Systematic assessment of the literature.
EVIDENCE: I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint
nerve blocks and diagnostic sacroiliac
intraarticular injections is good with 75% to 100%
pain relief as criterion standard with controlled
local anesthetic or placebo blocks. • The evidence is good in managing
disc herniation or
radiculitis for caudal, interlaminar, and transforaminal
epidural injections; fair for axial or discogenic
pain without
disc herniation,
radiculitis or facet joint
pain with caudal, and interlaminar
epidural injections, and limited for transforaminal
epidural injections; fair for
spinal stenosis with caudal, interlaminar, and transforaminal
epidural injections; and fair for post surgery syndrome with caudal
epidural injections and limited with transforaminal
epidural injections. • The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint
nerve blocks, and limited for
intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled
radiofrequency neurotomy is fair; limited for
intraarticular injections and periarticular
injections; and limited for both pulsed radiofrequency and conventional
radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity
pain secondary to post surgery syndrome and
spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal
therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc
decompression, the evidence is limited for automated percutaneous lumbar
discectomy (APLD), percutaneous lumbar
laser disc
decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint
nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar
epidural injections for cervical
disc herniation or
radiculitis; fair for axial or discogenic
pain,
spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical
radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical
intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint
nerve blocks with a criterion standard of at least 75%
pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic
epidural injections in managing thoracic
pain. • The evidence for therapeutic thoracic facet joint
nerve blocks is fair, limited for
radiofrequency neurotomy, and not available for thoracic
intraarticular injections. IV. Implantables • The evidence is fair for
spinal cord stimulation (SCS) in managing patients with
failed back surgery syndrome (FBSS) and limited for implantable intrathecal
drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic
therapy if discontinued, spontaneous epidural
hematomas with or without traumatic injury in patients with or without
anticoagulant therapy to discontinue or normalize INR with
warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (
NSAIDs), including low dose
aspirin prior to performing interventional techniques. • There is fair evidence with excessive
bleeding, including epidural
hematoma formation with interventional techniques when antithrombotic
therapy is continued, the risk of higher thromboembolic phenomenon than epidural
hematomas with discontinuation of antiplatelet
therapy prior to interventional techniques and to continue
phosphodiesterase inhibitors (
dipyridamole,
cilostazol, and
Aggrenox). • There is limited evidence to discontinue antiplatelet
therapy with
platelet aggregation inhibitors to avoid
bleeding and epidural
hematomas and/or to continue antiplatelet
therapy (
clopidogrel,
ticlopidine,
prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer
antithrombotic agents dabigatran (
Pradaxa) and rivaroxan (
Xarelto) to discontinue to avoid
bleeding and epidural
hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events.
CONCLUSIONS: Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed.
DISCLAIMER: The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."