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Laxmaiah Manchikanti - One of the best experts on this subject based on the ideXlab platform.
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epidural interventions in the management of chronic Spinal Pain american society of interventional Pain physicians asipp comprehensive evidence based guidelines
Pain Physician, 2021Co-Authors: Laxmaiah Manchikanti, Annu Navani, Nebojsa Nick Knezevic, Paul J Christo, Gerard Limerick, Aaron K Calodney, Jay S Grider, Michael E Harned, Lynn Cintron, Christopher GhariboAbstract:Background Chronic Spinal Pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. Objective To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic Spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. Methods The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. Results In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic Pain: The evidence for axial discogenic Pain without facet joint Pain or sacroiliac joint Pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Limitations The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including Spinal stenosis, post-surgery syndrome, and discogenic Pain. Conclusions These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
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methodology for evidence synthesis and development of comprehensive evidence based guidelines for interventional techniques in chronic Spinal Pain
Pain Physician, 2021Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Alan D Kaye, Sairam Atluri, Nebojsa Nick Knezevic, Aaron K Calodney, Kenneth D Candido, Sanjeeva Gupta, Sudhir Diwan, Alaa AbdelsayedAbstract:Background Despite epidurals being one of the most common interventional Pain procedures for managing chronic Spinal Pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. Objectives This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. Study design The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year.• A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only.• Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. Results Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections. Limitations Expenditures for epidural procedures in chronic Spinal Pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. Conclusions After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures.
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lack of superiority of epidural injections with lidocaine with steroids compared to without steroids in Spinal Pain a systematic review and meta analysis
Pain Physician, 2020Co-Authors: Nebojsa Nick Knezevic, Laxmaiah Manchikanti, Amol Soin, Mahendra R Sanapati, Shalini Shah, Ivan Urits, Vwaire Orhurhu, Brahma Prasad Vangala, Rachana Vanaparthy, Amit MahajanAbstract:Background Multiple randomized controlled trials (RCTs) and systematic reviews have been conducted to summarize the evidence for administration of local anesthetic (lidocaine) alone or with steroids, with discordant opinions, more in favor of equal effect with local anesthetic alone or with steroids. Objective To evaluate the comparative effectiveness of lidocaine alone and lidocaine with steroids in managing Spinal Pain to assess superiority or equivalency. Study design A systematic review of RCTs assessing the effectiveness of lidocaine alone compared with addition of steroids to lidocaine in managing Spinal Pain secondary to multiple causes (disc herniation, radiculitis, discogenic Pain, Spinal stenosis, and post-surgery syndrome). Methods This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for literature search, Cochrane review criteria, and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) to assess the methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and quantitative analysis utilizing conventional and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2019. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Outcome measures A hard endpoint for the primary outcome was defined as the proportion of patients with 50% Pain relief and improvement in function. Secondary outcome measures, or soft endpoints, were Pain relief and/or improvement in function. Effectiveness was determined as short-term if it was less than 6 months. Improvement that lasted longer than 6 months, was defined as long-term. Results Based on search criteria, 15 manuscripts were identified and considered for inclusion for qualitative analysis, quantitative analysis with conventional meta-analysis, and single-arm meta-analysis. The results showed Level II, moderate evidence, for short-term and long-term improvement in Pain and function with the application of epidural injections with local anesthetic with or without steroid in managing Spinal Pain of multiple origins. Limitations Despite 15 RCTs, evidence may still be considered as less than optimal and further studies are recommended. Conclusion Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing Spinal Pain secondary to disc herniation, Spinal stenosis, discogenic Pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results were similar for lidocaine, with or without steroids.
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update of utilization patterns of facet joint interventions in managing Spinal Pain from 2000 to 2018 in the us fee for service medicare population
Pain Physician, 2020Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Alan D Kaye, Sairam Atluri, Amol Soin, Mahendra R Sanapati, Joysree Subramanian, Joshua A HirschAbstract:BACKGROUND Interventional techniques for managing Spinal Pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic Spinal Pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic Spinal Pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic Spinal Pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.
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utilization patterns of facet joint interventions in managing Spinal Pain a retrospective cohort study in the us fee for service medicare population
Current Pain and Headache Reports, 2019Co-Authors: Vidyasagar Pampati, Laxmaiah Manchikanti, Alan D Kaye, Amol Soin, Dharam P Mann, Sanjay Bakshi, Joshua A HirschAbstract:Purpose of Review To assess patterns of utilization and variables of facet joint interventions in managing chronic Spinal Pain in a fee-for-service (FFS) Medicare population from 2009 to 2016, with a comparative analysis from 2000 to 2009 and 2009 to 2016.
Mark V. Boswell - One of the best experts on this subject based on the ideXlab platform.
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methodology for evidence synthesis and development of comprehensive evidence based guidelines for interventional techniques in chronic Spinal Pain
Pain Physician, 2021Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Alan D Kaye, Sairam Atluri, Nebojsa Nick Knezevic, Aaron K Calodney, Kenneth D Candido, Sanjeeva Gupta, Sudhir Diwan, Alaa AbdelsayedAbstract:Background Despite epidurals being one of the most common interventional Pain procedures for managing chronic Spinal Pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. Objectives This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. Study design The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year.• A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only.• Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. Results Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections. Limitations Expenditures for epidural procedures in chronic Spinal Pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. Conclusions After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures.
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efficacy of epidural injections in managing chronic Spinal Pain a best evidence synthesis
Pain Physician, 2015Co-Authors: Alan D Kaye, Laxmaiah Manchikanti, Ramsin M Benyamin, Mark V. Boswell, Sairam Atluri, Sanjay Bakshi, Salahadin Abdi, Ricardo M Buenaventura, Kenneth D Candido, Harold CordnerAbstract:Background Epidural injections have been used since 1901 in managing low back Pain and sciatica. Spinal Pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic Spinal Pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic Spinal Pain have yielded conflicting results. Objective To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic Spinal Pain. Study design A systematic review of randomized controlled trials of epidural injections in managing chronic Spinal Pain. Methods In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were Pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar Spinal stenosis. The evidence is Level III for cervical Spinal stenosis management with an interlaminar approach. The evidence is Level II for axial or discogenic Pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level III in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level III with cervical interlaminar epidural injections. Limitations Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic Spinal conditions.
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a systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic Spinal Pain
Pain Physician, 2015Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Alan D Kaye, Dharam P Mann, Sanjay Bakshi, Jay S Grider, Christopher Gharibo, Sanjeeva Gupta, Sunny Jha, Devi E NampiaparampilAbstract:BACKGROUND The therapeutic Spinal facet joint interventions generally used for the treatment of axial Spinal Pain of facet joint origin are intraarticular facet joint injections, facet joint nerve blocks, and radiofrequency neurotomy. Despite interventional procedures being common as treatment strategies for facet joint pathology, there is a paucity of literature investigating these therapeutic approaches. Systematic reviews assessing the effectiveness of various therapeutic facet joint interventions have shown there to be variable evidence based on the region and the modality of treatment utilized. Overall, the evidence ranges from limited to moderate. OBJECTIVE To evaluate and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic Spinal Pain. STUDY DESIGN A systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic Spinal Pain. METHODS The available literature on lumbar, cervical, and thoracic facet joint interventions in managing chronic Spinal Pain was reviewed. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized trials and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary outcome measure was Pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake consumption. RESULTS A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement. LIMITATIONS The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections. CONCLUSION Based on the present assessment for the management of Spinal facet joint Pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy.
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an update of comprehensive evidence based guidelines for interventional techniques in chronic Spinal Pain part ii guidance and recommendations
Pain Physician, 2013Co-Authors: Laxmaiah Manchikanti, Ramsin M Benyamin, Mark V. Boswell, Sairam Atluri, Salahadin Abdi, Ricardo M Buenaventura, David A Bryce, Patricia A Burks, David Caraway, Aaron K CalodneyAbstract:Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic Spinal Pain. Methodology 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."
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explosive growth of facet joint interventions in the medicare population in the united states a comparative evaluation of 1997 2002 and 2006 data
BMC Health Services Research, 2010Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Mark V. Boswell, Vijay Singh, Howard S Smith, Joshua A HirschAbstract:Background The Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006. The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing Spinal Pain.
Joshua A Hirsch - One of the best experts on this subject based on the ideXlab platform.
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update of utilization patterns of facet joint interventions in managing Spinal Pain from 2000 to 2018 in the us fee for service medicare population
Pain Physician, 2020Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Alan D Kaye, Sairam Atluri, Amol Soin, Mahendra R Sanapati, Joysree Subramanian, Joshua A HirschAbstract:BACKGROUND Interventional techniques for managing Spinal Pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic Spinal Pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic Spinal Pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic Spinal Pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.
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utilization patterns of facet joint interventions in managing Spinal Pain a retrospective cohort study in the us fee for service medicare population
Current Pain and Headache Reports, 2019Co-Authors: Vidyasagar Pampati, Laxmaiah Manchikanti, Alan D Kaye, Amol Soin, Dharam P Mann, Sanjay Bakshi, Joshua A HirschAbstract:Purpose of Review To assess patterns of utilization and variables of facet joint interventions in managing chronic Spinal Pain in a fee-for-service (FFS) Medicare population from 2009 to 2016, with a comparative analysis from 2000 to 2009 and 2009 to 2016.
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retrospective cohort study of usage patterns of epidural injections for Spinal Pain in the us fee for service medicare population from 2000 to 2014
BMJ Open, 2016Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Joshua A HirschAbstract:Objective To assess the usage patterns of epidural injections for chronic Spinal Pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. Design A retrospective cohort. Methods The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. Results Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. Conclusions Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.
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explosive growth of facet joint interventions in the medicare population in the united states a comparative evaluation of 1997 2002 and 2006 data
BMC Health Services Research, 2010Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Mark V. Boswell, Vijay Singh, Howard S Smith, Joshua A HirschAbstract:Background The Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006. The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing Spinal Pain.
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comprehensive review of epidemiology scope and impact of Spinal Pain
Pain Physician, 2009Co-Authors: Laxmaiah Manchikanti, Sukdeb Datta, Steven P Cohen, Joshua A HirschAbstract:Persistent Pain interfering with daily activities is common. Chronic Pain has been defined in many ways. Chronic Pain syndrome is a separate entity from chronic Pain. Chronic Pain is defined as, "Pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent Pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine Pain control methods; and healing may never occur." In contrast, chronic Pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic Pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic Pain disorders, Pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of Spinal Pain has been reported as 54% to 80%. Studies of the prevalence of low back Pain and neck Pain and its impact in general have shown 23% of patients reporting Grade II to IV low back Pain (high Pain intensity with disability) versus 15% with neck Pain. Further, age related prevalence of persistent Pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck Pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal Pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck Pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various Pain problems including low back Pain. Frequent use of opioids in managing chronic non-cancer Pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic Pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in Spinal Pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of Spinal Pain and its relevance to health care interventions.
Alan D Kaye - One of the best experts on this subject based on the ideXlab platform.
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methodology for evidence synthesis and development of comprehensive evidence based guidelines for interventional techniques in chronic Spinal Pain
Pain Physician, 2021Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Alan D Kaye, Sairam Atluri, Nebojsa Nick Knezevic, Aaron K Calodney, Kenneth D Candido, Sanjeeva Gupta, Sudhir Diwan, Alaa AbdelsayedAbstract:Background Despite epidurals being one of the most common interventional Pain procedures for managing chronic Spinal Pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. Objectives This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. Study design The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year.• A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only.• Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. Results Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections. Limitations Expenditures for epidural procedures in chronic Spinal Pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. Conclusions After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures.
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comprehensive evidence based guidelines for facet joint interventions in the management of chronic Spinal Pain american society of interventional Pain physicians asipp guidelines facet joint interventions 2020 guidelines
Pain Physician, 2020Co-Authors: Alan D Kaye, Sairam Atluri, Amol Soin, Sheri L Albers, Douglas P Beall, Richard E Latchaw, Mahendra R Sanapati, Shalini Shah, Alaa AbdelsayedAbstract:Background Chronic axial Spinal Pain is one of the major causes of significant disability and health care costs, with facet joints as one of the proven causes of Pain. Objective To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. Methods The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of facet joint interventions, was reviewed, with a best evidence synthesis of available literature and utilizing grading for recommendations.Summary of Evidence and Recommendations:Non-interventional diagnosis: • The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. • The level of evidence is IV for accurate diagnosis of facet joint Pain with physical examination based on symptoms and signs, with weak strength of recommendation. Imaging: • The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. • The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . • The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT) .Interventional Diagnosis:Lumbar Spine: • The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. • Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant Pain relief criterion standard of ≥80% were included. • The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥80% Pain relief.Cervical Spine: • The level of evidence is II with moderate strength of recommendation. • Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant Pain relief with a criterion standard of ≥80% were included. • The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability. Thoracic Spine: • The level of evidence is II with moderate strength of recommendation. • Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant Pain relief, with a criterion standard of ≥80% were included. • The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%.Therapeutic Facet Joint Interventions: Lumbar Spine: • The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of 3 relevant randomized controlled trials, with long-term improvement. • The level of evidence is IV with weak strength of recommendation for lumbar facet joint intraarticular injections with inclusion of 9 relevant randomized controlled trials, with majority of them showing lack of effectiveness without the use of local anesthetic. Cervical Spine: • The level of evidence is II with moderate strength of recommendation for cervical radiofrequency ablation with inclusion of one randomized controlled trial with positive results and 2 observational studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic cervical facet joint nerve blocks with inclusion of one relevant randomized controlled trial and 3 observational studies, with long-term improvement. • The level of evidence is V with weak strength of recommendation for cervical intraarticular facet joint injections with inclusion of 3 relevant randomized controlled trials, with 2 observational studies, the majority showing lack of effectiveness, whereas one study with 6-month follow-up, showed lack of long-term improvement. Thoracic Spine: • The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies. • The level of evidence is II with moderate strength of recommendation for thoracic therapeutic facet joint nerve blocks with inclusion of 2 randomized controlled trials and one observational study with long-term improvement. • The level of evidence is III with weak to moderate strength of recommendation for thoracic intraarticular facet joint injections with inclusion of one randomized controlled trial with 6 month follow-up, with emerging evidence. Antithrombotic Therapy: • Facet joint interventions are considered as moderate to low risk procedures; consequently, antithrombotic therapy may be continued based on overall general status. Sedation: • The level of evidence is II with moderate strength of recommendation to avoid opioid analgesics during the diagnosis with interventional techniques. • The level of evidence is II with moderate strength of recommendation that moderate sedation may be utilized for patient comfort and to control anxiety for therapeutic facet joint interventions. Limitations The limitations of these guidelines include a paucity of high-quality studies in the majority of aspects of diagnosis and therapy. Conclusions These facet joint intervention guidelines were prepared with a comprehensive review of the literature with methodologic quality assessment with determination of level of evidence and strength of recommendations. Key words Chronic Spinal Pain, interventional techniques, diagnostic blocks, therapeutic interventions, facet joint nerve blocks, intraarticular injections, radiofrequency neurolysis.
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update of utilization patterns of facet joint interventions in managing Spinal Pain from 2000 to 2018 in the us fee for service medicare population
Pain Physician, 2020Co-Authors: Laxmaiah Manchikanti, Vidyasagar Pampati, Alan D Kaye, Sairam Atluri, Amol Soin, Mahendra R Sanapati, Joysree Subramanian, Joshua A HirschAbstract:BACKGROUND Interventional techniques for managing Spinal Pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic Spinal Pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic Spinal Pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic Spinal Pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.
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utilization patterns of facet joint interventions in managing Spinal Pain a retrospective cohort study in the us fee for service medicare population
Current Pain and Headache Reports, 2019Co-Authors: Vidyasagar Pampati, Laxmaiah Manchikanti, Alan D Kaye, Amol Soin, Dharam P Mann, Sanjay Bakshi, Joshua A HirschAbstract:Purpose of Review To assess patterns of utilization and variables of facet joint interventions in managing chronic Spinal Pain in a fee-for-service (FFS) Medicare population from 2009 to 2016, with a comparative analysis from 2000 to 2009 and 2009 to 2016.
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efficacy of epidural injections in managing chronic Spinal Pain a best evidence synthesis
Pain Physician, 2015Co-Authors: Alan D Kaye, Laxmaiah Manchikanti, Ramsin M Benyamin, Mark V. Boswell, Sairam Atluri, Sanjay Bakshi, Salahadin Abdi, Ricardo M Buenaventura, Kenneth D Candido, Harold CordnerAbstract:Background Epidural injections have been used since 1901 in managing low back Pain and sciatica. Spinal Pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic Spinal Pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic Spinal Pain have yielded conflicting results. Objective To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic Spinal Pain. Study design A systematic review of randomized controlled trials of epidural injections in managing chronic Spinal Pain. Methods In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were Pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar Spinal stenosis. The evidence is Level III for cervical Spinal stenosis management with an interlaminar approach. The evidence is Level II for axial or discogenic Pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level III in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level III with cervical interlaminar epidural injections. Limitations Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic Spinal conditions.
Salahadin Abdi - One of the best experts on this subject based on the ideXlab platform.
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efficacy of epidural injections in managing chronic Spinal Pain a best evidence synthesis
Pain Physician, 2015Co-Authors: Alan D Kaye, Laxmaiah Manchikanti, Ramsin M Benyamin, Mark V. Boswell, Sairam Atluri, Sanjay Bakshi, Salahadin Abdi, Ricardo M Buenaventura, Kenneth D Candido, Harold CordnerAbstract:Background Epidural injections have been used since 1901 in managing low back Pain and sciatica. Spinal Pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic Spinal Pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic Spinal Pain have yielded conflicting results. Objective To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic Spinal Pain. Study design A systematic review of randomized controlled trials of epidural injections in managing chronic Spinal Pain. Methods In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were Pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar Spinal stenosis. The evidence is Level III for cervical Spinal stenosis management with an interlaminar approach. The evidence is Level II for axial or discogenic Pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level III in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level III with cervical interlaminar epidural injections. Limitations Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic Spinal conditions.
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an update of comprehensive evidence based guidelines for interventional techniques in chronic Spinal Pain part ii guidance and recommendations
Pain Physician, 2013Co-Authors: Laxmaiah Manchikanti, Ramsin M Benyamin, Mark V. Boswell, Sairam Atluri, Salahadin Abdi, Ricardo M Buenaventura, David A Bryce, Patricia A Burks, David Caraway, Aaron K CalodneyAbstract:Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic Spinal Pain. Methodology 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."
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comprehensive evidence based guidelines for interventional techniques in the management of chronic Spinal Pain
Pain Physician, 2009Co-Authors: Laxmaiah Manchikanti, Ramsin M Benyamin, Bert Fellows, Mark V. Boswell, Vijay Singh, Salahadin Abdi, Ricardo M Buenaventura, Ann Conn, Richard Derby, Stephanie ErhartAbstract:Background Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic Spinal Pain are described here to provide recommendations for clinicians. Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic Spinal Pain. Design Systematic assessment of the literature. Methods Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Outcomes Short-term Pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, Spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term. Results The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint Pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic Pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of Pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing Pain of post-lumbar surgery syndrome, and lumbar Spinal stenosis, for cervical interlaminar epidural injections in managing cervical Pain (Level II-1); for lumbar transforaminal epidural injections; and Spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2. Limitations The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations. Conclusion The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic Spinal Pain and recommendations for managing Spinal Pain. However, these guidelines do not constitute inflexible treatment recommendations. Further, these guidelines also do not represent "standard of care."
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epidural steroids in the management of chronic Spinal Pain a systematic review
Pain Physician, 2007Co-Authors: Salahadin Abdi, Sukdeb Datta, Sairam Atluri, Andrea M Trescot, David M Schultz, Rajive Adlaka, Howard S Smith, Laxmaiah ManchikantiAbstract:Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic Spinal Pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing Spinal Pain. Objective: To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic Spinal Pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is Pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular Pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular Pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root Pain is moderate. The evidence is moderate in managing lumbar radicular Pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic Pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root Pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root Pain and chronic low back Pain.
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interventional techniques evidence based practice guidelines in the management of chronic Spinal Pain
Pain Physician, 2007Co-Authors: Mark V. Boswell, Sukdeb Datta, Nalini Sehgal, Vijay Singh, Rinoo V Shah, Hans Hansen, Andrea M Trescot, Salahadin Abdi, David M Schultz, Ramsin M BenyaminAbstract:Background: The evidence-based practice guidelines for the management of chronic Spinal Pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic Spinal Pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint Pain, whereas, it is moderate in the diagnosis of thoracic facet joint Pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular Pain, and limited in managing Pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root Pain, whereas, it is moderate for cervical nerve root Pain and limited in managing Pain secondary to lumbar post laminectomy syndrome and Spinal stenosis.
