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Evidence for Precision Diagnosis

and Management of Spinal Pain

and Radicular Pain
Dr Sanjeeva Gupta

Consultant in Pain Management and Anaesthesia

Bradford Teaching Hospitals NHS Trust

Outline of the Talk

What is Precision Diagnosis & Management?

Lumbar Facet Joint Pain
Sacroiliac Joint Pain
Lower Limb Radicular Pain
Failed Back Surgery Syndrome
Cervical Axial Pain
Cervicogenic Headache
Upper Limb Radicular Pain

Location Location Location


Current diagnostic methods

1. History
2. Physical examination
3. Imaging
4. Blood tests
5. Nerve conduction studies
Slide from Dr J Richardson

80% of patients with persistent low

back pain cannot be diagnosed
using the conventional model

Slide from Dr J Richardson

Precision diagnostic methods

1. Innervated
2. Blockade Relief
3. Stimulation - Pain

Slide from Dr J Richardson

Neuroanatomy of the Spine

Facet joints supplied by Median Branches of Dorsal Rami
Outer third of Annulus Fibrosis richly innervated
Branches of the Sinuvertebral Nerves
The Grey Rami Communicantes
Lumbar Ventral Rami
Bogduk N, et al. J Anat 1981; 132: 39-56

Bogduk N, Spine 1983; 8:286-293.

Yoshizawa H. J Pathology 1980;132:95-04
Groen G, et al. Am J Anat 1990; 188: 282-96

Inner 1/3rd - Not innervated

Middle 1/3rd - May or may not
be innervated

ALL, disc,

PLL, dura,
disc, vertebra





ALL nerve plexus

r. comm.

PLL nerve plexus

After Groen GJ et al. Am J Anat 1990; 188: 282-96

Where does back pain come from?

1. Facet Joints
2. Discs
3. Sacroiliac joint
4. Nerve root / dura
5. Vertebral Body
6. Ligaments
7. Muscles

Where does back pain come from?

Facet Joint Pain
21% - 40% in general
16% in post lumbar
surgery patients (FBSS)
Schwarzer N et al. Spine 1994 & Ann
Rheum Dis 1995
Datta S, et al. Pain Physician 2009;
12: 437-460

Facet Joint Pain - Evaluation

Facet Joint Injections
Medial Branch Block
False positive rate - 30%
Datta S, et al. Pain Physician 2009; 12: 437-460

High on the eye of the Scotty dog

Median Branch Block - Diagnostic

Lumbar medial branch blocks have been

shown to have both diagnostic and therapeutic

Datta S, et al. Pain Physician 2009; 12:437-460.7-460.

Sehgal N, et al. Pain Physician 2007; 10:213-228.
Hancock MJ, et al. Eur Spine J. 2007 Oct;16(10):1539-50.
Rubinstein SM,et al. Best Pract Res Clin Rheumatol 2008; 22:471-482.
ISIS. Lumbar MBB. In: Bogduk N, ed. Practice Guidelines for Spinal Diagnostic and Treatment
Procedures. SanFrancisco, CA: ISIS; 2004:4765.
Cohen SP,et al. Anesthesiology. 2010 Aug;113(2):395-405.
Cohen SP, et al. Spine J. 2008 May-Jun;8(3):498-504
Bogduk N: The innervation of the lumbar spine. Spine 1983; 8:286-293
Schwarzer AC, et al. Spine 1994; 19:1132-1137
Schwarzer AC, et al. Ann Rheum Dis 1995; 54:100-106
Dreyfuss P, et al. Spine 1997; 22:895-902
Kaplan M, et al. Spine 1998; 23:1847-1852

Therapeutic Effectiveness of Lumbar, Thoracic

and Cervical Median Branch Blocks

LS: LM 2001 = 1 3 inj LA+Sarapin/ LA+ sarapin + steroid: LM 2008 = 3 4 inj

CS: LM 2008 = LA/ LA+ Steroid

Facet Joint Radiofrequency Denervation

Summary of Invalid Studies of Facet Joint

Denervation due to Technical Flaws

Laclaire et al Study

Summary and Outcomes of Valid

Studies of Facet Joint Denervation

Tom-Bermejo F, et al. J Spinal Disord Tech. 2011 Apr;24(2):69-75.

Dobrogowski J, et al. Pharmacol Rep. 2005;57(4):475-80.
Schofferman J, et al. Effectiveness of repeated RFD for lumbar facet pain.
2004 Nov 1;29(21):2471-3.

Kornick C, et al. Complications of lumbar facet RFD. Spine (Phila Pa 1976).

2004 Jun 15;29(12):1352-4.


Critiquing the critiques: the American Pain Society guideline and
the American Society of
Interventional Pain Physicians response to it

Short Title: Critiquing the critique

Corresponding Author: Sherdil Nath

In the above letter to the editor, Roger Chou implies that the results could be biased and concludes that, I quote,
It is difficult to see how the Nath et al trial could be taken as reliable evidence that radiofrequency denervation is
The reason for this, as quoted in the letter was
because the sham control group (which had higher baseline scores) had greater potential to experience
improvement from baseline (There is a mistake here as it was the active treatment group that had higher
baseline scores of pain, Not the sham group as stated)


Generalised Pain


Global Improvement

There are seven systematic reviews of

radiofrequency denervation for chronic LBP
Author conclusions:
Boswell 2007: evidence for pain relief with radiofrequency neurotomy of medial
branch nerves was moderate to strong in cervical and lumbar spine.
Datta 2009: level II-2 evidence for radiofrequency neurotomy
Guerts 2001 moderate evidence that radiofrequency lumbar facet denervation was more
effective for chronic low back pain than placebo
Manchikanti 2002 moderate to strong evidence for radiofrequency neurotomy
Niemisto 2003 conflicting short-term effect on chronic low back pain
Boswell 2005 moderate to strong evidence for radiofrequency neurotomy
Slipman 2003 the evidence for radiofrequency denervation is Level III or moderate.

International Low Back Pain Guidelines

Do not refer for radiofrequency denervation
American Pain Society Low back pain guideline
Evidence on efficacy of RF denervation of the MB of the
primary dorsal ramus is difficult to interpret
European Low Back Pain Guideline
We cannot recommend RF facet denervation for patients
with non-specific chronic low back pain

International Low Back Pain Guidelines

ASIPP Guideline - Comprehensive Evidence-Based Guidelines for
Interventional Techniques in the Management of Chronic
Recommendation: Based on Guyatt et als criteria, for lumbar
radiofrequency neurotomy the recommendation is 1C/strong
American Society of Anaesthesiologists - Practice Guidelines for
Chronic Pain Management
RF of the MB nerves to the FJ should be performed for LBP when
previous diagnostic or therapeutic injections of the joint or MB nerve
have provided temporary relief (Category A1 evidence)

Precision Diagnosis and

of Sacroiliac Joint (SIJ) Pain

Where does back pain come from?

SIJ Pain Prevalence

217 patients with maximal

pain below L5 evaluated
Anatomic controlled (neg z-jt blocks) and/or
dual positive (>75% relief) SIJ blocks
Prevalence of SIJ pain was 10-20%

Schwarzer, Spine, 20:31, 1995, Maigne, Spine 21,1889, 1996

SIJ pain below a L/S fusion

In 74 combined patients with low back pain
after lumbosacral fusion, the SIJ was the pain
source in 32% as established by single IA SIJ
Katz. J Spinal Disorders 16;96-99, 2003, Maigne. Euro
Spine J 14;654-658, 2005

SIJ was found to be a source of postfusion pain in 32% of patients by single

IA block

SIJ Referral Zones

Maximal SIJ pain is below L5 but can refer
into the entire lower extremity with 94%
having buttock, 48% with thigh pain and 28%
with lower leg pain

Schwarzer. Spine 1995, Maigne. Spine 1996, Dreyfuss. Spine 1996, Slipman. Arch Phys
Med Rehabil 2000;81:334-338

Based on dual blocks, maximal pain is below

L5 and in the buttock

SIJ Interventions

The medial joint lines are the margins of the posterior

SI joint line (arrow)

Contrast medium spread

along the SI joint line

Double Needle Technique: An Alternative Method for Performing

Difficult SIJ Injections.
S Gupta. Pain Physician 2011; 14: 281-284

Double Needle Technique: An Alternative Method for Performing

Difficult SIJ Injections.
S Gupta. Pain Physician 2011; 14: 281-284
On Dynamic Fluoroscopy the needle is not in the SIJ line

Double Needle Technique for Sacroiliac Joint Injection

S Gupta. Pain Physician 2011; 14: 281-284
A Second Needle in Inserted into the Newly Identified Joint Line on
Dynamic Fluoroscopy

Double Needle Technique for Sacroiliac Joint Injection

S Gupta. Pain Physician 2011; 14: 281-284
Contrast Injected Through the Second Needle Identifies the SIJ

Double Needle Technique for Sacroiliac Joint Injection

S Gupta. Pain Physician 2011; 14: 281-284
Contrast Injected Trough the First Needle ? Vascular Spread

SIJ Interventions - Evidence

Most experts maintain low-volume intraarticular local anaesthetic injections to be the
only reliable diagnostic modality to diagnose SIJ
Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy,
diagnosis, and treatment. Anesth Analg. 2005;101:1440 1453
Dreyfuss P, Dreyer SJ, Cole A, et al. Sacroiliac joint pain. J Am Acad
Orthop Surg. 2004;12:255 - 265
Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint
interventions: a systematic review. Pain Physician. 2007;10:165Y - 84.

SIJ Interventions - Evidence

There is one double blind and 8 prospective observational studies
which conclude that Fluoroscopy / CT / MRI guided SIJ injection
of steroid provides good short to intermediate term pain relief (3
to 6 months)

Maugars Y, et al. Br J Rheum 1996; 35:767-770.

Braun J, et al. J Rheumatol 1996; 23:659-664
Liliang PC, et al. Spine. 34(9):896-900, 2009 Apr 20.
Gunaydin I, et al. Rheumatology International 2006; 26(5):396-400

Vanelderen et al, in their review graded therapeutic intraarticular injections with corticosteroids and LA as 1 B+
Pascal Vanelderen, et al. Pain Practice, Volume 10, Issue 5, 2010 470478

Levin et al in their review concluded intraarticular sacroiliac

joint corticosteroid injections are effective in patients with
Levin JH, et al. Spine Journal 2009 Aug; 9(8):690-703

SIJ Radiofrequency - Evidence

2 RCT and 3 Prospective observational studies inform
that >50% patients obtain >50% pain relief with
improved function for >6 months following SIJ RFD in
carefully selected patients following diagnostic injection
of local anaesthetic into the SIJ
S P. Cohen, et .al. Randomized Placebo-controlled Study Evaluating Lateral Branch RFD for
SIJ Pain. Anesthesiology 2008; 109:27988
N Patel, et al. A Randomized, Placebo Controlled Study to Assess the Efficacy of Lateral
Branch Denervation for Chronic SIJ Pain. Presented at the ASIPP Annual Meeting June 2011
S P. Cohen, et al. Outcome Predictors for Sacroiliac Joint (Lateral Branch)Radiofrequency
Denervation. Reg Anesth Pain Med 2009; 34: 206 214
H Karaman, et al. Acta Neurochir 2011. Published online April 20113
Buijs EJ, et al. Pain Clinic 2004; 16: 139-146.
Gevargez A, et al. Eur Radiol 2002; 12: 1360-1365


Presentation can
alter if treated

lancinating, shooting, or
electric pain; traveling
down the limb in a
narrow band.

Bogduk N, Govind J. Medical Management of Acute Lumbar Radicular Pain. An Evidence-Based

Approach. Newcastle: Newcastle Bone and Joint Institute, 1999




Ig M, Ig G



dorsal root

interleukins 8, 12


leukotriene B4
spinal nerve





Ig M, Ig G



dorsal root



interleukins 8, 12
leukotriene B4

spinal nerve



Radicular Pain
Epidurals Caudal, Interlaminar,
Catheter Neuroplasty
Spinal endoscopy
Spinal cord stimulator

Caudal Epidural Steroid Injection for

Lumbar disc herniation/radiculitis

Dashfield Single procedure

LM LA/LA+Steroid; Average procedure 3 to 4/year with > 50% pain relief and 40% improvement of ODI of 36/52
Significant decrease in opioid intake and employment status (12/52 per procedure)

Caudal Epidural Steroid Injection

LBP of Post Surgery Syndrome

LM and Revel Post lumbar laminectomy syndrome; LM - DB equivalence trial; LA or LA + Betamethasone;

Average procedure 3 to 4/year; > 50% pain relief and 40% improvement of ODI of 35-44/52
Significant decrease in opioid intake (10-14/52 per procedure)
Hesla herniated disc operated

Lumbar Interlaminar Epidural Steroid Injection

Summary Lumbar ESI

15 RCTs: 8 positive and 7 negative
Radicular pain relief between 6 wks & 3 mths
No fluoroscopy
In the posterior epidural space

Transforaminal Epidural

Randomised Trials of Effectiveness of

Transforamenal Epidural Injection

Ghahreman A, Ferch R, Bogduk N. Pain Medicne 2010; 11: 1149-1168

Ghahreman A, Bogduk N. Pain Med. 2011 Jun;12(6):871-9.

Left L4/5 Transforaminal Injection

Karppinen J, et al. Spine 2001; 23: 258795

Cost effectiveness of TFESI for sciatica
For contained herniations
Steroid better for leg pain, disability, SLR in the short
By 1 year steroid prevented operations costing
$12,666 less per responder

For extrusions
Steroid seemed to increase the op. rate and was more

Riew D, et al: Prospective RC Double Blind Trial

The main outcome measure was avoidance of surgery
Bupivacaine and

Bupavacaine only

Total Patients



Patients not
having surgery

20 (71%)

9 (33%)

P < 0.0004
Normally all would have been treated operatively
Treatment algorithm now includes 3 to 4 TFESI before considering surgery

Transforaminal Local Anaesthetic Injection

Transforaminal Steroid Injection

Change in Use of Health Care from before to after treatment

Degree of Pain Relief in the 5 different Groups

TFESI - Systematic Reviews

DePalma MJ, et al. Arch Phys Med Rehabil. 2005;86(7):1477-83
The evidence for TFESIs reveals level III (moderate) evidence in support of
these minimally invasive and safe procedures in treating painful lumbar
radicular symptoms. Current studies support use of TFESIs as a safe and
minimally invasive adjunct treatment for lumbar radicular symptoms.

Abdi S, et al. Pain Physician. 2007 Jan;10(1):185-212.

The evidence for cervical and lumbar TFESI is moderate for long-term
improvement in managing nerve root pain.

Roberts ST, et al. PM R. 2009 Jul;1(7):657-68.

There is fair evidence supporting TFESIs as superior to placebo for treating
radicular symptoms.
There is good evidence that TFESIs should be used as a surgery-sparing
TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for
radicular pain in patients with subacute or chronic radicular symptoms.

TFESI - Systematic Reviews

Buenaventura RM, et al. Pain Physician. 2009 JanFeb;12(1):233-51
The indicated evidence for TFESI is Level II-1 for short-term relief and
Level II-2 for long-term improvement in the management of lumbar nerve
root and low back pain

Manchikanti L, et al. Pain Physician. 2009;12(4):E123-98.

Based on Guyatt et als criteria, the recommendation for lumbar TFESI is
1C/strong in managing chronic low back and lower extremity pain

Benny B, et al. J Back Musculoskelet Rehabil. 2011 Jan

There was strong evidence for TFESI in the treatment of lumbosacral
radicular pain for both short term and long term relief

Our Response
Careful patient selection, fluoroscopy and contrast
injection are needed for effective spinal injections.
Mon, 2011-09-26 11:59

NICE Technology appraisal guidance 159
Recommended for chronic pain of neuropathic
Failed Back Surgery Syndrome
Complex Regional Pain Syndrome

Cervical Spinal Pain and Upper

Limb Radicular Pain Spinal
Diagnosis & Management of Neck Pain
Diagnosis and Management of Radicular Pain

Where does the Pain Come From?

Facet Joints
Intervertebral Discs
Dura mater
Nerve Root, DRG
Infection, Trauma, Tumour


Groen. Am J Anat 1990; 88:282-96

Bogduk. Spine 1988;13:2-8
Mendal. Spine 1992; 17:132-35

Facet Joints: Bogduk. Spine 1982; 7:319-30

Cervical / Neck Pain - Incidence

Lower Cervical Facet Joint Pain
(C4/5 to C6/7)
About 50% with neck pain
Spine 1992; 17:744-47; Spine 1996; 21:1737-45; Spine 1995; 20: 20-26

High speed MVA 88% J of Musculoskeletal Pain 2000; 8: 87-95

Upper Cervical FJ Pain - Cervicogenic Headache

(C0/1 to C3/4)
53% from C2-3 joint J Neurol Neurosurg Psychiatry 1994; 57: 1187-90

History and Clinical Examination: Cervical Somatic Referred Pain

Facet Joint Pain
Discogenic Pain

C5-6 facet joint most commonly

involved followed by C6-7


One can localise to within

+/- one joint on the basis


of referral maps

Dwyer et al. Spine 1990; 15:453-457

Grubb and Kelly. Spine 2000; 25:1382-1389






Fluoroscopic Anatomy
Centroid of the articular pillar

False Positive Blocks

Average false positive rate of single block
was 49% (range 27 to 63%)
Barnsley et al. The Clinical Journal of Pain 1993; 9:124-130
Manchikanti et al. Pain Pract 2008; 8:5-10
Manchukonda R, et al. J Spinal Disord Tech 2007; 20: 539-45

Median Branch Neurotomy - Evidence

Lord SM, Bogduk N, et al. Radiofrequency Neurotomy for ChronicZygapophyseal
Joint Pain. The New England Journal of Medicine 1996; 335:1721-1726

Randomised double-blind trail

24 patients following MVA
Source of pain identified by double-blind placebo
controlled LA blocks (Saline, lignocaine, Bupivacaine)
12 patients received RF neurotomy (C3/4 to C6/7)
Median time before pain returned to 50% of the
preoperative level was 263 days in the activetreatment group and 8 days in the control group

Median Branch Neurotomy - Evidence

McDonald GJ, Lord S, Bogduk N. Long term follow-up of patients treated with
cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999;
45: 61-68

28 patients treated 18 (64%) had complete pain

relief for a median period of 421 days
If pain recurred complete pain relief reinstated
by repeat RF neurotomy with some patients
having 4 to 6 successful repetitions
Sapir DA et al. RF MB neurotomy in litigant and nonlitigant
patients with cervical whiplash. Spine 2001; 26: E268-E273

Median Branch Neurotomy - Evidence

Cervicogenic Headache
Third Occipital Nerve (TON)

C2-3 Joint is the source of Cervicogenic Headache in

54% of patients
TON (C3): three points required, to cover variants in
longitudinal bisector C2-3 zygapophysial joint
High- opposite apex of C3 SAP
Low - opposite base of C2-3 foramen
mid - midway between

longitudinal bisector

high, mid, and low points


TON Evidence
Govind J, Bogduk N, et al. Radiofrequency neurotomy for the
treatment of third occipital headache. J Neurol Neurosurg Psychiat
2003; 74: 88-93

86% of 49 patients obtained complete pain

relief, the median duration of pain relief was
297 days
14 patients had repeat RF neurotomy when
their pain recurred and 12 (86%) regained
complete pain relief

Cervical Pain Algorithm

Cervical / Neck Pain

Facet joints
Headache Dominant Symptom Upper cervical facets
Headache Not Dominant Middle and Lower Cervical
Dwyer et al. Spine 1990; 15:453-457




Cervical / Neck Pain Algorithm

Cervical Pain
?Upper Limb Pain Cervical Axial Pain
No Upper Limb Radicular Pain
?Cervical Radicular Pain
(50-80% have neck pain)
Is Headache the Dominant Symptom
Cervical Radicular Yes
Pain Algorithm
Cervicogenic Headache
Cervical Axial Pain

Cervical Facet Joint Pain Algorithm

Select Most Likely Joint From Pain Maps
Perform First Block C5-6 common
>90% Pain Relief C6-7, C4-5, C7-T1
Yes No
Perform Confirmatory Block

Are Other Joints Implicated

(27% false positive)




Block Appropriate Joint Pain not

Perform Confirmatory Block

from CFJ

>90% Pain

Cervicogenic Headache Algorithm

Perform C2-3 Joint Block (54%)
Good Pain Relief
No Pain ReliefC3-4 block
Technically Adequate?
Can C1-2 block be done safely
Perform Confirmatory Block
Technically Adequate?
Yes Perform C1-2 block Can O-C1 Block be
done safely
Good Pain Relief
Good Pain Relief
Result Perform O-C1 block
not possible


Cervical Radicular Pain Algorithm

Does the pain satisfy the definition of Cervical Radicular Pain

Yes or Perhaps (shooting, lancinating)

Exit Does Physical Examination Reveal Radiculopathy

(numbness, weakness, hyporeflexia)
C6, C7 Common



C5 Uncommon
C4, C8 rear

Might a differential
Imaging MRI
Disc herniation or Spondylosis

diagnosis apply?

Might Electrophysiology help?

No Yes
Electrophysiology consistent
With Radiculopathy
for other causes
Epidural steroid (CE/TFE)
SNRB, PMP, Surgery

Upper Limb Radicular Pain

Cervical Interlaminar Epidural Steroid Injections
Always below C6 level
Ideally C7-T1 level or below

Cervical Epidural Steroid Injection

Cervical Transforamenal Epidural Injection

Right Anterior Oblique

Left C7 T.F.E.

Anterior Spinal Artery

If particulate material like
depot steroid preparation is
injected into the radicular
vessels it could reach the ASA
and spinal cord and act as an
Needle trauma or air embolus
Huntoon MA. Pain 2005; 117: 104-11
Cheshire WP, et al. Neurology 1996; 47:321-30

AP view of an angiogram
obtained after injection
of contrast medium
Conventional fluoroscopic

Digital Subtraction View

Summary Cervical ESI

Cervical ESI
Prospective study with good results
Pain 1994; 58(2): 239-43.

Cervical TFESI
3 Prospective Study

Eur Spine J 1996; 5:319-325

Radiology 2001; 218:886-892
AJNR 2004; 25(3): 441-45


P Dreyfuss. Pain Medicine 2006; 7: 237-42

30% obtain complete relief

30% obtain partial, lasting relief
To be tried before surgery
In the absence of controlled studies, it cannot be known whether
these outcomes are due to natural history, TFESI or non-specific
treatment effects

Pulsed Radiofrequency Treatment

for Radicular Neuropathic Pain
Double blind sham RCT
PRF adjacent to the cervical DRG compared to Sham
PRF group compared to sham at 3 months showed a significantly
better outcome with regards to the global perceived effect (>50%
improvement) and VAS (20-point pain reduction)
This translated to a NNT of 1.1 in the PRF group compared with
NNT of 3 in the sham group
Six months after the procedures, the NNT of PRF was 1.6 and 6
for the sham intervention.
Van Zundert J, Patijn J, Kessels A, Lam I, van Suijlekom H, van Kleef M. Pulsed radiofrequency
adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham
controlled randomized clinical trial. Pain 2007;127(1-2):173-82.

Most patients with LBP, neck pain and upper and lower
limb radicular pain will recover with conservative
Precision diagnostic techniques allows us to identify the
source of persistent pain & guides further management
Obtaining a diagnosis stops further futile investigations
and prevent surgery

Thank You for Your