Boswell et al • Interventional Pain Management Guidelines 1 Pain Physician Vol. 8, No. 1, 2005 Pain Physician. 2005;8:1-47, ISSN 1533-3159 Practice Guidelines Interventional Techniques in The Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines Mark V. Boswell, MD, PhD, Rinoo V. Shah, MD, Clifford R. Everett, MD, Nalini Sehgal, MD, Anne Marie Mckenzie- Brown, MD, Salahadin Abdi, MD, PhD, Richard C. Bowman, MD, PhD, Timothy R. Deer, MD, Sukdeb Datta, MD, James D. Colson, MD, William F. Spillane, MD, Howard S. Smith, MD, Linda F. Lucas, MD, Allen W. Burton, MD, Pradeep Chopra, MD, Peter S. Staats, MD, Ronald A. Wasserman, MD, and Laxmaiah Manchikanti, MD Background: The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients con- tinuing to have chronic pain five years or lon- ger after the initial episode. Spinal pain is as- sociated with significant economic, societal, and health impact. Available evidence docu- ments a wide degree of variance in the defi- nition and the practice of interventional pain management. Objective: To develop evidence-based clinical practice guidelines for intervention- al techniques in the management of chron- ic spinal pain, with utilization of all types of evidence, applying an evidence-based ap- proach, with broad representation of special- ists from academic and clinical practices. Design: A systematic review of diag- nostic and therapeutic interventions applied in managing chronic spinal pain by a poli- cy committee. Design consisted of formula- tion of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relation- ships between clinical interventions and out- comes. Methods: The elements of the guide- line preparation process included literature searches, literature synthesis, systematic re- view, consensus evaluation, open forum pre- sentation, formal endorsement by the Board of Directors of the American Society of Inter- ventional Pain Physicians (ASIPP), and blind- ed peer review. Methodologic quality evaluation crite- ria utilized included AHRQ criteria, 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 (in- determinate). Results: The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thorac- ic facet joint pain. The evidence was strong for lumbar discography, whereas, the evi- dence was limited for cervical and thoracic discography. The evidence was moderate for transfo- raminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imag- ing studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anes- thetics and steroids was moderate for short- term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural ste- roid injections was strong for short-term re- lief and moderate for long-term relief in man- aging chronic low back and radicular pain, and limited in managing pain of postlum- bar laminectomy syndrome. The evidence for interlaminar epidural steroid injections was strong for short-term relief and lim- ited for long-term relief in managing lum- bar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syn- drome and spinal stenosis. The evidence for percutaneous epidur- al adhesiolysis was strong. For spinal endo- scopic adhesiolysis, the evidence was strong for short-term relief and moderate for long- term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term re- lief and limited for long-term relief. The evi- dence for radiofrequency neurotomy for sac- roiliac joint pain was indeterminate. The evidence for intradiscal electrother- mal therapy was strong for short-term relief and moderate for long-term relief in manag- ing chronic discogenic low back pain, where- as, for nucleoplasty, the evidence was lim- ited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short- term relief and moderate for long-term relief. The evidence for implantable intrathecal in- fusion systems was moderate to strong. Conclusion: These guidelines included the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for man- aging spinal pain. However, these guidelines do not constitute inflexible treatment recom- mendations. These guidelines do not repre- sent a “standard of care.” Keywords: Interventional techniques, chronic spinal pain, diagnostic blocks, ther- apeutic interventions, facet joint interven- tions, epidural injections, epidural adhesioly- sis, discography, radiofrequency, spinal cord stimulation, intrathecal implantable systems From American Society Of Interventional Pain Physi- cians, Paducah, KY Address Correspondence: Mark V. Boswell, MD,PhD Chief, Pain Medicine Service, 2533 Lakeside, Uni- versity Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106 Disclaimer: Nothing of monetary value was received in the preparation of this manuscript. Conflict of Interest: None Funding: Internal funding was provided by American Society of Interventional Pain Physicians limited to travel and lodging expenses to the authors