Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES: The use of radiofrequency (RF) procedures in the peripheral nervous system to treat chronic spinal pain has been the subject of controversy. Publications concerned only uncontrolled studies, and irreversible nervous tissue damage was believed to be responsible for the effect, if any. In recent years, randomized, controlled studies have appeared, which have attested to an increasing use of these techniques. This is a systematic review of randomized controlled trials on RF procedures for spinal pain. METHODS: We performed a standardized literature search for randomized, controlled trials. Three adjudicators independently registered trial methodology and outcome using validated and subject-related instruments. Interadjudicator disagreement was resolved by discussion. It was found necessary to devise additional parameters of study assessment. RESULTS: Six trials met the inclusion criteria. This small number, along with clinical and technical heterogeneity precluded statistical analysis. All studies, whether high or low quality, reported positive outcomes. CONCLUSIONS: We conclude that there is moderate evidence that RF lumbar facet denervation is more effective for chronic low back pain than placebo. Limited evidence exists for efficacy of RF neurotomy in chronic cervical zygapophyseal joint pain after flexion-extension injury. There is limited evidence that RF heating of the dorsal root ganglion is more effective than placebo in chronic cervicobrachialgia. We recommend the systematic application of our additional parameter assessments for future evaluations of RF studies. These additional parameters should also be used in the preparation of future trial protocols of RF procedures for the treatment of chronic pain.     

Biomechanics of spinal manipulative therapy.

BACKGROUND CONTEXT: Modern scientific investigations into spinal manipulative therapy (SMT) began in 1975. Conditions often treated include acute and chronic low back pain, radicular pain, neck pain, and some forms of headache. The field of spinal manipulation has often been treated by the literature, incorrectly, as being homogeneous. Much of the confusion regarding this form of treatment can be traced to the ambiguity surrounding the procedures themselves. This report summarizes the clinical biomechanics of SMT and evidence for its associated manipulable lesion is reviewed. Finally, a classification system based on biomechanics is proposed that may facilitate more detailed research in the future. PURPOSE: A categorization system for SMT was sought that would be more objective than is clinically available. Such a system may serve as a means to strengthen future studies, determine operating principles, applicability, treatment effectiveness, and nature of the manipulable lesion. STUDY DESIGN: Literature synthesis. METHODS: A search of the indexed biomechanical and medical literature as well as a hand search of published works was conducted. The criteria for article selection consisted of studies that included measurements of mechanical characteristics of treatment techniques used under the general headings of SMT or manual therapy. A second set of studies was identified that explored the biomechanics of buckling behavior of vertebral segments as a model of the manipulable lesion. Quantitative characteristics of SMT were extracted and grouped to form a basis for classification. RESULTS: A total of 31 articles were identified that contained quantitative data on the biomechanical properties of SMT methods. An additional seven studies were found that quantified spinal buckling behavior. Common features of SMT procedures lead to a matrix that biomechanically characterizes the types of procedures in use. Buckling behavior was compared qualitatively with clinical observations to form a plausible and evidence-based hypothesis of the manipulable lesion. CONCLUSIONS: There currently are a number of named systems of manual procedures. No current triage system is available that predicts which patient has the greater likelihood of benefiting from manual treatment or the procedure type. The biomechanical parameters of SMT form a systematic characterization of manual procedures. Such a system may be used in future studies to test hypotheses of treatment effect from quantitatively defined procedures.     

Dextrose prolotherapy for recalcitrant coccygodynia

PURPOSE: To present the results of dextrose prolotherapy undertaken for chronic non-responding coccygodynia in 37 patients. METHODS: 14 men and 23 women (mean age, 36 years) with chronic coccygodynia not responding to conservative treatment for more than 6 months were included. 27 of them had received local steroid injections. A visual analogue score (VAS) was recorded for all patients before and after injection of 8 ml of 25% dextrose and 2 ml of 2% lignocaine into the coccyx. In 8 patients with a VAS of more than 4 after the second injection, a third injection was given 4 weeks later. RESULTS: The mean VAS before prolotherapy was 8.5. It was 3.4 after the first injection and 2.5 after the second injection. Minimal or no improvement was noted in 7 patients; the remaining 30 patients had good pain relief. CONCLUSION: Dextrose prolotherapy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. Randomised studies are needed to compare prolotherapy with local steroid injections or coccygectomies.     

The genetics of pain: implications for evaluation and treatment of spinal disease

Background contextVariability in human pain experience appears to be at least partially determined by genetic inheritance. To the extent that awareness of individual pain sensitivity and the tendency to develop chronic pain after injury or surgery would be informative for clinical decision making, development and use of genetic testing for specific pain markers could contribute to improved outcomes in management of spinal disease.PurposeTo review important and illustrative results from both classical and modern pain genetics studies and to introduce readers to critical definitions and concepts necessary to interpret the growing body of genetics literature relevant to spinal disease.Study design/settingLiterature review and commentary.MethodsA review was performed of published English language studies in which genetic techniques were used to analyze the molecular basis of nociceptive signaling or processing with a particular emphasis on studies addressing genetic determinants of interindividual variability in pain sensitivity or predisposition to chronic pain.ResultsThere is compelling evidence indicating that interindividual differences in pain sensitivity and the risk of developing chronic pain syndromes are genetically determined. Despite a growing list of putative “pain genes,” genetic association studies remain plagued with difficulty replicating initial findings in different cohorts.ConclusionsGenome-wide association studies are potentially powerful means of identifying clinically relevant genetic markers predicting disease susceptibility, severity, and treatment response. However, accurate results require rigorous study design with use of large homogeneous populations and precise phenotypes.     

Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders: a systematic review of the literature

Objective:

The purpose of this study was to conduct a systematic review of the literature investigating clinical outcomes involving the use of the Activator Adjusting Instrument (AAI) or Activator Methods Chiropractic Technique (AMCT).

Methods:

A literature synthesis was performed on the available research and electronic databases, along with hand-searching of journals and reference tracking for any studies that investigated the AAI in terms of clinical effectiveness. Studies that met the inclusion criteria were evaluated using an instrument that assessed their methodological quality.

Results:

Eight articles met the inclusion criteria. Overall, the AAI provided comparable clinically meaningful benefits to patients when compared to high-velocity, low-amplitude (HVLA) manual manipulation or trigger point therapy for patients with acute and chronic spinal pain, temporomandibular joint (TMJ) dysfunction and trigger points of the trapezius muscles.

Conclusion:

This systematic review of 8 clinical trials involving the use of the AAI found reported benefits to patients with a spinal pain and trigger points, although the clinical trials reviewed suffered from many methodological limitations, including small sample size, relatively brief follow-up period and lack of control or sham treatment groups.     

Failure of external spinal skeletal fixation to improve predictability of lumbar arthrodesis.

BACKGROUND: Whether lumbar arthrodesis can relieve isolated low-back pain in the absence of focal neurological findings or instability is unclear. The results of published studies are also inconsistent with regard to whether temporary back-pain relief with external spinal skeletal fixation can predict lasting back-pain relief after arthrodesis. This report presents the results, with regard to clinical benefit and complications, of more than 100 external spinal skeletal fixation procedures undertaken as a prelude to lumbar arthrodesis. METHODS: The records of all patients who underwent external spinal skeletal fixation between 1989 and 1999 were reviewed with attention to perioperative complications, pain relief from the test procedure, the clinical benefit from a subsequent arthrodesis, and the functional status after the arthrodesis. Analyzed data included the frequency of neurological complications and infections and the benefit (Prolo score) after staged spinal arthrodesis in patients who underwent arthrodesis after temporarily experiencing pain relief with the test procedure. RESULTS: A total of 103 external spinal skeletal fixation procedures were undertaken. Neurological complications occurred in two procedures (2%); one resulted in permanent sciatica. Infections occurred in five patients (5%). Sixty patients experienced pain relief during the external fixation test, but only twenty-seven of forty-nine patients who went on to have an arthrodesis and had sufficient follow-up reported that they were doing well at a minimum of one year later. In no case did the external spinal skeletal fixation procedure cause a permanent increase in low-back pain. CONCLUSIONS: On the basis of this analysis, external spinal skeletal fixation should not be used as a predictor of pain relief after lumbar arthrodesis.     

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis

ObjectiveTo summarize the evidence for dextrose prolotherapy in knee osteoarthritis.Data sourcesThe authors searched PubMed and Embase from inception to September 2020. All publications in the English language were included without demographic limits.Study selectionRandomized clinical trials comparing the effects of any active interventions or placebo versus dextrose prolotherapy in patients with knee osteoarthritis were included.Data extractionPotential articles were screened for eligibility, and data was extracted independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was performed on clinical trials with similar parameters. The Strength of Recommendation Taxonomy (SORT) was used for evaluating the strength of recommendations.Data synthesisIn total, eleven articles (n = 837 patients) met the search criteria and were included. The risk-of-bias analysis revealed two studies to be of low risk. The overall effectiveness was calculated using a meta-analysis method. Prolotherapy was no different from platelet-rich plasma on the pain subscale at the 6-month time point. Prolotherapy was inferior to platelet-rich plasma at 6 months (MD 0.45, 95% CI 0.06–0.85, p = 0.03) on the stiffness subscale. Prolotherapy was found to be safe with no major adverse effects.ConclusionProlotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).     

Spinal gout:A review with case illustration

AIM To summarize clinical presentations and treatment optionsof spinal gout in the literature from 2000 to 2014, and present theories for possible mechanism of spinal gout formation.METHODS The authors reviewed 68 published cases of spinal gout, which were collected by searching "spinal gout" on Pub Med from 2000 to 2014. The data were analyzed for clinical features, anatomical location of spinal gout, laboratory studies, imaging studies, and treatment choices. RESULTS Of the 68 patients reviewed, the most common clinical presentation was back or neck pain in 69.1% of patients. The most common laboratory study was elevated uric acid levels in 66.2% of patients. The most common diagnostic image finding was hypointense lesion of the gout tophi on the T1-weighted magnetic resonance imaging scan. The most common surgical treatment performed was a laminectomy in 51.5% and non-surgical treatment was performed in 29.4% of patients.CONCLUSION Spinal gout most commonly present as back or neck pain with majority of reported patients with elevated uric acid. The diagnosis of spinal gout is confirmed with the presence of negatively birefringent monosodium urate crystals in tissue. Treatment for spinal gout involves medication for the reduction of uric acid level and surgery if patient symptoms failed to respond to medical treatment.     

Platelet-rich plasma therapy for knee joint problems: review of the literature, current practice and legal perspectives in Korea

Platelet-rich plasma (PRP) is a concentrate extract of platelets from autologous blood, and represents a possible treatment option for the stimulation and acceleration of soft-tissue healing and regeneration in orthopedics. Currently, the availability of devices for outpatient preparation and delivery contributes to the increase in the clinical use of PRP therapy in practical setting of orthopedic fields. However, there is still paucity of scientific evidence in the literature to prove efficacy of PRP therapy for the treatment of ligament or tendon problems around the knee joint. Moreover, strong evidence from well-designed clinical trials to support the PRP therapy for osteoarthritis of the knee joint is yet scanty in the literature. Scientific studies need to be performed to assess clinical indications, efficacy, and safety of PRP, and this will require high powered randomized controlled trials. Nonetheless, some hospitals exaggeratedly advertise PRP procedures as the ultimate treatment and a novel technology with abundant scientific evidence for the treatment of knee problems. As a matter of fact, PRP protocols are currently approved only for use in clinical trials and research, and are not allowed for treatment purpose by any institutions in Korea. At present, clinical use of PRP therapy for ligament or tendon problems or osteoarthritis of knee joint is defined as illegal medical practice, regardless of whether it is performed as a sole procedure or as a part of prolotherapy, because the safety and validity are not yet approved by the Ministry of Health and Welfare and Health Insurance Review and Assessment Service. Practicing physicians should remember that injection of PRP to patients by imposing medical charge is still illegal as per the current medical law in Korea.     

Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systematic review of reported postoperative outcomes

Background contextWith improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.PurposeTo determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.Study designSystematic review of the literature.Patient sampleAll published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.Outcome measuresCyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.MethodsWe performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.ResultsEighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4–L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.ConclusionsSurgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.     

Neuraxial techniques for cancer pain: An opinion about unresolved therapeutic dilemmas

Background and Objectives. Epidural and intrathecal techniques are well established for minimizing cancer pain. However, several issues remain unresolved. Methods. A review of studies published in the last 10 years regarding neuraxial techniques in cancer pain management was made. The following issues were assessed: appropriate indications; techniques and delivery systems; conversion from systemic to spinal administration; route and modes of administration; choice of opioids, analgesic response and adverse effects of opioids; use of local anesthetics; use of adjuvants; technical complications; and possible problems only recognized at home. Results. Indications for the use of neuraxial opioids include patients treated with systemic opioids who received effective pain relief but with unacceptable side effects or unsuccessful treatment despite escalating doses with sequential, strong opioid drug trials. The choice of exteriorized or implanted delivery systems is based on different clinical considerations. The use of externalized, tunnelled intrathecal catheters has not been proven to be associated with higher rates of complications, and they may be easier to place and use at home in debilitated patients late in the course of their disease. Intrathecal administration has a lower incidence of catheter occlusion, lower malfunction rate, lower dose and volume requirements, and more effective pain control. Advantages of continuous infusion techniques are more evident when using local anesthetics, because intermittent administration of bupivacaine often results in motor paralysis and hemodynamic instability. Morphine appears to be the opioid of choice, and an epidural dose of 10% of the systemic dose is often used. Bupivacaine-induced adverse effects have been reported infrequently with bupivacaine doses less than 30–60 mg/d. Adjuvant drugs, such as clonidine and neostigmine, may further improve analgesia. Varied ranges of technical complication rates have been reported in the literature, with most being associated with epidural catheters. Conclusions. A subcutaneous tunnelling and fixation of the catheter, bacterial filters, minimum changes of tubings, weekly exit site care, site protection, and monitoring for any signs of infection are suggested for advanced cancer patients. Areas still needing clarification include the optimum use of spinal adjuvants, the appropriate spinal morphine-bupivacaine ratio, methods to improve spinal opioid responsiveness, and long-term catheter management during home-care programs.     

Dextrose prolotherapy versus radial extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: A randomized,controlled clinical trial

In the recent years, prolotherapy is increasingly being used in the field of musculoskeletal medicine. However, few studies have investigated its effectiveness in plantar fasciitis (PF). The purpose of this study was to compare the effectiveness of ultrasound-guided dextrose prolotherapy with radial extracorporeal shock wave therapy (ESWT) in the treatment of chronic PF. This randomized controlled trial was conducted on 59 patients with chronic PF. Patients were randomly assigned into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided intrafascial 2 cc dextrose 20% injection (30 patients). The following outcome measures were assessed before and then six weeks and 12 weeks after the treatments: pain intensity by visual analog scale (VAS), daily life and exercise activities by Foot and Ankle Ability Measure (FAAM), and the plantar fascia thickness by ultrasonographic imaging. The VAS and FAAM scales showed significant improvements of pain and function in both study groups 6 weeks and 12 weeks after the treatments. A significant reduction was noted for plantar fascia thickness at these intervals (all p < .05). The inter-group comparison revealed that except for the FAAM-sport subscale which favored ESWT, the interaction effects of group and time were not significant for other outcome measures. Dextrose prolotherapy has comparable efficacy to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with PF. No serious adverse effects were observed in either group.Level of evidenceLevel I, randomized controlled trial.     

Neuroimaging in traumatic spinal cord injury: an evidence-based review for clinical practice and research

OBJECTIVE: To perform an evidence-based review of the literature on neuroimaging techniques utilized in spinal cord injury clinical practice and research. METHODS: A search of the medical literature for articles on specific neuroimaging techniques used in SCI resulted in 2,302 published reports. Review at the abstract and full report level yielded 99 clinical and preclinical articles that were evaluated in detail. Sixty nine were clinical research studies subjected to quality of evidence grading. Twenty-three articles were drawn from the pre-clinical animal model literature and used for supportive evidence. Seven review articles were included to add an element of previous syntheses of current thinking on neuroimaging topics to the committee process (the review articles were not graded for quality of evidence). A list of clinical and research questions that might be answered on a variety of neuroimaging topics was created for use in article review. Recommendations on the use of neuroimaging in spinal cord injury treatment and research were made based on the quality of evidence. RESULTS: Of the 69 original clinical research articles covering a range of neuroimaging questions, only one was judged to provide Class I evidence, 22 provided Class II evidence, 17 Class III evidence, and 29 Class IV evidence. RECOMMENDATIONS: MRI should be used as the imaging modality of choice for evaluation of the spinal cord after injury. CT and plain radiography should be used to assess the bony anatomy of the spine in patients with SCI. MRI may be used to identify the location of spinal cord injury. MRI may be used to demonstrate the degree of spinal cord compression after SCI. MRI findings of parenchymal hemorrhage/ contusion, edema, and spinal cord disruption in acute and subacute SCI may contribute to the understanding of severity of injury and prognosis for neurological improvement. MRI-Diffusion Weighted Imaging may be useful in quantifying the extent of axonal loss after spinal cord injury. Functional MRI may be useful in measuring the anatomic functional/metabolic correlates of sensory-motor activities in persons with SCI. MR Spectroscopy may be used to measure the biochemical characteristics of the brain and spinal cord following SCI. Intraoperative Spinal Sonography may be used to identify spinal and spinal cord anatomy and gross pathology during surgical procedures. Further research in these areas is warranted to improve the strength of evidence supporting the use of neuroimaging modalities. Positron Emission Tomography may be used to assess metabolic activity of CNS tissue (brain and spinal cord) in patients with SCI.     

Avoiding Misdiagnosis and Missed Diagnosis for Appropriately Treating Spinal Osteoid Osteomas: A Single‐Center Experience

ObjectivesTo analyze the causes of misdiagnosis and missed diagnosis in spinal osteoid osteoma, and to put forward solutions to improve diagnosis accuracy and treatment efficacy in patients.MethodsWe performed a retrospective cohort study on patients with spinal osteoid osteoma in Beijing Jishuitan Hospital from January 1983 to September 2019. All patients underwent surgery. The outcome measures were the extent of local pain, nocturnal pain, radicular symptoms of extremities after surgery, and reduction or disappearance of lesions on CT after surgery.ResultsThirty‐seven patients with spinal osteoid osteoma were recruited in the study. A total of 27% were female, and the mean (SD) age at diagnosis was 21.3 (8.7) years. A total of 87.0% of patients presented with nocturnal pain, and 94.7% of patients were responsive to NSAIDS treatment. The mean (SD) time from the initial onset of symptoms to the final diagnosis was 14.7 (12.5) months. Only four of 37 (10.8%) patients were correctly diagnosed with spinal osteoid osteoma on the first visit to the local hospital. CT is associated with a higher diagnosis rate than X‐ray or MRI on the first visit. Surgical navigation was used in 88.9% of patients who underwent curettage resection, and in 10% of patients who underwent en bloc resection. A total of 37 of 37 patients (100%) reported relief of local pain and radicular symptoms of extremities after surgery, and no recurrence of tumors was found during follow‐ups.ConclusionsSpinal CTs are recommended to be performed if osteoid osteoma is suspected based on clinical manifestation, including nocturnal pain and responsiveness to NSAIDS treatment, to avoid misdiagnosis and missed diagnosis of spinal osteoid osteoma.     

Use of topiramate for spinal cord injury-related pain

BACKGROUND: Pain following spinal cord injury (SCI) has proved difficult to treat. Although the use of antiepileptic drugs to treat SCI-related pain has been studied previously, topiramate has not been investigated in this population. Our recent experience suggests that topiramate may be efficacious in the treatment of SCI-related pain. METHOD: Case Studies Findings: This report presents the clinical histories of two people with pain following SCI who reported beneficial effects of treatment with the new antiepileptic drug topiramate, even after failing treatment with standard analgesic medications. Topiramate was well tolerated in these patients. CONCLUSION: For post-SCI pain, topiramate appears to be an effective treatment in some patients. Based on the present anecdotal findings, larger controlled studies comparing topiramate with standard treatment for SCI-related pain are warranted.     

Comparison of Ultrasound-Guided Prolotherapy Versus Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis: A Randomized Clinical Trial

This study aimed to compare the effectiveness of extracorporeal shockwave therapy (ESWT) versus dextrose prolotherapy on pain and foot functions in patients with chronic plantar fasciitis with a prospective randomized-controlled trial. A total of 29 patients in whom conservative care failed were enrolled for the study after the clinical and ultrasonographic assessment. The patients were randomly assigned to receive ESWT (ESWT group, n = 15) or dextrose prolotherapy (dextrose prolotherapy group, n = 14). ESWT group received 1800 to 2000 focused shock waves (session of 0.20-0.30 mJ/mm² with a frequency of 4-6 Hz) followed by soft tissue 3000 to 3500 radial pulses (session of 1.8-3.0 bar with a frequency of 15-21 Hz). Dextrose prolotherapy group underwent an injection of 5 ml 15% dextrose solution with 2% lidocaine. ESWT and dextrose prolotherapy were repeated 3 times by 2 weeks apart. A 100-mm Visual Analog Scale (VAS) for overall and morning pain, Foot Function Index (FFI) and the Roles and Maudsley Scale score (RMS) were assessed at baseline, 6 weeks, and 12 weeks after the last intervention. Overall VAS, Morning VAS, RMS and FFI scores improved significantly in both treatment groups at 6 weeks and 12 weeks compared to baseline (p < .001). Comparison of changes in overall VAS, Morning VAS, RMS and FFI scores did not show a significant difference between the groups at each time point (p > .05) In our study dextrose prolotherapy and ESWT had similar effectiveness in patients with chronic plantar fasciitis who have not respond to conservative care. The results showed ESWT and dextrose prolotherapy were not superior to each other