerve root
compression or irritation.
Throughout the first 2 decades, 80-90% of the weight of the
lumbar spine's trijoint complex is transmitted across the posterior
third of the disk; however, as disk height decreases and the
biomechanical axis of loading shifts posteriorly, the posterior
articulations (ie, facet joints) bear a greater proportion of the
weight distribution. Bone growth (in the form of new osteophytes)
compensates for this increased biomechanical stress to stabilize
the trijoint complex.
Over time, hypertrophy of the facets and bony overgrowth of the
vertebral endplates contribute to progressive foraminal and central
canal narrowing. In addition to relative thickening of the ligament
flavum and disk herniation, these changes contribute to a reduction
of the anteroposterior canal diameter and foraminal patency with
neural compression. Spinal stenosis reaches a peak later in life
and may produce radicular, myelopathic, or vascular syndromes such
as pseudoclaudication and spinal cord ischemia.
LBP is most common in the early stages of disk degeneration, in
what Kirkaldy-Willis called the stabilization phase. Impaired
healing of the intervertebral disk due to its poor peripheral blood
supply has been proposed as a possible explanation for the
divergent behavior of this structure, which can produce chronic
nociception. Also, the discovery of the biochemical factors that
are responsible for causing increased sensitization of the disk and
other pain-sensitive structures within the trijoint construct will
eventually explain the mechanism of this discrepancy.
Characteristics of Pain-Sensitive Structures
Diskogenic pain
Many studies have demonstrated that the intervertebral disk and
other structures of the spinal motion segment can cause pain.
Kuslich et al used regional anesthesia in 193 patients who were
about to undergo lumbar decompressive surgery for disk herniation
or spinal stenosis.[29]Pain was elicited by using blunt surgical
instruments or an electrical current of low voltage in 30% of
patients who had stimulation of the paracentral annulus fibrosis
and in 15% with stimulation of the central annulus fibrosis.
However, it is unclear why mechanical back pain syndromes commonly
become chronic, with pain persisting beyond the normal healing
period for most soft-tissue or joint injuries in the absence of
nonphysical or operant influences.
In 1987, Mooney proposed that this LBP chronicity was best
explained by a tissue component of the spine that obeyed
physiological rules different from those of other connective
tissues in the body.[30]This divergent behavior is best illustrated
in the intervertebral disk with its composition of large, unique,
water-imbibing proteoglycan molecules. During adulthood, these
large molecules break into small molecules that bind less water.
Repair by means of proteoglycan synthesis is slow. Fissuring and
disruption of the annular lamellae further exacerbate molecular
breakdown and the dehydration of the disk. Arterial blood supply to
the peripheral one third of the outer annulus is meager and
inadequate to prevent subsequent internal degeneration. The annulus
and nucleus pulposus are similarly compromised, as they receive
nutrition only by means of diffusion through adjacent vertebral
endplates. Although sluggish healing of the intervertebral disk may
partially account for the tendency of a spinal lesion to lead to
chronicity, a direct concordance between structural degeneration
and spinal pain does not exist.
Recent elucidation of biochemical behaviors and
neurophysiological factors affecting the disk and other regional
pain-sensitive tissues may account for this discrepancy. In humans,
painful disks have a lower pH than nonpainful disks. Also,
experimental lowering of the pH in animal models induced
pain-related behaviors and hyperalgesia. Diskography of canine
disks that were normally or experimentally deformed seemed to show
increased concentrations of neuropeptides, such as substance P
(SP), calcitonin gene-related peptide (CGRP), and vasoactive
intestinal peptide (VIP) in the dorsal root ganglion (DRG),
implicating their possible role in the transmission or modulation
of pain. SP probably modulates initial nociceptive signals received
in the gray matter of the dorsal spinal cord.
Somatostatin is another neuropeptide found in high
concentrations in the dorsal gray matter of the spinal cord.
Somatostatin is released from the DRG after noxious thermal
stimulation and likely plays a role in pain transmission and in
producing neurogenic inflammation. Therefore, the release of
neuropeptides like SP, VIP, and CGRP may occur in response to
noxious biochemical forces and environmental factors (eg,
biomechanical stress, microtrauma, vibration), stimulating the
synthesis of inflammatory agents (eg, cytokines, prostaglandin E2)
and degradative enzymes (eg, proteases, collagenase). These factors
cause progressive deterioration of the motion segment structures,
especially the intervertebral disk.
Inflammatory factors may be responsible for pain in some cases
in which epidural steroid injections provide relief.
Corticosteroids inhibit the production of arachidonic acid and its
metabolites (prostaglandins and leukotrienes), inhibiting
phospholipase A2 (PLA2) activity. PLA2 levels, which play a role in
inflammation, are elevated in surgically extracted samples of human
herniated disks. Furthermore, PLA2 may play a dual role, inciting
disk degeneration and sensitizing annular nerve fibers. Afferent
nociceptors in nerve roots may be sensitive to various
proinflammatory mediators, which are inhibited by corticosteroids,
such as prostanoids produced from arachidonic acid and released
from cell membrane phospholipids by PLA2.
Research suggests that proinflammatory cytokines may also
contribute to diskogenic pain by sensitizing nociceptors and disk
degeneration by suppressing proteoglycan synthesis and increasing
diskal matrix degradation. Cytokines are produced in response to
neural injury in the CNS and may play a role in spinal neural
hypersensitization and chronic neuropathic pain. Cytokines known to
play a role in nociception include nerve growth factor, interleukin
(IL)-1, IL-6, IL-10, and tumor necrosis factor-alpha (TNF-).
Corticosteroids can inhibit activity of TNF-, which induces IL-1
and prostaglandin E2production. Once released, these substances
contribute to early and late effects of the inflammatory process
and stimulate nociception. A nociceptive role for nitric oxide (NO)
in diskogenic pain syndromes is under investigation. NO levels are
elevated in human disk herniations and when the hydrostatic
pressure of the disk is increased due to biomechanical stressors.
NO inhibits proteoglycan synthesis in cells in the nucleus
pulposus, leading to proteoglycan loss, reduced water content, and
disk degeneration.
Neurotransmitters and biochemical factors may sensitize neural
elements in the motion segment so that the normal biomechanical
stresses induced by previously asymptomatic movements or lifting
tasks cause pain. Furthermore, injury and the subsequent
neurochemical cascade may modify or prolong the pain stimulus and
initiate the degenerative and inflammatory changes described above,
which mediate additional biochemical and morphologic changes.
Whether the biochemical changes that occur with disk degeneration
are the consequence or cause of these painful conditions is
unclear. However, chemical and inflammatory factors may create the
environmental substratum on which biochemical forces cause axial or
limb pain with various characteristics and to various degrees.
Radicular pain
The pathophysiology of spinal nerve root or radicular pain is
unclear. Proposed etiologies include neural compression with axonal
dysfunction, ischemia, inflammation, and biochemical influences.
Spinal nerve roots have unique properties that may explain their
proclivity toward producing symptoms. Unlike peripheral nerves,
spinal nerve roots lack a well-developed intraneural blood-nerve
barrier, and this lack makes them more susceptible to symptomatic
compression injury.
Increased vascular permeability caused by mechanical nerve-root
compression can induce endoneural edemas. Furthermore, elevated
endoneural fluid pressure due to an intraneural edema can impede
capillary blood flow and cause intraneural fibrosis. Also, spinal
nerve roots receive approximately 58% of their nutrition from
surrounding cerebral spinal fluid (CSF). Perineural fibrosis, which
interferes with CSF-mediated nutrition, renders the nerve roots
hyperesthetic and sensitive to compressive forces.
Research has elucidated several vascular mechanisms that can
produce nerve-root dysfunction. Experimental nerve-root compression
showed that venous blood flow can be stopped at low pressures, ie,
5-10 mm Hg. The occlusion pressure for radicular arterioles is
substantially higher than this, approximating the mean arterial
blood pressure and showing a correlation with systolic blood
pressure; this factor increases the potential for venous
stasis.
Some investigators postulate that venous-then-capillary stasis
causes some congestion that, in turn, may induce symptomatic nerve
root syndromes. Nerve root ischemia or venous stasis may also
generate pathological biochemical changes that cause pain, unlike
the progressive sensory-then-motor dysfunction typically seen with
peripheral nerve compression. Studies of ischemia experimentally
induced with low-pressure nerve root compression demonstrated that
compensatory nutrition from CSF diffusion is probably inadequate
when epidural inflammation or fibrosis is present. Rapid-onset
neural and vascular compromise is more likely than a slow or
gradual mechanical deformity to produce symptomatic
radiculopathy.
Research has revealed other possible causative mechanisms for
symptomatic radiculopathy. A 1987 animal study showed that
autologous nucleus pulposus placed in the epidural space of dogs
produced a marked epidural inflammatory reaction that did not occur
in the comparison group, which received saline injections. Similar
studies have shown that myelin-related and axonal injury to nerve
roots exposed to autologous nucleus pulposus demonstrate reduced
nerve conduction velocities.
However, recent studies have demonstrated that experimental
exposure of nerve roots to degenerative nucleus pulposus and
annulus fibrosis does not produce the same dysfunctional neural
changes; therefore, viable cells of the nucleus pulposus are
necessary to induce localized neural dysfunction and generate
algogenic agents, such as metalloprotease (eg, collagenase,
gelatinase), IL-6, and prostaglandin-E2.
Other biochemical substances, including TNF, have been
implicated as causes. TNF increases vascular permeability and
appears to be capable of inducing neuropathic pain. When injected
into nerve fascicles, TNF produces changes similar to those seen
when nerve roots are exposed to the nucleus pulposus. In addition,
a still-unanswered question is whether an autoimmune response
occurs when the nucleus pulposus is exposed to the systemic
circulation, because it is usually sequestered by the annulus
fibrosis and, thus, the immune system may not recognize it as
normal. Indeed, research to date suggests that the cause of
symptomatic radiculopathy is more complex than just neural
dysfunction due to structural impingement.
Facet joint pain
The superior and inferior articular processes of adjacent
vertebral laminae form the facet or zygapophyseal joints, which are
paired diarthrodial synovial articulations that share compressive
loads and other biomechanical forces with the intervertebral disk.
Like other synovial joints, the facets react to trauma and
inflammation by manifesting pain, stiffness, and dysfunction with
secondary muscle spasm leading to joint stiffness and degeneration.
This process is borne out, as previously described, through the
degenerative cascade of the trijoint complex. Numerous radiological
and histological studies have shown that diskal and facet
degeneration are linked and that, over time, degeneration of the
segment leads to osteoarthritis of the facets.
Studies of provocative intra-articular injection techniques
demonstrated local and referred pain into the head and upper
extremities from cervical facets, into the upper midback and chest
wall from thoracic facets, and into the lower extremity from the
lumbar facets. The fibrous capsule of the facet joint contains
encapsulated, unencapsulated, and free nerve endings.
Immunohistochemical studies have demonstrated nerve fibers
containing neuropeptides that mediate and modulate nociception (eg,
SP, CGRP, VIP). SP-filled nerve fibers have been found in
subchondral bone and degenerative lumbar facets subjected to aging
and cumulative biomechanical loading. In fact, SP levels are
correlated with the severity of joint arthritis. The infusion of SP
into joints with mild disease reportedly accelerates the
degenerative process. Furthermore, these chemicals and inflammatory
mediators have been linked to proteolytic and collagenolytic
enzymes that cause osteoarthritis and degradation of the
cartilaginous matrix. Therefore, evidence of nociceptive afferents
and the presence of algogenic neuropeptides, such as SP and CGRP,
in facets and periarticular tissues support a role for these
structures as spinal pain generators. Clinical research has
demonstrated facet pain in 54-67% of patients with neck pain, 48%
of patients with thoracic pain, and 15-45% of patients with
LBP.
Sacroiliac pain
The sacroiliac joint is a diarthrodial synovial joint that
receives its primary innervation from the dorsal rami of the first
4 sacral nerves. Arthrography or injection of irritant solutions
into the sacroiliac joint provokes pain with variable local and
referred pain patterns into regions of the buttock, lower lumbar
area, lower extremity, and groin. As determined by using a variety
of blocking techniques, the reported prevalences of sacroiliac pain
have been widely variable (2-30%) in patients evaluated for chronic
LBP.
Muscular pain
Pain receptors in muscle are sensitive to a variety of
mechanical stimuli, including pressure, pinching, cutting, and
stretching. Pain and injury occur when the musculotendinous
contractual unit is exposed to single or recurrent episodes of
biomechanical overloading. Injured muscles are usually abnormally
shortened, with increased tone and tension due to spasm or
overcontraction. Injured muscles often meet the diagnostic criteria
for myofascial pain (MP) syndrome, a condition that Drs. Janet
Travell and David Simons originally described.
MP is characterized by muscles that are in a shortened or
contracted state, with increased tone and stiffness, and that
contain trigger points (TrPs). TrPs are tender, firm, 3- to 6-mm
nodules that are identified on palpation of the muscles. TrP
palpation provokes radiating, aching pain into localized reference
zones. Mechanical stimulation of the taut band, a hyperirritable
spot in the TrP, by needling or rapid transverse pressure often
elicits a localized muscle twitch.
Sometimes, TrP palpation can elicit a jump sign, an involuntary
reflex, or flinching disproportionate to the palpatory pressure
applied. MP may become symptomatic as a result of direct or
indirect trauma, exposure to cumulative and repetitive strain,
postural dysfunction, or physical deconditioning. MP can occur at
the site of tissue damage or as a result of radicular and other
neuropathic disorders at sites where pain is referred. Muscles
affected by neuropathic pain may be injured due to prolonged spasm,
mechanical overload, or metabolic and nutritional shortfalls.
The pathogenesis of MP and TrPs remains unproven. To date,
research suggests that myofascial dysfunction with characteristic
TrPs is a spinal segmental reflex disorder. Animal studies have
showed that TrPs can be abolished by transecting efferent motor
nerves or infusing lidocaine; however, spinal transection above the
level of segmental innervation of a TrP-containing muscle does not
alter the TrP response. Simons postulates that abnormal,
persistently increased, and excessive acetylcholine release at the
neuromuscular junction generates sustained muscle contraction and a
continuous reverberating cycle. This cycle has been postulated to
result in painful and dysfunctional extrafusal muscle contraction
that forms the basis for MP and possibly the actual structural
substrate of the TrP.
Neurophysiology of spinal pain
Nociception is the neurochemical process whereby specific
nociceptors convey pain signals through peripheral neural pathways
to the central nervous system (CNS). Acute tissue damage to the
spinal motion segment and associated soft tissues activates these
pathways. When the peripheral source of pain persists, intrinsic
mechanisms that reinforce nociception influence the pain. The
nervous system can enhance a pain stimulus generated by tissue
damage to levels far greater than any threat it signifies to the
human organism; this is a common clinical scenario in cases of
chronic spinal pain.
Noxious mechanical, thermal, and chemical stimuli activate
peripheral nociceptors that transmit the pain message through
lightly myelinated A-delta fibers and unmyelinated C-fibers.
Nociceptors are present in the outer annular fibrosis, facet
capsule, posterior longitudinal ligament, associated muscles, and
other structures of the spinal motion segment. Peripheral
transmission of pain stimuli leads to the release of excitatory
amino acids, such as glutamine and asparagine, which then act
onN-methyl-D-aspartic acid (NMDA) receptors, causing the release of
the neuropeptide SP. Neuropeptides such as SP, CGRP, and VIP are
transported to the endings of nociceptive afferents, which
inflammation and other algogenic mechanisms sensitize. Thereafter,
the affected nociceptors respond to mild or normal sensory stimuli,
such as a light touch or temperature change (allodynia).
Algogenic substances that are typically involved in tissue
damage and that can induce peripheral transduction include
potassium, serotonin, bradykinin, histamine, prostaglandins,
leukotrienes, and SP. Transduction leads to transmission, which is
the conduction of afferent pain signals to the DRG and dorsal horn
of the spinal cord. The DRG contains the cell bodies of various
primary afferent nociceptors, including for the neuropeptides SP,
VIP, and CGRP. The DRG is mechanically sensitive and capable of
independent pain transduction, transmission, and modulation.
Transduction is the process whereby noxious afferent stimuli are
converted from chemical to electrical messages in the spinal cord
that travel cephalad to the brainstem, thalamus, and cerebral
cortex.
Nociceptive modulation first occurs in the dorsal horn, where
nociceptive afferents converge to synapse on a single wide dynamic
range (WDR) neuron. WDR neurons respond with equal intensity
regardless of whether the neural signal is noxious or an
exaggerated nonpainful stimuli (hyperalgesia). Hyperalgesia and
allodynia initially develop at the injury site; however, when
peripheral and central sensitization occur by means of WDR neural
activity and central processing, the area of pain expands beyond
the initial more-limited region of focal tissue pathology.
Finally, a phenomenon termedwind-upresults from the repetitive
activation of C-fibers sufficient to recruit second-order neurons
that respond with progressively increasing magnitude; NMDA receptor
antagonists can block this effect. Wind-up contributes to central
sensitization, including hyperalgesia, allodynia, and persistent
pain. These nociceptive mechanisms, which reinforce the pain
signal, frequently recruit the sympathetic nervous system. Elevated
norepinephrine levels in injured areas increase pain sensitivity by
means of regional vasomotor and sudomotor changes. Also, higher
acetylcholine levels can augment ongoing local and regional
involuntary muscle contraction and spasm.
Evolutionary Mechanisms in Chronic LBP
Chronic LBP (cLBP) is not the same as acute LBP that persists
for a greater duration. Usually 6-7 weeks is sufficient for healing
to occur in most soft-tissue or joint injuries; however, 10% of LBP
injuries do not resolve in this period. The evolution of cLBP is
complex, with physiological, psychological, and psychosocial
influences. These influences can be divided into 3 major
categories, with subcategories, as follows:
Neurophysiological mechanisms
Peripheral
Peripheral to central
Psychological mechanisms
Behavioral
Cognitive-affective
Psychophysiological
Barriers to recovery
Medical and surgical
Physical
Psychological
Neuropsychological
Social
Neurophysiological mechanisms
Peripheral mechanisms may reinforce nociception when the source
of pain persists. If an ongoing pathological condition causes the
peripheral pain stimulus, continuous nociception may induce
repetitive stimulation and sensitization of pain receptors and
nerve fibers so that they adversely respond to even mild or normal
sensory stimuli (ie, allodynia). Furthermore, the liberation of
algogenic and other substances from damaged tissues may induce
changes in the microenvironment by means of neuroactive,
biochemical, inflammatory, or vasoactive effects that activate or
increase the sensitivity of nociceptors.
Peripheral-to-central processing may also modify nociception.
Persistent tissue damage may stimulate afferent nerve fibers that
project to internuncial neurons in the spinal cord and thereby set
up neuronal loops of continuous, self-sustaining abnormal
reverberating nociceptive activity. Peripheral inhibition, a
mechanism for reducing the intensity of an afferent pain signal,
may be impaired owing to persistently malfunctioning or diseased
large peripheral myelinated fibers, which normally dampen
nociception (eg, peripheral neuropathy, epidural scarring, chronic
herniated disk material).
Ectopic impulse generation is a theoretical mechanism Wall and
Gutnick proposed.[31]Damaged sensory nerves, affected by conditions
such as neuromata or demyelinating lesions in peripheral nerves,
produce aberrant signals. Deafferentation hypersensitivity also
purportedly causes abnormal and chronic nociceptive firing
patterns.
CNS bias of the signal may occur in the spinal cord, brainstem
reticular formation, or cortex. The brainstem reticular formation
acts to direct the attention of the CNS toward or away from central
and peripheral stimuli. Depending on the degree of focus, or the
lack thereof, the transmission of pain signals may be either
enhanced or inhibited. Furthermore, cortical influences, such as
cognitive and affective disorders, may affect the intensity of the
processed pain signal.
Psychological mechanisms
Psychological manifestations are 3-fold; they include
behavioral, cognitive-affective, and psychophysiological
mechanisms. Guarded movements, nonverbal and verbal expressions of
pain, and inactivity are called pain behaviors. Normal healthy
behavior patterns may become extinguished when these verbal and
nonverbal pain behaviors are reinforced by environmental
factors.
Cognitive-affective mechanisms often contribute to the
perception of chronic pain. Pain complaints are common in depressed
individuals, and patients with chronic pain frequently become
depressed. Depression acts though biochemical processes similar to
those that operate in chronic pain; this may enhance symptoms
through a synergistic relationship. Patients with pain who are
depressed may illogically interpret and distort life experiences,
further complicating the feasibility of treatment or
employment.
Psychophysiological mechanisms naturally triggered by pain and
injury can lead to generalized muscle overactivity, increased
fatigue, and other pain problems (eg, tension myalgia, headache).
The emotional stress that pain induces tends to heighten
norepinephrine activity and the general activity of the sympathetic
nervous system, which may further amplify nociception by means of
peripheral or central mechanisms.
Barriers to recovery
Barriers to recovery may be premorbid, result from traumatic
injury, or develop over time as a result of psychological and
environmental influences. These barriers strongly influence
chronicity and the patient's prognosis. For example, medical
problems, such as diabetes or heart disease, may make the patient a
poor candidate for rehabilitation or surgery. Failed back surgery
may create permanent physical and psychological obstacles.
Patients differ in their inherent capacity to exercise.
Deconditioning syndrome, a term Mayer coined, is caused by
prolonged reduction of physical activity due to cLBP. This syndrome
is associated with a gradual reduction in muscle strength, joint
mobility, and cardiovascular fitness, which over time may become a
self-sustaining and independent component of the individual's
musculoskeletal illness.
Preexisting psychological factors may combine with lower back
injuries to create a pain syndrome with predominantly psychiatric
features. Psychiatric interviews of 200 patients with cLBP entering
a functional restoration (FR) program revealed that 77% met
lifetime diagnostic criteria for psychiatric syndromes, even when
the category of somatoform pain disorder was excluded. In addition,
51% met the criteria for at least 1 personality disorder.
Psychological barriers to recovery include those listed
below.
Premorbid factors
Depression, dysthymia
Predisposition toward somatoform pain disorder
Psychoactive substance-abuse disorder
Personality disorder or traits thereof
Anxiety disorders including panic disorder
Childhood sexual abuse
Cognitive process
Psychosis, delusional pain
Traumatic factors
Anxiety/panic
Fear
Psychophysiological response
Loss of control
Abnormal dependence
Posttraumatic factors
Anxiety, panic
Depression
Posttraumatic stress disorder
Anger/hostility
Iatrogenic substance abuse
Somatoform pain disorder
Symptom magnification
Increasing time since injury
Disability mindset
Personality disorders or related traits often affect the
prognosis. People with borderline personalities may acquire pain as
a method for structuring an otherwise empty existence, whereas
patients who are narcissistic may acquire pain and seek medical
attention as a way of preventing more serious illness. Those with
an antisocial personality are often exploitative and prone to
complications, and they may easily adopt game-playing roles.
Patients with somatizing and hypochondriacal conditions are most
likely to develop pain as a symptom and least likely to respond to
treatments aimed at a presumed organic cause. Individuals with
depression are prone to chronic pain or to have pain as a symptom.
Other personality disorders or disorders that may influence chronic
pain include the paranoid, passive-aggressive, and avoidant
conditions.
Previous learning and role models also affect the patient's
prognosis and treatment outcome. An individual's cognitive or
attribution style (eg, the patient's tendency to catastrophize,
overgeneralize, personalize, or selectively attend to negative
aspects of the pain experience) heavily influence prognosis and
treatment outcomes. The physical and emotional trauma that occurred
during the injury or that was encountered during the ordeal of
convalescence may contribute to the psychosocial milieu and create
a host of emotional responses, including anxiety and fear.
Psychophysiological responses may be reinforced and include
nightmares, palpitations, diaphoresis, headaches, dizziness,
irritability, and fatigue. Patients are often overwhelmed and have
feelings of abnormal dependence. They perceive a loss of control
and look to their physician, attorney, or family for guidance. Some
advisors may be oversolicitous or encourage compensation-seeking or
litigation, creating further barriers to recovery.
Enduring prolonged pain also may cause emotional disturbances.
Depression has already been mentioned as a common partner to
chronic pain and is enhanced by the loss of physical function, low
self-esteem, loss of employment, and financial insecurity.
Heightened anxiety may occur secondary to continued pain and the
associated life disruption. Fear of injury and panic symptoms may
also enhance anxiety and complicate the person's recovery. Anger or
hostility directed at the workplace or perceived ineffective
medical care may hinder communication with physicians, employers,
family, and friends. As the length since the injury increases, the
aggregation of posttraumatic emotions becomes increasingly complex;
avoidance learning and deactivation further complicate the
situation.
As these barriers accumulate, the probability of a poor
prognosis rises. Neuropsychological factors may preexist or come
into effect due to the injury. Limited cognitive function, either
premorbid or from brain injury, may limit the patient's capacity to
make decisions or succeed in a rehabilitation program.
Neuropsychological barriers to recovery include the
following:
Intelligence
Brain injury
Dementia or other organic mental syndromes
Environmental and social influences may play the strongest role
in determining the patient's prognosis for chances of recovery. Job
dissatisfaction or conflict is a key predictor of chronic LBP with
disability. Compensated unemployment may reinforce chronicity in
these cases. Family, financial, and legal issues also affect
chronicity. A patient with chronic LBP may be unable to return to a
previous job that was strenuous or involved heavy lifting and may
be poorly equipped to pursue alternative vocational options because
of a lack of education. Older individuals may have reduced capacity
for work and less vocational potential; therefore, loss of
compensation becomes an overriding issue.
Social barriers to recovery include the following:
Job dissatisfaction or conflict
Compensated unemployment as a disincentive
Family or spousal dynamics
Perception of the norm, ie, family history
Legal influences
Financial security
Limited education or vocational potential
Age-related factors
Clinical Evaluation
History
In most cases, chronic LBP has been investigated with the
appropriate physician evaluation and perhaps imaging studies.
Characterization of the pain as mechanical is a primary goal when a
history is obtained from a patient with cLBP and sciatica.
Mechanical or activity-related spinal pain is most often aggravated
by static loading of the spine (eg, prolonged sitting or standing),
long-lever activities (eg, vacuuming or working with the arms
elevated and away from the body), and levered postures (eg, forward
bending of the lumbar spine). Pain is reduced when multidirectional
forces balance the spine eg, walking or constantly changing
positions) and when the spine is unloaded (eg, reclining). Patients
with mechanical LBP often prefer to lie still in bed, whereas those
with a vascular or visceral cause are often found writhing in pain,
unable to find a comfortable position.
Unrelenting pain at rest should suggest a serious cause, such as
cancer or infection. Imaging studies and a blood workup are usually
mandatory in these cases and in cases with progressive neurological
deficits. Other historical, behavioral, and clinical signs that
should alert the physician to a nonmechanical etiology requiring
diagnostic evaluation are outlined below.
Diagnostic red flags
Pain unrelieved by rest or any postural modification
Pain unchanged despite treatment for 2-4 weeks
Writhing pain behavior
Colicky pain or pain associated with a visceral function
Known or previous cancer
Fever or immunosuppressed status
High risk for fracture (eg, older age, osteoporosis)
Associated malaise, fatigue, or weight loss
Progressive neurological impairment
Bowel or bladder dysfunction
Severe morning stiffness as the primary complaint
Patients unable to ambulate or care for self
Nonphysiological or implausible descriptions of pain may provide
clues that operant or other psychosocial influences coexist.
Prognostic red flags
Nonorganic signs and symptoms
Dissociation between verbal and nonverbal pain behaviors
Compensable cause of injury
Out of work, disabled, or seeking disability
Psychological features, including depression and anxiety
Narcotic or psychoactive drug requests
Repeated failed surgical or medical treatment for LBP or other
chronic illnesses
Physical Examination
Physical examination is important to confirm a mechanical or
benign cause for the patient's LBP. Observations of verbal and
nonverbal behaviors suggesting symptom magnification should be
noted. Inspection of the spine requires the patient to disrobe.
Open-back gowns give the physician only 1 view of the spine;
therefore, swimming attire is often appropriate for complete, 360
inspection. Leg-length discrepancy and pelvic obliquity, scoliosis,
postural dysfunction with forward-leaning head and shoulders, or
accentuated kyphosis should be noted. Physicians' preferences vary
with regard to the importance of testing range of motion; however,
just asking the patient to bend forward often enables the most
worthwhile observations.
The patient is asked to drop his or her head and shoulders
forward and then move slowly into forward bending. Normal forward
bending is revealed when the patient recruits from each cephalic
segment to the level below, and so on, progressing from the
cervical spine through the thoracic and lumbar region, where
flexion of the hips completes the excursion into full flexion.
Patients with clinically significant mechanical back pain or lumbar
segmental instability usually stop cephalic-to-caudal segmental
recruitment on reaching the thoracolumbar junction, or sometimes
the involved lumbar level. To continue forward bending, they then
contract their lumbar muscles to brace the mechanically compromised
segment and then continue recruitment in a reverse direction,
beginning with motion through the hips, then proceeding cephalad,
level to level, completing the excursion of the spine to the erect
posture.
In cases of severe mechanical back pain and segmental
instability with regional muscular spasm, the patient often reports
an inability to perform any flexion below a thoracic spinal level.
Any soft-tissue abnormalities and tenderness to palpation should be
recorded. Palpation of lumbar paraspinal, buttock, and other
regional muscles should be performed early in the examination. The
examiner should palpate and note areas with superficial and
deep-muscle spasm, and he or she should identify TrPs and small,
tender nodules in a muscle that elicit characteristic regional
referred pain.
Dissociation of physical findings from physiological or
anatomical principles is the key with patients in whom
psychological factors are suspected to be influential. Examples of
this phenomenon include nondermatomal patterns of sensory loss,
nonphysiological demonstrations of weakness (give-way weakness when
not caused by pain, or ratchety weakness related to simultaneous
agonist and antagonist muscular contraction), and dissociation
between the lumbar spinal movements found during history-taking or
counseling sessions from movements observed during examination.
The assessment of Waddell signs has been popularized as a
physical examination technique to identify patients who have
nonorganic or psychogenic embellishment of their pain syndrome. One
of the examination techniques that Waddell proposed is simulated
rotation of the hipsen massewith the lumbar spine without allowing
for spinal rotation; this maneuver normally does not cause pain.
Another is the application of light pressure on the head, which
should also be painless. Likewise, gentle effleurage of superficial
tissues is unlikely to cause pain. Other techniques include a
striking dissociation between testing straight leg raising with the
patient sitting versus supine and the examiner's discovery of
nonphysiologic weakness and/or sensory deficits by the patient.
Straight leg raising with the patient supine should produce
ipsilateral leg pain between 10 and 60 to be declared positive.
Straight leg raising that produces pain in the opposite leg carries
a high probability of disk herniation, and an investigation should
be considered, especially if neurological evidence for
radiculopathy is present. Nonspecific complaints, overtly excessive
pain behavior, patient contraction of antagonist muscles that limit
the examiner's testing, or tightness of buttock and hamstring
muscles are commonly mistaken for positive results on straight leg
raising.
Reverse straight leg raising may elicit symptoms of pain by
inducing neural tension on irritated or compressed nerve roots in
the mid-to-upper lumbar region. In addition, this maneuver helps
the astute physician identify tightness of the iliopsoas muscle,
which commonly contributes to chronic lumbar discomfort.
A neurological evaluation is performed to determine the presence
or absence and levels (if present) of radiculopathy or myelopathy.
Anatomical localization is determined by muscle and reflex testing
combined with medical history details obtained during the interview
and the absence of neurological symptoms or signs that implicate
cerebral or brainstem involvement. Consistent myotomal weakness and
sensory findings that seem to coincide with segmental radiculopathy
or polyradiculopathies should not be ignored.
The neurologist should identify syndromes of the lower motor
neurons versus the upper motor neurons and the level of spinal
dysfunction. Hyperreflexia in caudal spinal levels may change to
reduced or absent reflexes in the upper extremities, determining
the radicular or spinal cord localization of dysfunction. Rectal
examination is indicated in patients in whom myelopathy, especially
cauda equina syndrome, is a diagnostic concern. The tone of the
anal sphincter; presence or absence of an anal wink; and
correlation with motor, sensory, and reflex findings are
appropriate to determine in these cases.
When LBP persists beyond 3 months, into the chronic phase,
appropriate clinical and diagnostic information supporting a benign
or mechanical cause should be collected, if it has not been
already. Also, a prompt physician evaluation, including reasonable
radiographic, laboratory, and electrophysiological testing, is
indicated in patients with persistent severe neurological deficit,
intractable limb pain, suspected systemic illness, or changes in
bowel or bladder control. The spectra of mechanical (or
activity-related) and nonmechanical causes of LBP are outlined
below.
Mechanical or activity-related causes of LBP
Diskal and segmental degeneration - May include facet
arthropathy from osteoarthritis
Myofascial, muscle spasm, or other soft-tissue injuries and/or
disorders
Disk herniation - May include radiculopathy
Radiographic spinal instability with possible fracture or
spondylolisthesis - May be due to trauma or degeneration
Fracture of bony vertebral body or trijoint complex - May not
reveal overt radiographic instability
Spinal canal or lateral recess stenosis
Arachnoiditis, including postoperative scarring
Differential diagnosis can include many neurological and
systemic disorders, as well as referred pain from viscera or other
skeletal structures such as the hip.
Disorders that may be associated with nonmechanical LBP
Neurological syndromes
Myelopathy from intrinsic or extrinsic processes
Lumbosacral plexopathy, especially from diabetes
Neuropathy, including the inflammatory demyelinating type (ie,
Guillain-Barr syndrome)
Mononeuropathy, including causalgia
Myopathy, including inflammatory and metabolic causes
Dystonia, truncal or generalized central pain syndrome
Systemic disorders
Primary metastatic neoplasm, including myeloma
Osseous, diskal, or epidural infection
Inflammatory spondyloarthropathy
Metabolic bone disease, including osteoporosis
Vascular disorders such as atherosclerosis or vasculitis
Referred pain
Gastrointestinal disorders
Genitourinary disorders, including nephrolithiasis, prostatitis,
and pyelonephritis
Gynecological disorders, including ectopic pregnancy and pelvic
inflammatory disease
Abdominal aortic aneurysm
Hip pathology
Psychosocial factors that may influence LBP chronicity and
disability
Compensable injury
Somatoform pain disorder
Psychiatric syndromes, including delusional pain
Drug-seeking
Abusive relationships
Seeking disability or out-of-work status
Diagnostic Strategies
As indicated in the last section, unrelenting pain at rest
should generate suspicion of cancer or infection. The appropriate
imaging study is mandatory in these cases and in cases of
progressive neurological deficit. Plain anteroposterior and lateral
lumbar spine radiographs are indicated for patients older than 50
years and for those with pain at rest, a history of serious trauma,
or other potential conditions (eg, cancer, fracture, metabolic bone
disease, infection, inflammatory arthropathy). The yield for
discovering a serious condition with radiography outside these
parameters is minimal, and the cost savings are substantial.
When LBP and sciatica persist into the subacute phase (pain
lasting 6-12 wk), appropriate consultation and diagnostic imaging
should be considered. Referring the patient to a physician with
expertise in spinal disorders may be the most appropriate procedure
for initial evaluation as opposed to relying on expensive
diagnostic testing.
CT scanning is an effective diagnostic study when the spinal and
neurological levels are clear and bony pathology is suspected.
MRI is most useful when the exact spinal and neurologic levels
are unclear, when a pathological condition of the spinal cord or
soft tissues is suspected, when postoperative disk herniation is
possible, or when an underlying infectious or neoplastic cause is
suspected.
Myelography is useful in elucidating nerve root pathology,
particularly in patients with previous lumbar spinal surgery or
with a metal fixation device in place. CT myelography provides the
accurate visual definition to elucidate neural compression or
arachnoiditis when patients have undergone several spinal
operations and when surgery is being considered for the treatment
of foraminal and spinal canal stenosis.
When leg pain predominates and imaging studies provide ambiguous
information, clarification may be gained by performing
electromyography (EMG), somatosensory evoked potential (SSEP)
testing, or selective nerve root blocks. When the cause of sciatica
is related to neural compression by bony or soft-tissue structures
in the spinal canal, a surgical consultation should be considered.
If the results of the diagnostic information are inadequate to
explain the degree of neurological deficit, pain, and disability, a
multidisciplinary evaluation may provide insight into the
perpetuating physical and psychosocial factors (see image
below).
Algorithm for the management of low back pain and
sciatica.Nonoperative Treatment
Support for Nonsurgical Treatment
Doubt remains regarding the relative efficacy and
cost-effectiveness of surgical versus nonsurgical treatment
approaches. An important longitudinal study was performed by Henrik
Weber, who randomly divided patients who had sciatica and confirmed
disk herniations into operative and nonoperative treatment
groups.[32]He found significantly greater improvement in the
surgically treated group at 1-year follow-up; however, the 2 groups
showed no statistically significant difference in improvement at 4
to 10 years.[32]Two prospective cohort studies compared the
surgical and nonsurgical management of lumbar spinal stenosis and
sciatica due to lumbar disk herniation.[33, 34]The results and
conclusions were similar in both studies. For patients with severe
symptoms, surgical treatment was associated with greater
improvement and satisfaction. This distinction persisted, but
diminished over time.[33, 34, 35]The recent and very ambitious
Spinal Patient Outcomes Research Trial (SPORT) had been hoped to
significantly clarify the surgical versus nonsurgical issues. So
far, with data analyzed for 2- and 4-year follow-ups, finding
definitive answers in this study is difficult, though they contain
a large amount of interesting information. For disk herniation, the
major conclusion at 4 years was that nonoperative treatment or
surgery led to improvement in intervertebral disk herniation. But
surgery may have a slight benefit.[36, 37]For spondylolisthesis,
the 2- and 4-year as-treated analysis showed an advantage to
surgical therapy.[38, 39]Likewise, for spinal stenosis, the 2-year
analysis showed somewhat more improvement for surgery.[40]With
regard to cost effectiveness, the surgical costs were rather high,
though not completely out of the range of other medical treatments.
For lumbar disk herniations, 1 quality-adjusted life year (Qaly)
cost about $70,000. For stenosis and spondylolisthesis the costs
per Qaly were $77,000 and $116,000, respectively.[41, 42]A
significant general problem with the SPORT data is that there was
so much switching between treatment groups that intention-to-treat
analysis (the usual criterion standard) was impossible. Therefore
as-treated analyses were used. As the SPORT analyses continue
beyond the 2- to 4-years, additional information or more definitive
changes between groups may be identified. But lack of an
intention-to-treat analysis will probably complicate definitive
conclusions. Hopefully, future studies and newer treatments may
someday provide clearer answers.
The rationale for nonoperative treatment of diskal herniation
has been supported by clinical and autopsy studies, which
demonstrate that resorption of protruded and extruded disk material
can occur over time.[43, 44]Other studies have correlated MRI or CT
improvement with successful nonoperative treatment in patients who
have lumbar disk herniations and clinical radiculopathy.[44, 45,
46]The greatest reduction in size typically occurred in patients
with the largest herniations. Recent uncontrolled studies have
shown that patients who have definite herniated disks and
radiculopathy and satisfy the criteria for surgical intervention
can be treated successfully with aggressive rehabilitation and
medical therapy. Good to excellent results were achieved in 83% of
cervical and 90% of lumbar patients.[47, 48]In general,
nonoperative treatment can be divided into 3 phases based on the
duration of symptoms. Primary nonoperative care consists of
passively applied physical therapy during the acute phase of
soft-tissue healing (< 6 wk). Secondary treatment includes spine
care education and active exercise programs during the subacute
phase between 6-12 weeks with physical therapydriven goals to
achieve preinjury levels of physical function and a return to work.
After 12 weeks, if the patient remains symptomatic, treatment
focuses on interdisciplinary care using cognitive-behavioral
methods to address physical and psychological deconditioning and
disability that typically develops as a result of chronic spinal
pain and dysfunction.[49]When spinal pain persists into the chronic
phase, therapeutic interventions shift from rest and applied
therapies to active exercise and physical restoration. This shift
is primarily a behavioral evolution with the responsibility of care
passed from doctor and therapist to patient.[18, 50]Bed rest should
be used sparingly for chronic spinal pain to treat a severe
exacerbation of symptoms. Therapeutic injections, manual therapy,
and other externally applied therapies should be used adjunctively
to reduce pain so that strength and flexibility training can
continue. When spinal pain is chronic or recurrent, traction or
modalities, such as heat and ice, can be self-administered by
patients for flare-ups to provide temporary relief.[18, 50]Rational
physical, medical, and surgical therapies can be selected by
determining the relevant pathoanatomy and causal pain generators.
Acute spinal injuries are first managed by the elimination of
biomechanical stressors, using short-term rest, supplemented by
physical and pharmacological therapies aimed directly at the
nociceptive or neuropathic lesion(s).
The paradigm that best represents the elimination of activity or
causative biomechanical loading is bed rest. Bed rest is usually
considered an appropriate treatment for acute back pain. However, 2
days of bed rest for acute LBP has been demonstrated to be as
effective as 7 days and resulted in less time lost from
work.[51]Furthermore, prolonged bed rest can have deleterious
physiological effects, leading to progressive hypomobility of
joints, shortened soft tissues, reduced muscle strength, reduced
cardiopulmonary endurance, and loss of mineral content from
bone.[18, 7, 20]For these reasons and because inactivity may
reinforce abnormal illness behavior, bed rest is usually avoided
when treating chronic spinal conditions.[18, 7, 20]Oral
Pharmacology
Rational pharmacology for the treatment of spinal pain is aimed
at causative peripheral and central pain generators, determined by
the types of pain under therapeutic scrutiny (eg, neuropathic
and/or nociceptive), and modified additionally to deal with the
evolving neurochemical and psychological factors that arise with
chronicity. In general, the published research for evaluating the
efficacy of medication in treating neck and back pain has
demonstrated faulty methodology and inadequate patient/subject
description.[52]However, medication continues to be used as adjunct
to other measures because of anecdotal reports, perceived standards
of care, and some supportive clinical research.
Some authors contend that analgesics like acetaminophen are a
reasonable first step for the treatment of cLBP[53, 54], although
others disagree and advocate its use only when treating acute
LBP.[55]There is evidence that acetaminophen has a similar efficacy
to nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with
acute LBP; however, little direct evidence exists regarding the
efficacy of acetaminophen in cLBP.[56]The possible beneficial
effects of long-term acetaminophen use must be weighed against
potential adverse hepatic and renal effects.[57]There is strong
evidence that both traditional and cyclooxygenase-2-specific NSAIDs
are more efficacious than a placebo for reducing LBP in the short
term, although the effects tend to be small.[56]One small
randomized study suggested that the NSAID diflunisal had a greater
efficacy than acetaminophen.[58]In addition, their findings
demonstrate that the various NSAIDs are, on average, equally
efficacious.[59]Gastrointestinal, renal, and potential cardiac
toxicities must be considered with long-term NSAID use.[56].
During the acute phase following biomechanical injury to the
spine, where there are no fractures, subluxation, other serious
osseous lesions, or significant neurological sequelae, mild
narcotic analgesics may assist patients in minimizing inactivity
and safely maximizing the increase in activity, including
prescribed therapeutic exercises. NSAIDs and muscle spasmolytics
used during the day or at bedtime may also provide some
benefit.[18, 50]The best available evidence advocates the use of an
antidepressant, analgesic, or both for chronic back pain. When
starting a new medication, patients should be educated as to why a
medication is chosen and its expected risks and benefits. Patient
preferences concerning medications should be considered, especially
after they are informed of potential risks. When anxiety lingers
regarding the risks or side effects of a medication (eg, NSAIDs or
muscle relaxants), a short trial of the medication at a low dosage
over 3-4 days can be effective for assessing the patient's
tolerance and response to the drug, as well as alleviating patient
and physician concerns. Most patients require medications in
relatively high therapeutic ranges over a protractile period of
time.[60]Patients may be resistant to multiple therapeutic
approaches and may require more individualized medication
combinations, including other analgesics. Pooled data from large
groups of patients have shown that no one medication in any of the
various drug classes provides more benefit to the patient than
another.[60]Furthermore, predicting which patient will respond best
to which medication within that class is impossible. Better studies
with greater numbers of patients and longer follow-up times are
needed to better compare classes of medications, including simple
analgesics, muscle relaxants, and NSAIDs.[54]NSAIDs
NSAIDs contain both analgesic and anti-inflammatory properties
and therefore may affect mediators of the pathophysiological
process. Clinical trials have demonstrated NSAIDs to be useful as a
treatment for pain, but the long-term use of NSAIDs should be
discouraged due to the frequent occurrence of adverse renal and
gastrointestinal side effects.[18, 52]A 2000 review and analysis of
randomized and double-blind controlled trials of NSAIDs as LBP
treatment revealed supportive evidence for short-term symptom
relief in patients with acute LBP. Evidence of any benefit for
chronic LBP or of any specific superiority of one NSAID is
lacking.[61, 60]Therefore, the effect of these medications in the
management of chronic musculoskeletal pain remains unclear, and no
studies have demonstrated a clear superiority over
aspirin.[52]Although the research does not support any specific
NSAID over others, switching to different chemical families through
sequential trials sometimes helps identify an agent that is the
most beneficial for an individual patient.[18]Muscle
spasmolytics
Muscle spasmolytics or relaxants are traditionally used to treat
painful musculoskeletal disorders. As a class, they have
demonstrated more CNS side effects than a placebo, sharing sedation
and dizziness as common side effects. Therefore, patients should be
cautioned about these side effects and weigh them against the
potential benefits.[56, 58, 62, 60]A recently published review and
analysis of randomized or double-blinded controlled trials showed
that muscle relaxants were effective for the management of LBP, but
adverse side effects limited their use.[62]With some patients,
these medications can only be considered for use at bedtime. Some
muscle spasmolytics are also potentially addictive and have abuse
potential, especially more traditional agents such as diazepam,
butalbital, and phenobarbital.
The category of muscle relaxants includes a heterogeneous group
of medications that some experts divide into benzodiazepines and
nonbenzodiazepines. Benzodiazepines may be appropriate for
concurrent anxiety states, and in those cases, clonazepam should be
considered for its clinical use. Clonazepam is a benzodiazepine
that operates via GABA-mediated mechanisms through the internuncial
neurons of the spinal cord to provide muscle relaxation.[63]Strong
evidence shows that another benzodiazepine, tetrazepam, is more
effective than a placebo at treating short-term pain and some
indicate that it also improves muscle spasms; however, data on
long-term outcomes are inadequate.[56]The data on nonbenzodiazepine
muscle relaxants are not as strong, but moderate evidence exists
for short-term overall improvements, although little or no
improvement has been shown in specific pain outcomes.[62]Examples
of commonly used nonbenzodiazepine muscle relaxants include
cyclobenzaprine, carisoprodol, methocarbamol, chlorzoxazone, and
metaxalone. A comprehensive evaluation and meta-analysis of
cyclobenzaprines effectiveness showed support for short-term use
(< 4 d) with a modest benefit early in LBP treatment, but with
the same problematic side effects.[64]Tizanidine is a central -2
adrenoreceptor agonist that was developed for the management of
spasticity due to cerebral or spinal cord injury, but also has
demonstrated efficacy when compared to other muscle
spasmolytics.[65]The muscle spasmolytic effects of tizanidine are
thought to relate primarily to centrally acting 2-adrenergic
activity at both the spinal cord and supraspinal levels.[66]Several
clinical trials have demonstrated the efficacy of tizanidine for
the treatment of acute neck and back pain.[67, 68, 69, 70,
71]Controlled studies have demonstrated reduced analgesic use and
muscle spasm in patients with acute neck and back
pain.[69]Specifically, comparison studies have shown that
tizanidine is as effective as diazepam and chlorzoxazone for
treatment of these acute conditions.[70]Tizanidine exerts no
significant effect on muscle tone, so patients report muscle
weakness less often as a side effect than with diazepam or other
muscle relaxants.[71]The onset of action of tizanidine is rapid
with peak plasma concentrations occurring at 1-2 hours following
oral administration.[71]The elimination half-life of tizanidine is
approximately 2.5 hours with significant interpatient
variability.[71]This rapid onset of action coupled with its muscle
spasmolytic and antinociceptive properties has spurred
investigation into clinical use not only for the treatment of acute
spinal pain with muscle spasm, but also as therapy for other
painful chronic muscular conditions.
Neuropathic pain analgesics
Conventional treatments for neuropathic pain, including
anticonvulsants, may be appropriate for trial use in specific cases
when nervous system structures are symptomatic and for myofascial
pain, which may also be a spine-mediated disorder. Neuropathic pain
may be seen in association with radiculopathy or myelopathy, and
the neurologist may be asked for treatment advice in cases without
a clear structural cause, following failed or complex surgical
treatment, or when surgical intervention is contraindicated.[18,
72]Antiepileptic drugs (AEDs), such as phenytoin, carbamazepine,
and divalproex sodium, have been used by neurologists for years to
treat neuropathic pain, including neuralgia and headaches.[18,
72]Only carbamazepine is FDA-approved for trigeminal neuralgia.
Recently, several newer AEDs have been scrutinized through research
and clinical trials as possible treatments for various neuropathic
pain syndromes. These recently developed AEDs have 4 basic
mechanisms of action:[54, 73]1. Inhibition of sodium channels
2. Inhibition of calcium channels
3. Regulation of the levels or activity of the inhibitory
neurotransmitter GABA
4. Regulation of the levels or activity of the excitatory amino
acid glutamate
An anticonvulsant popularly prescribed for chronic pain is
gabapentin; however, its exact mechanism of action is unclear.
Gabapentin has been demonstrated to be effective in multiple
double-blind, randomized, controlled studies for the treatment of
neuropathic pain syndromes including postherpetic neuralgia[74,
75], diabetic polyneuropathy[76], and spinal cord injury[77]. It
has also been shown to be effective as a treatment for myofascial
pain associated with neuropathic pain.[78]Lamotrigine has been
shown to be effective in several small studies for the treatment of
trigeminal neuralgia[79, 80], peripheral neuropathy[81, 82, 83],
and central post-stroke pain[84]. The advantages of this AED
include its long half-life, which allows once-daily dosing. On the
other hand, a rash, which may develop into toxic epidermal
necrolysis, has been reported in up to 10% of patients.[85]Other
adverse side effects include headaches, asthenia, dizziness, and
oversedation.[85]No studies have addressed whether it will be
useful for treating spinal pain syndromes. However, randomized,
controlled, double-blind studies to assess its efficacy for
neuropathic pain have been strongly recommended.[86]Other
contemporary AEDs showing promise as treatments for neuropathic
pain in small open-label studies include topiramate[87, 88],
zonisamide[89, 90, 91, 92], levetiracetam[93], tiagabine[94], and
oxycarbazepine.[95, 96, 97, 98]Double-blind, randomized,
placebo-controlled studies in specific neuropathic pain populations
with careful monitoring of dosage levels and adverse events are
necessary. Application of these medications to cases of refractory
spine-related neuropathic pain is empirical, but warrants
consideration.
Antidepressants
Tricyclic antidepressants (TCAs) are commonly used in chronic
pain treatment to alleviate insomnia, enhance endogenous pain
suppression, reduce painful dysesthesia, and eliminate other
painful disorders such as headaches. Research supports the use of
TCAs to treat both nociceptive and neuropathic pain syndromes.[54,
73, 99, 100]The presumed mechanism of action is related to the TCAs
capacity to block serotonergic uptake, which results in a
potentiation of noradrenergic synaptic activity in the CNS's
brainstem-dorsal horn nociceptive-modulating system.
Also, studies in animals suggest that TCAs may act as local
anesthetics by blocking sodium channels where ectopic discharges
are generated.[100, 101]Two systematic reviews found that
antidepressants reduced pain intensity in cLBP, but no consistent
improvement in functional outcomes was measured.[102, 56, 58]Any
efficacy for pain relief was seen primarily in tricyclic and
tetracyclic antidepressants, whereas selective serotonin reuptake
inhibitors (SSRIs) did not show similar properties or
efficacy.[102]Little evidence supports the use of SSRIs to
attenuate pain intensity, and studies have suggested that these
agents are inconsistently effective for neuropathic pain at
best.[73]Venlafaxine is a structurally novel antidepressant shown
to produce strong uptake inhibition with both serotonin and
norepinephrine and have anesthetic properties similar to the
TCAs.[103]An uncontrolled case series reported that venlafaxine
provided pain relief in a variety of neuropathic pain
disorders.[103]Recent studies have shown duloxetine (Cymbalta) to
provide significant pain relief compared with placebo for chronic
musculoskeletal pain, including low back pain and pain caused by
osteoarthritis. In November 2010, the US Food and Drug
Administration (FDA) approved duloxetine for treatment of chronic
musculoskeletal pain.[272, 273, 274, 275]The usefulness of TCAs is
limited, particularly in geriatric populations, due to
cardiovascular effects such as tachycardia; anticholinergic side
effects including dry mouth, increased intraocular pressure, and
constipation; oversedation; and dizziness, including orthostatic
hypotension.[104]SSRIs should be considered for a variety of
symptoms that commonly accompany chronic pain including reduced
coping, depression, anxiety, and fatigue.[104]Overall, SSRIs have
fewer adverse side effects than TCAs. Side effects associated with
SSRIs include anxiety, nervousness, and insomnia; drowsiness and
fatigue; tremor; increased sweating; appetite and gastrointestinal
dysfunction; and male sexual dysfunction. Many pain specialists
still consider TCAs as first-line pain medications for the
treatment of persistent neuropathic pain, especially as an adjunct
to peripheral therapies and to manage the adverse influences of
chronic illness.
Opioid analgesics
The authors of a 2008 summary and analysis of the best available
evidence concluded that all the high-quality studies involving
opioid analgesics demonstrated improvements in pain compared with a
placebo that were clinically and statistically significant enough
to support the their use as a treatment adjunct for patients with
cLBP.[105]Although evidence-informed data show stronger support for
short- than long-term use, there is still sufficient support for
prolonged use as an adjunct treatment for chronic spinal pain.
Randomized controlled trials showed a relatively high dropout
rate (20-40%) of patients due to adverse side effects. On average,
a third were excellent responders, a third were fair responders,
and the remainder tended to be nonresponders. Generally, the
evidence for improvements in function is less impressive than
reports of a reduction in pain. Opioids appear to be generally safe
when used appropriately, and serious side effects are relatively
infrequent. Despite contrary opinions among experts, an analysis of
the literature also demonstrates that aberrant behaviors in a
controlled medical environment, such as recreational abuse and drug
divergence, have remained at acceptably low levels.[105]In another
evidence-based review, the author cites his findings with more
skepticism regarding the long-term use of opioids for chronic back
pain.[102, 54, 55]A review of 6 trials compared opioids with
placebo or nonopioid analgesics and showed that opioids performed
better than the controls in pain reduction; however, in a
meta-analysis of the 4 studies that used the best methodology for
analysis, this difference was not statistically
significant.[106]The conclusions from this systematic review were
consistent in demonstrating that opioids are useful for short-term
pain relief, but that long-term efficacy or benefit with respect to
cLBP is yet to be demonstrated. Furthermore, a review of studies
investigating deviant medication-taking behaviors found a wider
variation of aberrancy ranging from 5-24%.[106]However, from a
practical standpoint, low to moderate doses of opioids may be
helpful for activating an injured patient to participate in
physical and psychological rehabilitation, including functional
restoration, especially with patients whose pain is associated with
acute radiculopathy, particularly in those cases that are pre- or
postoperative. Opioid analgesics may be helpful for sufferers of
chronic intermittent back pain during an acute exacerbation;
however, the continuous use of opioid analgesics for chronic neck
and back pain is usually reserved as a tertiary treatment
option.
Over the past decade, physicians, specifically pain specialists,
have adopted a greater willingness to prescribe opioid analgesics
for the treatment of refractory spinal pain and radiculopathy. Most
patients reclaim what life they can. Inherent dangers include side
effects such as respiratory depression cardiac toxicity, bowel
dysfunction, sometimes paralysis or obstruction, and hormonal
suppression, especially of testosterone, as well as addiction,
naive withdrawal, and death from overdosage. The side effect
profiles among long-acting opioids are similar, but the cost is
variable between current pharmaceutical offerings, which include
orally routed methadone, long-acting oxycodone, long-acting
morphine, long-acting oxymorphone, and the controlled delivery of
fentanyl by transdermal patch.
Several principles apply to prescribing long-acting opioids for
chronic pain. These medications should be taken in a
time-contingent, rather than pain-contingent manner, and they
should only be provided by 1 prescribing physician and pharmacy.
The need and purpose of the opioids and their medical necessity
should be affirmed by an agreement signed by both patient and
doctor and placed in the medical record. The achievement of
vocational, recreational, and social goals is a better measure of
medication efficacy than subjective estimates of pain
relief.[102]For chronic spinal pain, an ongoing, active, preferably
independent exercise program aimed at functional restoration should
be considered mandatory.
Topical therapy
Topical treatment is drug delivery over or onto the painful
site. The medication is delivered through the skin to a shallow
depth (< 2 cm) and acts locally, without producing significant
systemic serum levels or side effects. A commonly prescribed
topical treatment for nociceptive and neuropathic pain is the 5%
lidocaine patch. The patch is FDA-approved for the treatment of
postherpetic neuralgia and has been demonstrated as an effective
treatment for chronic LBP.[107]Almost any imaginable drug
combination can be compounded by a competent local pharmacist to
create an effective topical application. NSAIDs can be mixed with
local anesthetics, AEDs, TCAs, and norepinephrine/epinephrine
(sympathetic nervous system) antagonists to calm down pain and
autonomic dysfunction associated with chronic spinal-radicular
syndromes. Sometimes, compounding topical creams/lotions gives the
treating physician the greatest latitude to treat symptoms,
especially allodynia, without worrying about the medications'
systemic side effects.
Novel/emerging pharmacology
The role of inflammation in causing segmental and radicular pain
has been reviewed. Cytokines, released by activated macrophages,
mast cells, Schwann cells, and microglia, play a major role in
nociception and inducing chronic neuropathic pain.[108]Infliximab
is a chimeric monoclonal antibody against TNF-, a cytokine with a
known role in eliciting spinal nociception. In a recent study, 10
patients with severe sciatica from disk herniation received
intravenous infliximab and were compared with a group who were
treated with a periradicular infiltration of saline. The infliximab
group showed a more than 75% reduction in pain, and the difference
was sustained at 3 months.[109]To date, no published data are
available regarding the treatment of mechanical spinal pain or
sciatica using etanercept (a TNF- blocker) and anakinra (an IL-1
blocker).
Bisphosphonates, specifically pamidronate, have recently
attracted attention as a potential new treatment for mechanical
spinal pain involving the diskal and radicular structures. These
compounds have demonstrated antinociceptive effects and the
capacity to inhibit cytokine release by causing apoptosis of
reactive macrophages in experimental animal models.[110, 111, 112,
113, 114, 115, 116]The cytokine IL-2 possesses antinociceptive
(analgesic) effects upon the peripheral and central nervous
systems. Preliminary animal work has produced an antinociceptive
effect in the spinal dorsal horn via IL-2 gene therapy.[117]A new
chemical compound, designed to be a NO-releasing derivative of
gabapentin, was synthesized and designated as NCX8001. This moiety
released physiologically relevant active concentrations of NO
consequent to experimentally induced sciatic nerve or spinal cord
injuries. Observed results included the inhibition of TNF- and
reduced allodynia in the injured rats.[118]Other potential future
treatments include drugs targeted at the nociception (opioid)
receptor[119, 120]and the NMDA receptor. NMDA receptor antagonists,
such as dextromethorphan (DM), ketamine, and memantine, are thought
to be beneficial in cases of chronic pain and long-term opioid
therapy. DM has been shown to reduce morphine requirements in
randomized controlled trials.[121, 122, 123]Ziconotide is a
neuronal calcium channel blocker that affects neurotransmitter
release from primary nociceptive afferents at a spinal level.
Studies suggest that it has promise for patients with chronic
refractory neuropathic pain that is unresponsive to opioids.[124,
125]Alternative medications (eg, glucosamine) are widely used by
patients, but limited data are available to suggest efficacy.
Wilkens et al conducted a randomized, placebo-controlled trial in
patients with chronic low back pain (LBP) and degenerative lumbar
osteoarthritis (OA) (n=250). Patients received either glucosamine
(1500 mg/d PO) or placebo for 6 months. Compared with placebo,
glucosamine did not reduce pain-related disability after the
6-month intervention and after 1-year follow-up.[126]Spinal
Interventional Procedures
Local anesthetics, corticosteroids, or other substances may be
directly injected into painful soft tissues, facet joints, nerve
roots, or epidural spaces. They may also be given intrathecally.
Therapeutic injections have been advocated to alleviate acute pain
or an exacerbation of chronic pain, help patients remain ambulatory
outpatients, allow them to participate in a rehabilitation program,
decrease their need for analgesics, and avoid surgery. Local
injections into paravertebral soft tissues, specifically into
myofascial trigger points, are widely advocated. However, a
double-blind study to compare local anesthetic with saline
injections and a prospective randomized double-blind study to
compare dry needling with acupressure spray applications of
lidocaine, corticosteroids, and vapor coolants revealed no
statistically significant difference in therapeutic effects.
Injections can also be used to irritate pain-sensitive spinal
tissues to determine whether they are pain generators. Carefully
placed contrast dye or normal saline can provoke a pain pattern
similar to the patient's primary complaint. Performed under
fluoroscopy, contrast dye will document the targeted structure and
provocation site, and it is followed by the application of a local
anesthetic to ablate the pain, which further verifies the targets
role as a pain generator. Some believe that a successful
therapeutic intervention can be achieved by using local anesthetic
combined with corticosteroids. Some structures can be denervated by
radiofrequency ablation or chemical neurolysis to eliminate pain
for a prolonged period of time. These techniques receive some
support from evidence-based informed data reviewed in this
section.
A comprehensive review of the literature was conducted by
Boswell et al in 2007, whereby evidence-based data was published by
the American Society of Interventional Pain Physicians (ASIPP).
This group of physicians has been extremely open regarding their
methodology and more than willing to respond to published criticism
by other societies who do not use Spinal Interventional Physicians
(SIPs) on their panel of reviewing physicia