SPINESCAN LITERATURE REVIEW
Issue 1, Volume 1
Implications of the SPORT Study
Recent Research on Operative and Non-operative Spine Care

Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us

Spine J. 2009;9(8):690-703

Joshua H. Levin, MD, published a review article in the August 2009 issue of The Spine Journal.  He wanted to “find all prospective, double-blind, randomized, placebo-controlled trials (PDBRPCTs) in the interventional spine literature and summarize them in one article, so that physicians can easily review the best quality data that this field of medicine has to offer.”

Dr. Levin reviewed all available PDBRPCTs for the following interventional treatments;

  • Fluoroscopically guided lumbosacral transforaminal epidural cortiosteroid injections for lumbosacral radiculopathy
  • Cervical epidural corticosteroid injections for cervical radiculopathy
  • Lumbosacral intra-articular zygapophysial joint corticosteroid injections when using at least one diagnostic injection for patient selection
  • Lumbar medial branch nerve corticosteroid or Sarapin injections
  • Cervical intra-articular zygapophysial joint corticosteroid injections when using at least one diagnostic injection for patient selection
  • Cervical medial branch nerve corticosteroid or Sarapin injections
  • Percutaneous radiofrequency lumbar medial branch neurotomy for lumbosacral zygapophysial joint pain when using at least one diagnostic injection for patient selection
  • Percutaneous radiofrequency cervical medial branch neurotomy for cervical zygapophysial joint pain when using at least one diagnostic injection for patient selection
  • Intra-articular sacroiliac joint corticosteroid injections
  • IDET for discogenic pain
  • Percutaneous radiofrequency neurotomy of the ramus commuicans for discogenic pain
  • Intradiscal corticosteroid injections for discogenic pain

This review concluded that the following interventional treatments are effective:

  • For treating acute/subacute lumbosacral radicular pain, fluoroscopically guided lumbosacral transforaminal epidural corticosteroid injections are effective in the short-term (and possibly at 6 months).  These injections are also more effective than placebo when it comes to preventing surgery.
  • Percutaneous radiofrequency lumbar medial branch neurotomy is more effective than placebo in patient with chronic lumbosacral zygapophysial joint pain.
  • Also for patients with chronic lumbosacral zygapophysial joint pain—this time specifically caused by whiplash—percutaneous radiofrequency cervical medial branch neurotomy is more effective than placebo.
  • For patients with spondyloarthropathy and low back pain, sacroiliac joint corticosteroid injections are more effective than placebo at 1 month.
  • In patients with < 20% disc height loss and who have been diagnosed with discogenic pain (via the discography criteria of concordant pain multiple times at similar PSI with negative control discs), IDET is modestly more effective than placebo at 6 months.
  • As a treatment for discogenic pain, percutaneous radiofrequency neurotomy of the ramus communicans is more effective than placebo.

The review concluded that the following treatments are not effective:

  • For patients with chronic cervical zygapophysial joint pain caused by whiplash, one-level intra-articular cervical zygapophysial joint corticosteroid injections are not more effective than placebo.  Additionally, corticosteroid injections or Sarapin injections are not more effective than placebo.
  • Corticosteroid injections or Sarapin injections are not more effective than placebo for patients with chronic lumbar zygapophysial joint pain.

Commentary

The breadth and depth of Level One evidence supporting interventional spine treatments far outweighs the surgical equivalent.  Joshua Levin presents a concise review of the top literature in pain management therapies.

While I disagree that provocative discography is essential for the diagnosis of discogenic pain, Levin presents well the need for further studies in discogenic pain.

Rationale for the treatment of zygapophysial joint pain and radicular pain is far better substantiated in the literature.

Next Article:
Do Epidural Steroid Injections Affect the Outcome of Patients Treated for Lumbar Stenosis? A Subgroup Analysis of the SPORT
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