Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials

Original Text

Dr Roberta T Chow MBBS a Corresponding AuthorEmail Address, Prof Mark I Johnson PhD b, Prof Rodrigo AB Lopes-Martins PhD c, Prof Jan M Bjordal PT d e
Summary
Background
Neck pain is a common and costly condition for which pharmacological management has limited evidence of efficacy and side-effects. Low-level laser therapy (LLLT) is a relatively uncommon, non-invasive treatment for neck pain, in which non-thermal laser irradiation is applied to sites of pain. We did a systematic review and meta-analysis of randomised controlled trials to assess the efficacy of LLLT in neck pain.

Methods
We searched computerised databases comparing efficacy of LLLT using any wavelength with placebo or with active control in acute or chronic neck pain. Effect size for the primary outcome, pain intensity, was defined as a pooled estimate of mean difference in change in mm on 100 mm visual analogue scale.

Findings
We identified 16 randomised controlled trials including a total of 820 patients. In acute neck pain, results of two trials showed a relative risk (RR) of 1·69 (95% CI 1·22—2·33) for pain improvement of LLLT versus placebo. Five trials of chronic neck pain reporting categorical data showed an RR for pain improvement of 4·05 (2·74—5·98) of LLLT. Patients in 11 trials reporting changes in visual analogue scale had pain intensity reduced by 19·86 mm (10·04—29·68). Seven trials provided follow-up data for 1—22 weeks after completion of treatment, with short-term pain relief persisting in the medium term with a reduction of 22·07 mm (17·42—26·72). Side-effects from LLLT were mild and not different from those of placebo.

Interpretation
We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain.

________________________________

a Nerve Research Foundation, Brain and Mind Research Institute, University of Sydney, Sydney, NSW, Australia
b Faculty of Health, Leeds Metropolitan University, Leeds, UK
c Institute of Biomedical Sciences, Pharmacology Department, University of São Paulo, São Paulo, Brazil
d Faculty of Health and Social Science, Institute of Physiotherapy, Bergen University College, Bergen, Norway
e Section of Physiotherapy Science, Institute of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
Corresponding Author Information Correspondence to: Dr Roberta T Chow, Honorary Research Associate, Nerve Research Foundation, Brain and Mind Research Institute, University of Sydney, 100 Mallett Street, Sydney, NSW 2050, Australia

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961522-1/fulltext

Many of the day-to-day activities: Sitting, lifting, bending, carrying and standing for long or lying in congested places can put a strain on your back. This strain can cause severe backache. Aching back is a nightmare for those who have this. It can happen with people while sleeping on uneven bed or mattress or in wrong posture or picking an article in a wrong way. It can happen sometimes while standing or sitting in a wrong posture for a long time. It can happen with any body in any age. It is seen that it generally happens with those with sedentary lifestyle. Those who don’t exercise suffer more from this as compared to others who are exercise regularly. Youngsters suffer from this condition due to pulling or lifting heavy loads. Elders suffer from this condition due to weakened muscles or Asthi kshaya (Osteoporosis).
It is really very depressing sometimes when living with backache. However, hold your nerves and don’t panic. Before pressing the panic button here are some handy solutions:

(I) Instant remedy: Instead of going for pain killers always prefer simple remedies- rest, fomentation, dietary regulations and gentle massage with home-made hot oil. First effort should be to remove the inflammation and stiffness of back. Haridra or Haldi (Turmeric) which is present in every Indian kitchen is of great help in such conditions. Haridra is used to help in such conditions since ancient times and is recommended in Ayurveda too. 2- 3 gms of Turmeric powder taken with warmed milk is of great help. Researches of modern times have proved its excellent analgesic and anti inflammatory properties. I personally saw the good result of Turmeric powder many times. If you don’t have any back relaxing oil ready at home here is one simple recipe: Take Til Tail (Sesame oil) or Sarshapi Tail (Mustard oil) – 50 ml and add ½ teaspoon of Ajwain and 1 clove of Lashuna (Garlic), crush together to make a paste and boil this in oil, till it starts floating on surface of oil. Apply and massage this gently on whole of the back for 3 – 5 minutes till you feel the oil is vanished. Always sleep on your back afterwards and always in life.

(II) Lifestyle improvement: As I mentioned above people with sedentary lifestyle suffer more from backache than others as back muscles turn weak because of non exercising. It should be understood well that while we exercise we not only strengthen our muscles but our bones also and it is our skeleton which supports our body to live in shape. Walking is found to be the most simple and the best exercise for muscles of whole body. This is the exercise during which we move most of our muscles. You should not start long or brisk walking from first day but should gradually increase the distance and intensity. So go and buy a pair of jogging or sports shoe today and start this from tomorrow. We don’t need much infrastructure for it. Do try to start using stairs instead of escalators for up to 2-3 floors. Avoid scooter or car for nearby places. Do try to go to bed early so that you wakeup early as it will energize you and will help you to finish your morning routine in time. Drink a glass of fresh water instead of bed tea. Spare some time for Meditation as it helps to relieve stress and soothes your muscles. Start you day on a positive note.

(III) Diet: Relish your food and avoid talking or watching television. Follow your fixed schedule of breakfast, lunch and dinner. Always eat freshly cooked food and that too when hungry as it will digest easily and properly. Stop munchies as it will suppress your desire to have nourishing food at the time of lunch or dinner. Avoid tea or coffee just before or at the time of food. Drink a glass of milk everyday and that too some time before going to bed. Eat simple, light and vegetarian food at dinner time to avoid indigestion and bloating.

(IV) Go to bed: Taking a complete bed rest is really helpful for relieving the stiffness of back muscles. Relaxing works as a remedy as your muscles will heal and come into shape during rest. Do put a pillow beneath your legs to give extra comfort to your back. If your backache happened during sleep it might be due to the uneven surface of your bed or sagging mattress. If you feel it is due to that do try to correct this cause. It is seen that soft and sagging mattress also contribute to the development of back problems or worsen an existing back trouble. So check your mattress and change as soon as possible if you find it sagging or with lumps. Try to get a mattress which is not very soft at least on surface.

(V) Rest and relax: Excessive and regular working without rest is one of the most common causes of backache. Such pain is due to continuous tightening of back muscles during our working schedules. Emotional tension to finish the job quickly or in time also causes backache. Try to take small relaxing breaks on frequent intervals as this helps to relax your back muscles. If you don’t want to leave your chair than just stretch your legs and just bend your back backwards and breathe deeply 8 – 10 times. By such small breaks you will feel energized. Small walk of 50 steps also helps in a big way as this helps your blood to circulate throughout and will help your stiff back and other muscles. Drinking a glass of water or chatting with your colleague for some moments is very soothing and relaxing after a long stretch of work. The persons with a history of frequent bouts of back ache should relax after a sitting of not more than half an hour.

(VI) Soothe your back: If you are into such a profession that you need to bend your back forward for a long time as of engineer, do try to put your arm behind your back. This will help to relax your back muscles. If you need to sit in the chair for a long period, do put a small cushion between chair and your back. This will not only comfort your back but also provide excellent support to your lower back. The chairs with claims of best back support are of no use as sitting itself is stressful for your back. You should always try to make small adjustments in the curvature, especially of your lower back as that is the part we hurt most while sitting for longer durations. The advice mentioned above also applies to those traveling for long distances, even in world’s most comfortable car. Buy a small cushion for long journeys. Putting one small cushion between lower back and your seat and leaning back is proved to be the most comfortable posture while traveling for long distances.

The suggestions made above indirectly relax and balance your body so that it is composed to face physical and mental stresses of modern lifestyle and to your aching back.

This article in nutshell:
- Rest for immediate relief.
- Switch over from sedentary to active lifestyle as early as possible.
- Exercise regularly to make you back muscles strong.
- Sleep on even surface with a moderately hard mattress.
- Avoid sitting for long in same posture while working.
- Eat freshly cooked, nourishing food and always on time.
- Regulate your working schedule to spare some time for relaxation.
- Always sleep on your back and try to avoid pillow.
-Avoid bending forward and picking or lifting articles.

THE FACET SYNDROME

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist
Introduction


The facet joints are a pair of joints in the posterior aspect of the spine. Although these joints are most commonly called the facet joints, they are more properly termed the zygapophyseal joints (abbreviated as Z-joints), a term derived from the Greek roots zygos, meaning yoke or bridge, and physis, meaning outgrowth. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint or the posterior intervertebral joint.
As is true of any synovial joint, the facet-joint is a potential source of pain. In fact, the facet-joint is one of the most common sources of low back pain (LBP). The first discussion of the facet-joint as a source of LBP was by Goldwaith in 1911. (1) In 1927, Putti (2) illustrated osteoarthritic changes of facet-joints in 75 cadavers of persons older than 40 years. In 1933, Ghormley(3) coined the term facet syndrome, suggesting that hypertrophic changes secondary to osteoarthritis of the zygapophyseal processes led to lumbar nerve root entrapment, which caused LBP. In the 1950s, Harris and Mcnaz (4) and McRae (5) determined that the etiology of facet-joint degeneration was secondary to intervertebral disc degeneration. Hirsch et al were later able to reproduce LBP with injections of hypertonic saline solution into the facet-joints, thus affirming the role of the facet-joints as a source of LBP (6)
Functional Anatomy
The spine is composed of a series of functional units. Each unit consists of an anterior segment, which is made up of 2 adjacent vertebral bodies and the intervertebral disc between them, and the posterior segment, which consists of the laminae and their processes. One joint is formed between the 2 vertebral bodies, whereas the other 2 joints, known as the facet-joints, are formed by the articulation of the superior articular processes of one vertebra with the inferior articular processes of the vertebra above. Thus, the facet-joints are part of an interdependent functional spinal unit consisting of the disc-vertebral body joint and the 2 facet-joints, with the facet-joints paired along the entire posterolateral vertebral column.(7)
Facet joints are well innervated by the medial branches of the dorsal rami. In the thoracic and lumbar spine, the facet joints are in¬nervated by medial branches of the dorsal rami of the spinal nerves except at L5 lev¬el (8). After the medial branch splits off from the dorsal ramus, it courses caudally around the base of the superior articular process of the level below toward that level's Z-joint (e.g., the L2 medial branch wraps around the L3 superior articular process to approach the L2-L3 facet-joint). The medial branch then continues in a groove between the superior articular process and transverse process (or, in the case of the L5 medial branch, between the superior articular process of S1 and the sacral ala of S1, which is the homologous structure to the transverse processes of the lumbar vertebrae). As it makes this course, the medial branch is held in place by a ligament joining the superior articular process and the transverse process, termed the mamillo-accessory ligament (MAL).
The MAL is so named because it adjoins the mamillary process of the superior articular process to the accessory process of the transverse process. The MAL is clinically important because it allows precise location of the medial branch of the dorsal ramus using only bony landmarks, which is essential for fluoroscopically guided procedures.
After passing underneath the MAL, the medial branch of the dorsal ramus gives off 2 branches to the nearby facet-joints. One branch innervates the facet-joint of that level, and the second branch descends caudally to the level below. Therefore, each medial branch of the dorsal ramus innervates 2 joints—that level and the level below (e.g., the L3 medial branch innervates the L3-L4 and L4-L5 facet-joints). Similarly, each facet-joint is innervated by the 2 most cephalad medial branches (e.g., the L3-L4 facet-joint is innervated by the L2 and L3 medial branches). Medial branch also innervates the multifidus, interspinales, and intertransversarii mediales muscles, the interspinous ligament, and, possibly, the ligamentum flavum. (9)
This has several important clinical implications. First, pain relief from anesthetizing the medial branch does not necessarily implicate the facet-joints as the primary pain generator, because one of the other structures innervated by the medial branch may have been the pain generator. Second, denervation of the medial branch by RFA may affect the nerve supply to the multifidus muscle. This is important because lumbosacral radiculopathy is often another consideration in the differential diagnosis of LBP.
The L5 dorsal ramus divides into me¬dial and lateral branches, with the medi¬al branch continuing medially, innervat¬ing the lumbosacral joint.

Pathogenesis
As with any synovial joint, degener¬ation, inflammation and injury of facet joints can lead to pain upon joint motion. Pain leads to restriction of motion, which eventually leads to overall physical decon¬ditioning. Irritation of the facet joint in¬nervation in itself also leads to secondary muscle spasm. It has been assumed that degeneration of the disc would lead to as¬sociated facet joint degeneration and sub¬sequent spinal pain. These assumptions were based on the pathogenesis of degen¬erative cascade in the context of a three joint complex that involves the articula¬tion between two vertebrae consisting of the intervertebral disc and adjacent fac¬et joints, as changes within each mem¬ber of this joint complex will result in changes in others (10, 11). It was also the view of Vernon-Roberts and Pi¬rie (12) that disc degeneration causes os¬teophyte formation and facet joint chang¬es, because facet joints at relatively normal disc levels are either normal or only slight¬ly degenerate.

The Facet joint is a common pain generator in the lower back. The 2 common mechanisms for this generation of pain are either (1) direct, from an arthritic process within the joint itself, or (2) indirect, in which overgrowth of the joint (e.g., facet joint hypertrophy or a synovial cyst) impinges on nearby structures. (13)
The Facet-joints are diarthrodial joints with a synovial lining, the surfaces of which are covered with hyaline cartilage, which is susceptible to arthritic changes and arthropathies. Repetitive stress and osteoarthritic changes to the facet joint can lead to zygapophyseal hypertrophy. Like any synovial joint, degeneration, inflammation, and injury can lead to pain with joint motion, causing restriction of motion secondary to pain and, thus, deconditioning. In addition, facet-joint arthrosis, particularly trophic changes of the superior articular process, can progress to narrowing of the neural foramen. In addition, as is the case for any synovial joint, the synovial membrane can form an outpouching and, thus, a cyst. Facet-joint cysts are most commonly seen at the L4-L5 level (65%), but they are also seen at the L5-S1 (31%) and L3-L4 (4%) levels. These synovial cysts can be clinically significant, particularly if they impinge on nearby structures (e.g., the exiting nerve root).
Facet-joint hypertrophy or a synovial cyst can also contribute to lateral and central lumbar stenosis, which can lead to impingement on the exiting nerve root. Thus, facet-joint pain can occasionally produce a pain referral pattern that is indistinguishable from disc herniation.
Numerous other causes, including rheumatoid arthritis, ankylosing spondy¬litis and capsular tears, etc., also have been described as sources of facet joint pain (14).

Facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain (15), 54% to 67% of patients with neck pain and 48% of patients with thoracic pain in controlled stud¬ies. These figures were based on respons¬es to controlled diagnostic blocks of these joints, in accordance with the criteria es¬tablished by the International Associa¬tion for the Study of Pain


Diagnosis

Clinical
Establishing a diagnosis of lumbosacral facet syndrome is difficult because the findings are nonspecific and correlation between the history and physical examination findings is poor. However, obtaining a detailed history and performing a physical examination help rule out other entities and assist with guiding the examiner in establishing the diagnosis of facet-joint–mediated LBP.
Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet-joint injection (16):
1. Older age
2. Previous history of LBP
3. Normal gait
4. Maximal pain with extension from a fully flexed position
5. The absence of leg pain
6. The absence of muscle spasm
7. The absence of exacerbation with a Valsalva maneuver
Facet-joint pathology should be considered if the patient describes nonspecific LBP with a deep and achy quality that is usually localized to a unilateral or bilateral Paravertebral area.

The common referral areas for facet-joint–mediated pain are flank pain, buttock pain (often extending into the posterior thigh, but rarely below the knee), pain overlying the iliac crests, and pain radiating into the groin.

The pain is often exacerbated by twisting the back, by stretching, by lateral bending, and in the presence of a torsional load. Some patients describe their pain as worse in the morning, aggravated by rest and hyperextension, and relieved by repeated motion. Often, this lumbosacral facet syndrome may occur after an acute injury (e.g., extension and rotation of the spine), or it
may be chronic in nature.

Unlike other lumbar spine pathologies such as disc herniation, facet-joint–mediated pain likely will not worsen with an increase in intra-abdominal and thoracic pressure. Therefore, worsening of pain with coughing, laughing, or a Valsalva maneuver is suggestive that the facet-joint is not the primary pain generator.

Examination
• Sensory examination: Sensory examination (i.e., light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet-joint pathology.
• Muscle stretch reflexes: Patients with facet-joint–mediated LBP usually have normal muscle stretch reflexes. Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst.
• Straight leg–raise test: This maneuver is usually normal for facet-joint–mediated pain. However, if facet-joint hypertrophy or a synovial cyst encroaches on the intervertebral foramen, causing nerve root impingement, this maneuver may elicit a positive response.

Diagnostic blocks

It has been postulated that for any structure to be deemed a cause of back pain, the structure should have been shown to be a source of pain in patients, using diagnostic techniques of known reliability and validity (25). The diagnostic blockade of a structure with a nerve supply with the ability to generate pain can be performed to test the hypothesis that the target structure is a source of a patient’s pain

The choice between intraarticular blocks and medial branch blocks is to some extent preference and training of the physician. However, various considerations apply in choosing either intraarticular injection or medial branch. Intraarticular injections are more difficult and time consuming than nerve blocks because they require accurate placement of the needle within the joint cavity with care not to over distend the joint. In contrast, medial branch blocks are expeditious and carry no risk of over distention. Furthermore, at times joint entry may be impossible because of the severe age related changes or post traumatic arthropathy; no such processes affect access to the nerves .Significant leakage of intraarticular injected fluid into epidural space and spillage over to the nerve roots has been described. With appropriate care this is minimal with medial branch blocks. Finally, intraarticular blocks are appropriate if intraarticular therapy is proposed but if radiofrequency therapy is proposed, medial branch blocks become the diagnostic procedure of choice. In addition, in the past only intraarticular injections were considered as therapeutic. However, recent evidence has shown that medial branch blocks have better evidence for the therapeutic effectiveness than intraarticular blocks (17).

o Valid information is only obtained by performing controlled blocks, either in the form of placebo injections of normal saline or comparative local anesthetic blocks, in which on two separate occasions, the same joint is anesthetized using local anesthetics with different durations of action. . In a double-block protocol, the patient is given an injection with a short-acting anesthetic (e.g., lidocaine) and records the duration of pain relief in a diary. On a follow-up visit (typically 1-2 wk later), a second injection is performed, using an anesthetic with a different duration of action (e.g., bupivacaine, which has a longer half-life than lidocaine), and the patient again should chart pain relief in a diary. A patient is diagnosed as having a positive block if they receive pain relief (typically >80%) for both injections for a length of time corresponding to the duration of action of the medication. (18, 19,20) Given the dual innervation of each Z-joint, one must anesthetize or block the cephalad and subadjacent medial branches (eg, anesthetize the L3 and L4 medial branches for the L4-L5 Z-joint). Injections are diagnostic if patients report significant relief of symptoms, usually at least a 50% reduction in pain.
Lab Studies
• Laboratory studies are not generally necessary for the diagnosis of lumbosacral facet joint syndrome.
Imaging Studies
• Plain radiography
•
o Plain radiographs are traditionally ordered as the initial step in the workup of lumbar spine pain. The main purpose of plain films is to determine underlying structural pathologic conditions. These studies are not generally recommended in the first month of symptoms in the absence of red flags. An exception to this would be if the low back symptoms are related to a sports injury and a fracture is suggested.
o Three views are commonly obtained, including an anteroposterior (AP), lateral, and oblique; however, the utility of oblique views has been questioned.
o Plain radiographs may reveal degenerative changes, but these findings have not been found to correlate with facet-joint–mediated pain.
• Bone scanning
•
o Bone scanning can be helpful when a tumor, infection, or fracture (occult or traumatic) is suggested.
o Bone scanning is not usually indicated in the initial workup, and the results are normal in persons with lumbosacral facet joint syndrome.
o Bone scan findings have not been found to correlate with facet-joint–mediated pain.
• Computed tomography (CT) scanning
•
o Generally, CT scanning is not necessary unless other bony pathology (eg, fracture) must be excluded.
o A CT scan of the lumbosacral spine provides excellent anatomic imaging of the osseous structures of the spine, especially to rule out fractures or arthritic changes. Single-photon emission CT (SPECT) images may offer better resolution if spondylolysis is suggested.
o With facet-joint pathology, one may find arthritic changes in the facet-joints and degenerative disc disease; however, facet-joint pathology is also frequently seen in asymptomatic patients, and, therefore, abnormal findings on a CT scan are not diagnostic.
o Despite the excellent imaging of the bony anatomy of the facet-joint, CT scans are not useful for the diagnosis of the facet-joint as a pain generator. For example, Schwarzer et al found no correlation between facet-joint pathology on a CT scan and those patients who responded to diagnostic facet-joint blocks. (21) .Therefore, the correlation of an abnormal facet-joint anatomy as observed on CT scans with true facet -joint–mediated pain is poor.
• Magnetic resonance imaging (MRI)
o In general, MRI is not indicated for the evaluation of nonradicular LBP.
o The main utility of MRI is for excluding pathologies other than facet-joint arthropathy, because many degenerative changes in the facet-joint are asymptomatic. Similarly, true facet-joint–mediated pain may be present despite a normal MRI examination.
o MRI provides detailed anatomic images of the soft structures of the spine, such as the intervertebral discs, which often show degenerative changes before facet-joint pathology. (22)
o MRI also may illustrate nerve root entrapment secondary to facet-joint hypertrophy or a synovial cyst and may help visualize the intervertebral foramen; however, facet-joint pathology may be present despite normal imaging study findings.
o MRI is particularly useful for the evaluation of a synovial cyst emanating from a facet-joint and for distinguishing a synovial cyst from other abnormalities. Gadolinium enhancement is useful in the evaluation of a potential synovial cyst. Also helpful is to make the radiologist aware that a synovial cyst is part of the differential diagnosis because this entity is often overlooked.
Other Tests
• Electrodiagnosis
o Electro diagnostic studies, such as nerve conduction studies and needle EMG, are not usually indicated for possible lumbosacral facet syndrome. However, these studies should be considered if the history and physical examination findings suggest nerve root impingement or if the diagnosis remains unclear.
o Persons with facet-joint pathology typically present with normal sensory and motor examination findings; however, some patients describe the pain as radiating in nature and others report a positive straight leg–raise test result. Thus, electro diagnostic testing may be helpful for excluding other causes of pain, such as radiculopathy.
o RFA of the medial branch of the dorsal ramus affects the innervation of not only the facet-joint, but also the multifidus muscle. Normally, denervation potentials in the multifidus muscles in the setting of LBP are most commonly associated with lumbosacral radiculopathy. In the setting of a patient who has had previous RFA, however, the denervation potential is likely secondary to denervation from the procedure and not a radiculopathy.
TREATMENT
Therapeutic Interventional Techniques
The requirements for safe use of therapeutic interventions include a sterile operating room or a procedure room, appropriate monitoring equipment, radiological equipment; special instruments based on technique, sterile preparation with all the resuscitative equipment, needles, gowns, injectable drugs, intravenous fluids, anxiolytic medications, and trained personnel for preparation and monitoring of the patients. Minimum requirements include history and physical examination, informed consent, and appropriate documentation of the procedure.

Facet joint pain may be managed by intraarticular injections, medial branch blocks, or neurolysis of medial Branches (Facet denervation). (24)

Based on the available literature and scientific application, the most commonly used formulations of long-acting steroids, which include methylprednisolone (Depo-Medrol), triamcinolone diacetate (Aristocort), triamcinolone acetonide (Kenalog), and betamethasone acetate and phosphate mixture (Celestone Soluspan), appear to be safe and effective (23)

Based on the present literature, it appears that if repeated within 2 weeks, betamethasone may be the best choice in avoiding side effects; whereas, if treatment is carried out at 6-week intervals or longer, any one of the 4 formulations will be safe and effective.

Facet Joint Injections and Medial Branch Blocks

♦ In the diagnostic phase, a patient may receive 2 procedures at intervals of no sooner than 1 week or preferably 2 weeks.
♦ In the therapeutic phase (after the diagnostic is completed), the suggested frequency would be 2–3 months or longer between injections, provided that >50% relief is obtained for 6 weeks.
♦ If the interventional procedures are applied for different regions, they may be performed at intervals of no sooner than 1 week or preferably 2 weeks for most types of procedures. It is suggested that therapeutic frequency remain at 2 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures can be performed safely.
♦ In the treatment or therapeutic phase, the interventional procedures should be repeated only as necessary according to the medical necessity criteria, and it is suggested that these be limited to a maximum of 4 to 6 times for local anesthetic and steroid blocks over a period of 1 year, per region.
♦ Under unusual circumstances with a recurrent injury or cervicogenic headache, procedures may be repeated at intervals of 6 weeks after stabilization in the treatment phase.



Medial Branch Neurotomy (Facet denervation)
♦ The suggested frequency would be 3 months or longer (maximum of 3 times per year) between each procedure, provided that > 50% relief is obtained for 10 to 12 weeks.
♦ The therapeutic frequency for medial branch neurotomy should remain at intervals of at least 3 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures are performed safely.


Contraindications
Contraindications include ongoing bacterial infection, possible pregnancy, bleeding diathesis, and anticoagulant therapy. Precautions are warranted in patients with anticoagulant or antiplatelet therapy, diabetes mellitus and artificial heart valves.

Special Concerns:
Always obtain informed consent for any interventional procedure. In addition, patients must be informed of the risks, benefits, and potential outcomes associated with the procedure.
Patients with LBP who demonstrate red flags, such as unexplained weight loss, fever, and chills, should be further evaluated to rule out malignancy or occult infectious processes.
Interventional procedures with anesthetics and corticosteroids, can lead to transient lower-extremity weakness, insomnia, headache, fluid and electrolyte disorders (especially in patients with congestive heart failure), GI upset, bone demineralization, and impaired glucose tolerance (patients with diabetes). Less common effects are mood swings, increased appetite, and, the most serious, adrenocortical insufficiency. Dural puncture can lead to infection and an increased incidence of headaches.

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Low Back Pain

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist


Back pain is a problem which is very often faced by all the human beings at least once in their lifetime. This pain, if not taken seriously can turn in to a deadly disease which can put your life at stake.

Some Important Facts about back pain

• Low back pain is the most common musculoskeletal complaint, with potentially devastating consequences.

• 90% of patients with acute low back pain do not require surgery. Most specialists agree that non-surgical treatment should be tried first.

• Surgery as first line treatment is indicated only in few selected cases. These are medical emergencies such as a broken neck or if you have symptoms such as weakness in the legs that gets progressively worse and/or bladder and/or bowel incontinence caused by the back problem.

• The incidence of back pain is highest between the ages of 35 and 55.

• Disc is not always the culprit. Small joints of spine are the source of pain in majority of patients.

• The pain combined with depression and anxiety in long-term cases places sufferers at risk for suicide.

• People who work at sedentary occupations are at a higher risk of disk injury than those who do moderate amounts of physical work.

• Up to 85 per cent of persons with back pain can’t recall a specific incident that brought on their pain.

• Early interventional treatments in Back pain management have been found to return patients to work and regular activities more rapidly than past conservative therapies.

• Early intervention decreases unnecessary chronic pain, long-term treatments and disabilities.

• Heat and massage therapy cannot cure the disease. These do not provide long term solutions to the problems of back. These are mainly used for managing pain during the recovery period.




Important Causes of back pain

The most common causes of low back pain are:
• Injury or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.
• Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by:
o A herniated disc, often brought on by repeated vibration or motion (as during machine use or sport activity, or when lifting improperly), or by a sudden heavy strain or increased pressure to the lower back.
o Osteoarthritis (joint degeneration), which typically develops with age. When osteoarthritis affects the small facet joints in the spine, it can lead to back pain. Osteoarthritis in other joints, such as the hips, can cause you to limp or to change the way you walk. This can also lead to back pain.
o Spondylolysis and spondylolisthesis, vertebra defects that can allow a vertebra to slide over another when aggravated by certain activities.
o Spinal stenosis, or narrowing of the spinal canal, which typically develops with age.
o Fractures of the vertebrae caused by significant force, such as from an auto or bicycle accident, a direct blow to the spine, or compressing the spine by falling onto the buttocks or head.
o Spinal deformities, including curvature problems such as severe scoliosis or kyphosis.
• Compression fractures. Compression fractures are more common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid use. In a person with osteoporosis, even a small amount of force put on the spine, as from a sneeze, may cause a compression fracture.
Less common spinal conditions that can cause low back pain include:
• Ankylosing spondylitis, which is a form of joint inflammation (arthritis) that most often affects the spine.
• Bacterial infection. Bacteria are usually carried to the spine through the bloodstream from an infection somewhere else in the body or from IV drug use. But bacteria can enter the spine directly during surgery or injection treatments, or as the result of injury. Back pain may be the result of an infection in the bone (osteomyelitis), in the spinal discs, or in the spinal cord.
• Spinal tumors, or growths that develop on the bones and ligaments of the spine, on the spinal cord, or on nerve roots.
• Paget's disease, which causes abnormal bone growth most often affecting the pelvis, spine, skull, chest, and legs.
• Scheuermann's disease, in which one or more of the bones of the spine (vertebrae) develop wedge-shaped deformities. This causes curvature of the spine (rounding of the back, or kyphosis), most commonly in the chest region
Newer Developments and Better Understanding in Management of Back pain
A wide range of treatment is available for low back pain, depending on what is causing the pain and how long it lasts. Most people find that their low back pain improves within a few weeks. Chances are good that your pain will go away soon with some basic self-care.
• If you have recently developed low back pain, stay active and consider taking over-the-counter pain medicines .
• Staying active is better for you than bed rest. In fact, staying in bed more than 1 or 2 days can actually make your pain worse and lead to other problems such as stiff joints and muscle weakness.
• If your low back pain has lasted longer than 3 months, you will probably benefit from more intensive treatment.
• Must visit Interventional pain and spine specialist :-
• if you have moderate to severe low back pain that lasts more than a couple of days;
• if you have back or leg symptoms that have gotten worse;
• if your symptoms have not gone away after 2 weeks of home treatment;
• or if improved symptoms flare up again.
• A physical examination by pain specialist and possibly an imaging(x-ray/MRI) test may produce new information about your condition and help direct your treatment decisions.
• Physical Therapy: TENS, Ultrasound, Heat and Cryotherapy:
o These Modalities should always be considered an adjunct to an active treatment program in the management of acute low back pain.
o They should never be used as the sole method of treatment.

Interventions: Minimally invasive non surgical procedures for management of Back Pain


For back pain sufferers, interventional pain management techniques can be particularly useful. In addition to a thorough medical history and physical examination, interventional pain management physicians have a wide array of treatments that can be used including the following:

Epidural injections (in all areas of the spine):

The use of anesthetic and anti-inflammatory medications injected into the epidural space to relieve pain or diagnose a specific condition.

Nerve, root, and median branch blocks:

Injections done to determine if a specific spinal nerve root is the source of pain. Blocks also can be used to reduce inflammation and pain.

Facet joint injections:

An injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief.

Discography:

An "inside" look into the discs to determine if they are the source of a patient's pain. This procedure involves the use of a dye that is injected into a disc and then examined using x-ray or CT Scan.

Pulsed Radiofrequency Neurotomy (PRFN):

A minimally invasive procedure that disables spinal nerves and prevents them from transmitting pain signals to the brain.

Rhizotomy:

A procedure in which pain signals are "turned off" through the use of heated electrodes that are applied to specific nerves that carry pain signals to the brain.

Spinal cord stimulation:

The use of electrical impulses that are used to block pain from being perceived in the brain.

Intrathecal pumps:

A surgically implanted pump that delivers pain medications to the precise location in the spine where the pain is located.

Percutaneous Discectomy / Nucleoplasty:

A minimally invasive day care procedure in which tissue is removed from the disc with the help of decompressor through a very minute hole ,in order to decompress and relieve pressure on the spinal nerves.


Ozoneucleolysis or Ozone discectomy:

Has emerged as an affordable, least invasive approach and costs 2/3 of the price of conventional surgery. Ozone injected inside the affected intervertebral disc under c- arm guidance, causes shrinkage of disc and thus reducing the volume and lessening the pressure on nerves.

Intradiscal Electrothermoplasty (IDET)
This procedure involves the insertion of a needle into the affected disc with the guidance of an x-ray machine. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc.

These techniques are exciting. They offer the possibility of treating low back pain and sciatica with much less trauma and risk than surgery.


Quick tips to a healthier back


• Following any period of prolonged inactivity, begin a program of regular low-impact exercises.
• Speed walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and flexibility.
• Yoga can also help stretch and strengthen muscles and improve posture
• Always stretch before exercise or other strenuous physical activity.
• Don’t slouch when standing or sitting. When standing, keep your weight balanced on your feet. Your back supports weight most easily when curvature is reduced.
• At home or work, make sure your work surface is at a comfortable height for you.
• Sit in a chair with good lumbar support and proper position and height for the task. Keep your shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your back can provide some lumbar support. If you must sit for a long period of time, rest your feet on a low stool or a stack of books.
• Wear comfortable, low-heeled shoes.
• Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.
• Ask for help when transferring an ill or injured family member from a reclining to a sitting position or when moving the patient from a chair to a bed.
• Don’t try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles, and keep your head down and in line with your straight back. Keep the object close to your body. Do not twist when lifting.
• Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight around the waistline that taxes lower back muscles.
• If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.

Pain treatment begins with an assessment of the severity of the pain. Commonly, the first steps of treatment are rest, application of cold or heat and intake of OTC (over the counter) medication. The next step in the treatment of pain is a combination of physical therapy and prescribed pain medication. It is important to note that sometimes, interventional pain management needs to be started prior to Physical Therapy in order to stop acute pain (i.e. acute radiculopathy) and allow the patient to comply with necessary exercise. If prescribed pain medication and physical therapy don't work, the next step is usually interventional pain management, unless the patient has acute loss of function or acute neurological deficit (in which case surgery is needed. However, even after surgery interventional pain management has a very important role in the treatment of patients, especially when all other options are exhausted (eg. "failed back surgery" syndrome).
The Specialty of “Pain Management” has progressed significantly in the last 20 years through a better understanding of anatomy and physiology, and through advances in pharmacology and technology.
The goals of interventional pain management are to relieve, reduce, or manage pain and improve a patient's overall quality of life through minimally invasive techniques specifically designed to diagnose and treat painful conditions. Interventional pain management also strives to help patients return to their everyday activities quickly and without heavy reliance on medications. Often other treatments are include such as physical therapy, occupational therapy, and lifestyle modification (such as exercise, diet, and smoking cessation) to further enhance these procedures.
Before any treatments are started, we may perform diagnostic tests to rule out other conditions that may present similar symptoms. These tests may include x-rays, CT scan, MRI, and possibly blood tests.
Early Intervention:

Early interventional treatments in Pain Medicine have been found to return injured patients to work and regular activities more rapidly than past conservative therapies. Early treatment of inflamed injured tissues and articulations quickly resolves the insult, not allowing chronic inflammation with resultant joint and tissue destruction. Pain Medicine physicians are trained in diagnostic patient evaluations, including radiographic interpretations and diagnostic injections when indicated. Early intervention decreases unnecessary chronic pain, long-term treatments and disabilities.

Some facts about the Speciality

American society of Interventional pain physician
In USA, The Department of Health and Human Services Centers for Medicare and Medicaid Services issued a memo March 4, 2005, including Interventional Pain Management specialists on the list of clinical specialties to be included in carrier advisory committees.

Pain relief a human right – WHO (world health organization)
"Pain relief should be a human right, whether people are suffering from cancer, HIV/AIDS or any other painful condition,"

Study by International association for study of pain and European federation of IASP
One person in five suffers from moderate to serious chronic pain, and one in three are unable or only with difficulty able to lead an independent life .One in four sufferers say pain disrupts or destroys relations with family and friends.

American cancer society
30%-50% have pain at the time of diagnosis of cancer. 70% to 90% have severe pain when the disease is advanced.
40% die with severe pain. 60%-80% complains of inadequate pain relief by their physician.30% are not relieved by drug treatment alone, so require interventional pain management.
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• More than 90% cancer pain can be adequately controlled.