Interventional
pain management, and the interventional techniques which are an integral part of that specialty, are subject to widely varying definitions and practices. How interventional techniques are applied by various specialties is highly variable, even for the most common procedures and conditions. At the same time, many payors, publications, and guidelines are showing increasing interest in the performance and costs of interventional techniques. There is a lack of consensus among interventional
pain management specialists with regards to how to diagnose and manage spinal
pain and the type and frequency of spinal interventional techniques which should be utilized to treat spinal
pain. Therefore, an algorithmic approach is proposed, providing a step-by-step procedure for managing chronic spinal
pain patients based upon evidence-based guidelines. The algorithmic approach is developed based on the best available evidence regarding the epidemiology of various identifiable sources of chronic spinal
pain. Such an approach to spinal
pain includes an appropriate history, examination, and medical decision making in the management of
low back pain,
neck pain and thoracic
pain. This algorithm also provides diagnostic and therapeutic approaches to clinical management utilizing case examples of cervical, lumbar, and thoracic spinal
pain. An algorithm for investigating chronic
low back pain without
disc herniation commences with a clinical question, examination and imaging findings. If there is evidence of
radiculitis,
spinal stenosis, or other demonstrable causes resulting in
radiculitis, one may proceed with diagnostic or therapeutic
epidural injections. In the algorithmic approach, facet joints are entertained first in the algorithm because of their commonality as a source of chronic
low back pain followed by sacroiliac joint blocks if indicated and provocation discography as the last step. Based on the literature, in the United States, in patients without
disc herniation, lumbar facet joints account for 30% of the cases of chronic
low back pain, sacroiliac joints account for less than 10% of these cases, and discogenic
pain accounts for 25% of the patients. The management algorithm for lumbar spinal
pain includes interventions for
somatic pain and radicular
pain with either facet joint interventions, sacroiliac joint interventions, or intradiscal
therapy. For radicular
pain,
epidural injections, percutaneous adhesiolysis, percutaneous disc
decompression, or spinal endoscopic adhesiolysis may be performed. For non-responsive, recalcitrant,
neuropathic pain, implantable
therapy may be entertained. In managing
pain of cervical origin, if there is evidence of
radiculitis,
spinal stenosis, post-surgery syndrome, or other demonstrable causes resulting in
radiculitis, an interventionalist may proceed with therapeutic
epidural injections. An algorithmic approach for chronic
neck pain without
disc herniation or
radiculitis commences with clinical question, physical and imaging findings, followed by diagnostic facet joint
injections. Cervical provocation discography is rarely performed. Based on the literature available in the United States, cervical facet joints account for 40% to 50% of cases of chronic
neck pain without
disc herniation, while discogenic
pain accounts for approximately 20% of the patients. The management algorithm includes either facet joint interventions or
epidural injections with surgical referral for disc-related
pain and rarely implantable
therapy. In managing thoracic
pain, a diagnostic and therapeutic algorithmic approach includes either facet joint interventions or
epidural injections.