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Spine Research Articles

I. Cervical Spine (Neck)

A. Cervical Spine Injections (Neck Injections)

1. Cervical Discograms (Disc Injection in the Neck for Diagnosis)

a. In 2005, researchers from multiple academic institutions published a review article in the Journal “Pain Physician”. Review articles are typically very useful for the practice of medicine since they review many of the published studies about a subject and try to come up with a summary of what the studies showed.

This study reviewed many published articles about the use of Discography as a test for spinal pain. In all, 9 studies of the use of Discography of the neck (cervical spine), 2 studies of the mid-back (thoracic spine), and 59 studies of the Low Back were chosen for review. Only the best designed studies were included in the review. The study used statistics to analyze the results of all these articles. The statistics then point to a certain “degree of evidence”, meaning how much proof were they able to show.

The evidence of the results has 5 categories:

- Conclusive evidence (proof)

- Strong evidence

- Moderate evidence

- Limited

- Indeterminate (not enough evidence)

The study had the following findings:

1. There is strong evidence that the X-Ray images from Discography are accurate for the diagnosis of a painful disc of the low back.

2. There is strong evidence that Discography can cause pain in a painful disc. This helps to verify that the back pain is coming from a disc in the low back.

3. There is strong evidence that Discography can help identify patients with low back pain coming from painful discs.

4. There is moderate evidence that Discography can identify patients with painful discs in the neck.

5. There is limited evidence that Discography can identify patients with painful disc in the mid-back.

In summary, Discography for discs in the low back seems to be a useful tool to diagnose a disc problem. There is less evidence that Discography is useful to diagnose disc problems in the neck and even less so for the mid-back.

b. In 2009, physicians from the Pain Center of Paducah, Kentucky published an article in the Journal “Pain Physician”.

This article reviewed previously published studies about using Discograms for discs in the neck to help doctors find the cause of chronic neck pain in certain patients. Only high quality scientific studies were included in the review. Statistics were used to analyze the data from each study. The data for all the studies was then combined to create an overall picture.

The results of the review article showed that Cervical Discograms may be a useful tool to diagnose chronic neck pain for patients who do not have a disc herniation or compression of the spinal nerves.

In summary, Discograms may help with the diagnosis of patients who have chronic neck pain. Apparently, Discograms can help isolate a degenerated disc in the neck which is responsible for chronic neck pain. Previously it was thought that the discogram could only help isolate disc herniations in the neck which were compressing spinal nerves causing mostly arm pain.

c. In 2000, researchers from the University of Connecticut published an article in the “Connecticut Journal of Medicine”.

The article was a study about the use of Discograms of the neck (cervical spine) to find out if a disc is responsible for a patient’s neck pain.

In this study Discography was performed on a total of 46 discs in 16 patients (each patient had multiple discs examined with Discography). On average, the patients had neck pain for 1 year before the Discography was performed. 14 of the 16 patients then went on to have a neck fusion (Anterior Cervical Discectomy and Fusion) at the same discs which were found to be painful with the Discography.

Right after surgery, all 14 patients either reported good or excellent pain relief. After a little over 6 months, 11 of the 14 patients (78.6%) still reported either good or excellent relief.

In summary, this study seems to show that Discograms can help find the painful discs in the neck which are causing chronic neck pain. The study was somewhat limited by the small number of patients (16) and the short time period over which they were followed (6 months).

2. Cervical Epidural Injections (Epidural Injections in the Neck)

a. In 2012, physicians from the “Spine and Pain Institute of New York” published an article in the Journal “Pain Physician”.

The article examined how effective Cervical Interlaminar Epidural Injections are to help patients with chronic neck and arm pain. The researchers examined published studies between 1966 and 2011. They found 34 studies and chose the 9 best designed studies. They examined the data of these 9 studies to draw conclusions about how effective the injections were.

Here are the conclusions:

1. The studies showed that there was good evidence that epidural injections which use a combination of steroid and local anesthetic medications work well for patients who have arm pain from nerve compression by a disc herniation.

2. There was less evidence that the epidural steroid injections worked well for neck pain from disc herniations, pain from spinal stenosis and pain from prior neck surgery.

In summary, this article found that Cervical Interlaminar Epidural Injections with steroids work best for nerve pain from disc herniations in the neck.

b. In 2012, researchers from the Department of Orthopaedic Surgery of the Kyung Hee University Hospital at Gangdong, South Korea published a study in the Journal “Spine”.

The study evaluated the benefit from Cervical Epidural Steroid Injections for patients with nerve pain from disc herniations in the neck.

The study included 98 patients, all of whom were candidates for Cervical Disc Surgery for Disc Herniation. All patients received Cervical Epidural Steroid Injections (average of 2 injections) and were then followed for over 2 years.

The results showed that 79 of the 98 patients (80.6%) did not have surgery due to the pain relief from the injections. The 19 patients (19.4%) who did have surgery, overall had more nerve pain from the beginning and a previous history of nerve pain.

In summary, this study seems to show that surgery for painful Disc Herniations in the neck can be potentially avoided in a large percentage of patients.

c. In 2008, the National Institute for Health Research conducted a review study to determine the effectiveness of Cervical Interlaminar Epidural Injections. They reviewed studies which were completed between 1966 and 2008. They selected the best studies, 3 “Randomized Clinical Trials” of 226 patients and 5 “Observational Studies” with 273 patients enrolled. A Randomized Clinical Trial is the best scientific study since patients are randomly assigned into different treatment groups. These types of studies are designed so that one type of treatment can be compared to others. An Observational Study is not quite as scientific, since the researchers just observe how patients do with a specific treatment.

All 3 Randomized Clinical Trials showed that patients received pain relief for at least the short-term (less than 6 months). 2 of the 3 studies also showed that patients received long-term pain relief (more than 6 months).

The 5 Observations Studies showed that patients with neck and arm pain received more relief than those who only had neck pain. 83% of the patients who received an epidural injection still had some pain relief after 3 months, while 41% still had excellent relief after 6 months.

Overall, this review study by the National Institute for Health Research seems to indicate that Cervical Epidural Steroid Injections are helpful for most patients in the short term, and at least some patients for the longer term. Patients who have neck and arm pain rather than just neck pain alone, seemed to get more relief from the injections.

3. Cervical Facet Injections (Injections of the Neck Joints)

a. In 2001, researchers from the Department of Rehabilitation Medicine at the University of Pennsylvania published a study in the American Journal of Physical Medicine and Rehabilitation.

The study followed patients with headaches after whiplash injuries of the neck. The goal of the study was to investigate how many of these patients had headaches due to an injury to the C2/3 Facet Joint in the neck.

18 patients were studied who had neck pain for an average of 34 months (almost 3 years) after a whiplash injury. All patients failed to improve after 3 months of Physical Therapy, medications and activity restrictions.

All patients had some immediate benefit from a C2/3 Facet Joint Injection. Approximately 1.5 years later, 61% of patients had fewer than 3 headaches a week which were controlled with medication.

In summary the study showed Facet Joint Injections of the C2/3 Facet Joints can be helpful for patients with chronic headaches due to whiplash injuries.

b. In 2002, a study was published in the Journal “Pain Physician” by physicians from the Pain Management Center of Paducah in Kentucky.

The goal of the study was to find out how often the facet joints in the neck are the culprit of chronic neck pain.

The study followed 106 patients who had neck pain from either a type of trauma (48%) or no specific injuries (52%).

The patients were initially given a Facet Joint Injection with a short-lasting Local Anesthetic (Lidocaine), and then another injection 2-4 weeks later with a longer-lasting Local Anesthetic (Bupivacaine). The reason for the second injection was to confirm the results of the first injection with a different medication to verify that the results were accurate.

81 patients (70%) received relief of their neck pain with the Lidocaine injection. 64 of these 81 patients (79%) had relief when they were given the second injection with Bupivacaine. Overall then, of the initial 106 patients who were studied, 64 patients (60%) appeared to have pain stemming from the Facet Joints.

In summary, this study showed that 60% of patients with chronic neck pain from either an injury or degeneration may have pain coming from the Facet Joints in the neck.

B. Cervical Spine Surgeries

1. Cervical Fusion Surgery (Fusion of the Neck Vertebrae)

a. In August of 2009, researchers from the University of Alabama published a review article in the Journal Neurosurgery Spine.

This article systematically reviewed published studies about surgeries for compressed spinal nerves in the neck (cervical radiculopathy). One specific surgery that was studied was the Anterior Cervical Decompression and Fusion (ACDF). This is the standard surgery done for severe radiculopathies.

The findings of the review article showed that ACDF surgery provided faster relief than Physical Therapy or Neck Braces. The relief with surgery is usually present within 3-4 months.

b. In February of 2012 researchers from the Washington University in St. Louis published an article in the Journal “Evidence Based Spine Care”.

It is known that Anterior Cervical Discectomy and Fusion (ACDF) surgeries stress the discs next to the fusion which causes degeneration over time. One of the hopes for the C-ADR devices is that they would not stress the discs next to them and avoid degeneration. This article examined whether Cervical Artificial Disc Replacements (C-ADR) protect the discs next to them from degeneration.

The article primarily examined the results from published Clinical Trails which had at least a 4-5 year follow-up, however also included data from studies with at least a 2 year follow-up. Three FDA clinical trials were analyzed. They included results from 3 different types of C-ADRs: the “Bryan Disc”, the “Prodisc-C”, and the “Prestige ST” disc.

The results of the review article showed that so far there is no evidence that C-ADR devices lower the risk of developing degeneration at the discs next to as compared to the

2. Cervical Artificial Disc Replacements (Artificial Disc Replacement of a Disc in the Neck)

a. In March of 2012, researchers from the Spine Institute of Louisiana published an article in the Journal “Spine”.

The topic of the article was “Adjacent Segment Disease”. “Adjacent Segment Disease happens when a disc next to the one receiving surgery begins to degenerate. This phenomenon is known to happen to discs next to a Fusion. One of the hypotheses of Cervical Artificial Disc Replacements is that the discs next to them would not degenerate as rapidly as it would next to a Fusion. The hope is that the movement created by the Cervical Artificial Disc Replacements would be more natural, possibly preventing stress on the discs next to them.

The article reviewed the data from 3 Clinical Trial studies about Cervical Artificial Disc Replacements. 170 patients participated in these studies. 113 patients received the Artificial Disc Replacements and 67 patients received an Anterior Cervical Discectomy and Fusion.

The study found that at an average of 38 months, patients in the Artificial Disc Replacement group and those in the Fusion group had similar rates of Adjacent Segment Disease. At 3 years after surgery, the Artificial Disc Replacements do not seem to protect the discs next to them from degeneration. However, more time and more studies are needed to get a more complete picture.

b. In September of 2011, researchers from the Indiana Spine Group published an article in the Journal of Bone and Joint Surgery of America.

This article compared the outcomes from Cervical Artificial Disc Replacements with those of Anterior Cervical Discectomy and Fusions at 4 years after surgery. The specific Artificial Disc studied was the “Bryan Disc” type.

242 patients received the Artificial Disc, whereas 221 patients received the Fusion Surgery. The patients in both groups were closely studied over the course of 4 years.

The results of the study showed that patients who had received the Bryan Artificial Disc Replacement had better outcomes from Surgery that did those who received the Fusion Surgery. However, more studies over the long term are needed to verify this early result.

c. In February of 2012, researchers from the University of California in San Francisco published a review article in the Journal “Evidence Based Spine Care”.

This article reviewed the results of two FDA Clinical Trials which compared Cervical Artificial Disc Replacement (C-ADR) surgery with Anterior Cervical Discectomy and Fusion surgery (ACDF). The results at 4-5 years following surgery were analyzed. One study used the “Bryan Disc” type of C-ADR, while the other used the “Prestige” type of C-ADR.

Here are the results:

1. The patients in the C-ADR group reported less neck disability, more pain relief in the neck and arm, and better function.

2. The rate of degeneration at the discs next to the surgery was less for the C-ADR patients than for the ACDF patients after 5 years.

3. The C-ADR devices provided normal motion.

4. The C-ADR patients had fewer complications which required further surgery.

More studies over longer periods of time are needed to verify these findings.

d. In 2012, researchers from the Cochran Collaboration conducted a study which compared Cervical Fusion surgery to Cervical Artificial Disc Replacements.

The Cochrane Collaboration is a highly respected organization which publishes evidence based medicine articles.

This review article examined all published studies which compared Cervical Artificial Disc Replacements (C-ADR) to Cervical Fusions for one single degenerated Disc in the neck.

The researchers from the Cochran Back Group reviewed studies published until May of 2011. The studies had to have at least 1 year of follow-up after the surgery. Only the most scientific studies were included. In all, 9 studies met these criteria. They included 2,400 patients.

The researchers made the following conclusions:

1. The patients who received the Cervical Artificial Disc Replacement as opposed to a Fusion seemed to be doing slightly better at the 1-2 year mark after surgery.

2. The Cervical Artificial Disc Replacement surgery and the Fusion Surgery both seem to be good surgical options to treat one single degenerated disc in the neck.

3. The Cervical Artificial Disc Replacements do provide motion at the segment where the Disc was replaced.

4. There was no evidence yet after 1-2 year of surgery that the Cervical Artificial Disc Replacement devices protect the other Discs next to them from degenerating.

e. In January of 2013, researchers from the Mount Sinai School of Medicine in New York published an article in the “Journal of the American Academy of Orthopaedic Surgery”.

The article summarized the development of “Adjacent Segment Disease” after Cervical Spine Surgery. “Adjacent Segment Disease” is the development of degeneration of the discs next to a segment of the spine which underwent surgery. This phenomenon is known to occur after Anterior Cervical Discectomy and Fusion (ACDF) surgeries. Approximately 3% of these patients per year will have Adjacent Segment Disease. 10 years after the ACDF surgery, 25% of the patients will have Adjacent Segment Disease.

The authors concluded that to date, the published studies have failed to show that Adjacent Segment Disease will be prevented by the Artificial Disc Replacements as opposed to the fusions.

3. Surgery for Cervical Spondylotic Myelopathy (Surgery for Severe Neck Degeneration with a Compressed Spinal Cord)

a. In March of 2010, researchers from Orthopaedics International in Seattle published a review article in the Journal “Spine”.

This review article analyzed published studies about the different types of surgeries used for the treatment of Cervical Spondylotic Myelopathy (spinal cord compression in the neck from severe degeneration).

The specific types of surgeries studied were as follows:

1. Corpectomy: Removal of a part of the body of the Vertebrae to free up the Spinal Cord

2. Anterior Cervical Decompression and Fusion (ACDF): Removal of the Disc followed by Fusion of the front of the Vertebrae

3. Laminoplasty: Removal of a portion of the Lamina bone on the back of the Spine followed by replacing the removed section with a small metal plate.

4. Laminectomy and Fusion: Removal of the entire Lamina bone on the back of the Spine followed by a Fusion of the back of the Spine.

The researchers found initially 1,735 articles and chose the 11 best studies for the review.

The results of the review article were as follows:

1. The four different types of surgeries all had similar benefits for the recovery of the spinal cord.

2. The Laminoplasty surgery when compared to Corpectomy surgery caused more neck pain following surgery.

3. The ACDF surgery caused more degeneration at discs next to the fusion than did the Laminoplasty surgery.

4. The Corpectomy surgery and the Laminectomy surgery have more complications when they are done at more than one segment in the spine when compared to the ACDF and Laminotomy surgeries.

5. The Corpectomy and Laminectomy with Fusion surgeries cause more loss of mobility in the neck when done at more than one segment in the spine when compared to the Laminoplasty surgery.

In summary, all surgeries had a similar benefit for the recovery of the spinal cord, but each has its own drawbacks.

b. In May of 2012, researchers from AOSpine North America published the results of a study in the “Journal of Neurosurgery Spine”.

This study examined the complications from Surgery for the condition “Cervical Spondylotic Myelopathy”. This is a condition where the spinal cord in the neck is compressed due to severe degeneration. Due to the compression of the spinal cord, this condition often requires surgery.

302 patients participated in this study. They were closely followed over the course of 2 years to look for any complications related to the surgery.

Here are some of the results:

1. 47 of the 302 patients (15.5%) had a complication.

2. Most complications were minor.

3. The most common complications were minor heart and lung issues (3%), trouble swallowing (3%), and wound infections (2.3%).

4. Surgery performed from the back of the neck had a higher rate of wound infections.

5. Trouble swallowing (dysphagia) was more common if the surgery was done in combination from the front and the back of the neck.

6. More complications occurred in older patients and those who had combination surgery from the front and the back of the neck.

7. More complications also occurred in patients who had longer surgeries and more blood loss.

In summary, most complications of Cervical Spondylotic Myelopathy were minor and treatable. Certain risk factors for complications were identified.

4. Cervical Endoscopic Spine Surgery (Endoscopic Spine Surgery of the Neck)

a. In December of 2009, researchers from the University of Witten/Herdecke in Germany published an article in the Journal “International Orthopaedics”.

The researchers had compared the results of two different surgeries for disc herniations in the neck. Anterior Cervical Decompression and Fusion (ACDF) surgeries were compared to Full Endoscopic Cervical Discectomy (FACD) surgeries. The ACDF surgery is an open surgery with a larger incision which results in a fusion. This is the standard surgery done for disc herniations in the neck. The FACD surgery is done with a small incision through an endoscope and does not result in a fusion. It is a Minimally Invasive type of surgery. The specific disc herniations which were treated with the two surgeries were more recent herniations of softer disc material and those which herniated mostly backwards rather than further off to the side of the disc.

The study included 103 patients for up to 2 years after surgery (either ACDF or FACD).

Here are the results:

1. Nerve pain in the arm was eliminated in 85.9% of all patients, regardless of which surgery they had. 10.1% of patients had occasional pain.

2. Overall, both groups of patients seemed to be doing equally well with their surgery.

In summary, the researchers concluded that the Minimally Invasive Endoscopic Surgery (FACD) was a sufficient and safe alternative the Fusion Surgery (ACDF).

However, larger Clinical Trials and longer term studies are needed to verify this finding.

b. In October 2011, researchers from the Chang Gung Memorial Hospital in Taiwan published a study in the “Journal of Spinal Disorders Techniques”.

The researchers studied a specific surgery for disc herniations in the neck, called “Anterior Percutaneous Endoscopic Cervical Discectomy” (APECD). This is a minimally invasive surgery done with an endoscope.

107 patients were enrolled in the study who then underwent the APECD surgery. Most of the patients (80%) were followed for 1 year after surgery.

Here are the results:

1. 91% of patients reported either an excellent or good outcome.

2. 2 patients had complications, one major and one minor.

In summary, the authors concluded that the Minimally Invasive Endoscopic Disc Surgery (APECD) for Disc Herniations seems to be safe and effective in selected patients.

5. Cervical Laminectomy (Removal of the Lamina Bone in the Neck)

In August of 2009, researchers from the University of Iowa published a review article in the Journal Neurosurgery Spine.

This article evaluated the usefulness of a Cervical Laminectomy (removal of the Lamina bone on the back of the spine to make more room for the spinal cord) for Cervical Degenerative Myelopathy (spinal cord compression due to degeneration in the neck). The article reviewed published studies and then analyzed the results of these studies.

The conclusion from the study was that the Laminectomy surgery is an acceptable treatment for Spinal Cord Compression from degeneration in the neck. However, patients are at risk to develop a forward-bend (kyphosis) in the neck over time following this surgery. This forward-bend does not necessarily mean that patient would develop pain or require more surgery.

 

II.  Thoracic Spine (Mid-Back)

A. Thoracic Facet Joint Injections (Injections of the Mid-Back Joints)

In 2002, doctors from the Pain Management Center of Paducah, Kentucky pulished a study in the Journal “Pain Physician”.

The goal of the study was to find out how many patients with chronic pain in the mid-back (thoracic spine) had pain from the Facet Joints.

The study followed 46 patients with thoracic spine pain who had failed to get pain relief from Physical Therapy, Chiropractic Care and medications.

These patients initially received a Thoracic Facet Joint Injection with a short-lasting Local Anesthetic (Lidocaine) and then one with a long-acting Local Anesthetic (Bupivacaine). The short-acting Local Anesthetic was used to see if the Facet Joint appeared to be the source of the patient’s pain. The long-acting Local Anesthetic was the injected to confirm this.

36 of the 46 patients (78%) had pain relief from the short-acting Local Anesthetic (Lidocaine). 22 0f these 36 patients (61%) had relief with the long-lasting Local Anesthetic (Bupivacaine). Overall then, 22 of the original 36 patients (48%) of the patients with chronic thoracic spine seemed to have pain from the Thoracic Facet Joints.

In summary, this study showed that almost half of patients with chronic mid-back (thoracic spine) pain had relief with Thoracic Facet Joint injections.

III. Lumbar Spine (Low-Back)

A. Lumbar Injections (Low-Back Injections)

1. Lumbar Epidural Injections (Epidural Injections of the Low-Back)

a. In 2011, researchers from the Department of Physical Medicine and Rehabilitation at the University of Texas and Baylor College of Medicine published a review article in the Journal Back Musculoskeletal Rehabilitation.

The article reviewed published studies about the effectiveness of Lumbar Transforaminal Epidural Steroid Injections to control sciatica.

The researchers analyzed a total of 17 studies to see how effective the injections were for the short and longer term.

The results showed that there was strong evidence from the published studies that Lumbar Transforaminal Epidural Injections were effective in relieving pain from sciatica.

b. In 2006, researchers from the Emory University in Atlanta published a study in the Journal “Pain Physician”. The study compared Interlaminar Epidural Steroid Injections to Transforaminal Epidural Steroid Injections for patients with sciatica from lumbar disc herniations. This study reviewed patient records from treatments they had received at the Emory University.

A total of 40 patients were reviewed, 20 in the Interlaminar injection group and 20 in the Transforaminal injection group. The patient charts were then examined to see how the patient were doing for one year following the injection.

A success of the injection was determined when patients had a pain improvement of 2 or more points on a scale of 0-10. For instance, a patient with a pain score of 6 out of 10, reported a new pain score of 4 out of 10.

14 of the 20 patients (70%) in the Transforaminal Injection group were found to have successful injections. 9 of the 20 patients (45%) in the Interlaminar Injection group were found to have successful injections. The average improvement in the Pain Scores was 46% in the Transforaminal Injection group versus 19% in the Interlaminar injection group. This means that for the average patient who received a Transforaminal Injection, the pain scores dropped, for example, from 8 out of 10 to 4 out of 10. In the Interlaminar injection group the pain scores dropped, for example, from an average of 8 out of 10 to 6 out of 10.

Another observation was made about the number of patients who required surgery despite the injections. In the Trsansforaminal Injection group, 2 of 20 patients (10%) eventually had surgery. In the Interlaminar Injection group, 5 of 20 patients (25%) eventually had surgery.

In summary, this study seems to show that Transforaminal Epidural Steroid Injections for sciatica from disc herniations are more successful than Interlaminar Epidural Steroid Injections. Also, it appears that fewer of the patients who received a Transforaminal Epidural Steroid Injection went on to have spine surgery.

c. In 2002, researchers from the Florida Spine Institute published a study in the American Journal of Physical Medicine and Rehabilitation. The goal of the study was to identify how much relief patients with leg pain (one leg) from spinal stenosis received when they were given an X-Ray guided Lumbar Transforaminal Epidural Steroid Injections.

A total of 34 patients were studied for 1 year. A successful outcome was defined as more than 50% improvement in pain. 75% of the patients studied had a successful outcome at 1 year. On average these patients received 1.9 injections during that time. 64% of patients reported being able to walk better and 57% of patients were able to stand for longer periods of time.

In summary, this study seems to show that Transforaminal Epidural Steroid Injections are helpful for Lumbar Spinal Stenosis.

d. In 2000, researchers from the University of Washington published an article in the Journal of Bone and Joint Surgery. The researches tried to find out if Nerve Root Blocks (injections around an inflamed spinal nerve) could keep patients from having spine surgery.

55 patients with sciatica were studied. All of them had compressed spinal nerves and were candidates for spine surgery to relieve the compression.

Half the patients (28) received a Nerve Root Block with a combination of a Steroid and a Local Anesthetic, while the other half (27) received a Nerve Root Block with only a Local Anesthetic.

20 of the 28 patients (71%) who received the Nerve Root Block with the Steroid and the Local Anesthetic combination decided not to have surgery. 9 of the 27 patients (33%) who had the Nerve Root Block with the Local Anesthetic only, decided not to have surgery.

In summary, the study seems to show that adding a steroid to the Nerve Root Block makes the injection more effective. Also it appears that patients with sciatica should first undergo a Nerve Root Block with steroids before deciding on surgery, since a significant number of them (71%) may not need to have surgery.

e. In 2002, a study by researchers from the Hospital for Special Surgery in New York City was published in “Spine”, which is one of the leading Spine Journals in the world.

This study compared the usefulness of a Transforaminal Epidural Steroid Injection to that of a Trigger Point Injection (muscle injection with a Saline Solution) for patient suffering from sciatica from a disc herniation. The Trigger Point Injection was basically a Placebo. Having a Placebo Procedure can help study how effective a procedure is since it can be compared to another procedure.

48 patients were studied over an average of 16 months. The patients were initially given the choice of having either a Transforaminal Epidural Steroid Injection or a Trigger Point Injection done. Each patient received only one injection.

Success from the injection was measure by satisfaction with the procedure and how much pain relief they experienced. For a success, the patient satisfaction had to be either “good” or “very good”. The pain relief had to be at least 50%.

After an average of 16 months, 84% of the patients who had received a Transforaminal Epidural Steroid reported success. 48% of the patients who had received a Trigger Point Injection reported success.

In summary, this study shows that Transforaminal Epidural Steroid Injections are more helpful as a treatment for sciatica due to disc herniations than a Trigger Point Muscle Injection.

2. Lumbar Facet Joint Injections (Injections into the Joints of the Low-Back)

a. In 2004, researchers from the Department of Orthopaedic Surgery at the University of Texas Southwestern Medical Center published an study in the Journal “Spine”.

The study was a Clinical Trial to find out about treatments for a part of the low back which is painful and lacks motion (segmental rigidity). The lack of motion was determined by X-Rays. The study was trying to find out if Facet Joint Injections in combination with exercise was a better treatment than just exercise by itself.

70 patients were studied who were randomly given either a Facet Joint Injection and exercises (36 patients) or just exercise by itself (34 patients).

Physical Therapists saw the patients an average of twice a week to help them with a home exercise program.

The study showed that the patients who were treated with the Facet Joint Injection plus the exercises had more range of motion and a better quality of range of motion than those who had exercise alone as a treatment. Both groups of patients had a similar improvement in pain.

In summary, this study showed that patients who have back pain and lack motion in the low back do better when they have a combination of Facet Joint Injections plus back exercises than just back exercises.

b. In 2006 a study by the Center for Spinal Surgery at the University of Zurich in Switzerland was published in the American Journal of Roentgenology.

42 patients were studied who had an MRI or CT scan of the low back showing signs of Facet Joint Degeneration. All the patients received a Facet Joint Injection done with an X-Ray machine (Fluoroscope). A combination of Local Anesthetic and Steroid was injected.

The patients were asked how much pain relief they had immediately after the injection, at 1 week and 3 months.

31 patients (74%) had some immediate relief after the injection. 14 patients (33%) still had relief at 3 months.

In summary, it appears from this study that Facet Joint Injections in the Low Back can be useful for perhaps a third of patients with back pain from degenerated facet joints. Another observation from the study was that the degree of facet joint degeneration seen on an MRI or CT scan did not seem to have a relationship to who had relief from the injection. In other words, even if the MRI or CT scan showed very advanced degeneration, some patients can still have significant relief of pain from an injection.

c. In 2008, researchers from the Smartklinken (Pain Clinic) in Umea, Sweden published an article in the Journal “Spine”.

The goal of the study was to evaluate the usefulness of Lumbar Facet Joint Nerve Radiofrequency Disruption (Rhizotomy) as a treatment for chronic low back pain.

The study included 40 patients who had pain from the Lumbar Facet Joints proven by 3 separate Facet Joint Injections which showed significant improvement in the low back pain. 20 patients received the Radiofrequency procedure and 20 patients received a sham procedure. All patients were evaluate before the procedure and 6 months after the procedure.

The results showed that the patients who received the Radiofrequency procedure received significant improvements in back pain and leg pain, as well as improved mobility of the low back and hip. The improvement in this group was significantly greater than the placebo group.

In summary, this study showed that Radiofrequency Nerve Disruption (Rhizotomy) procedures for low back pain are more useful than placebo.

d. In 2005, researchers from the Department of Anesthesia at the Royal Adelaide Hospital and Queen Elizabeth Hospital in Adelaide Australia published an article in the Clinical Journal of Pain.

The goal of the study was to evaluate the usefulness of Radiofrequency Disruptions (Rhizotomies) of the Lumbar Facet Joint Nerves for chronic back pain.

The study was designed to randomly assign patients into a group which received the actual Radiofrequency Disruptions procedure and another group which received a sham procedure (placebo procedure). 40 patients received the actual procedure and 41 patients received the placebo procedure.

The results showed that both groups showed equal improvements.

In summary this study showed that low back pain in patients who received the Radiofrequency procedure and the Placebo procedure both improved. The researchers speculated that patients who are carefully selected may respond better to the Radiofrequency procedure than to a Placebo.

 

B. Lumbar Spine Surgery (Surgery of the Low-Back)

1. Lumbar Disc Surgery (Surgery of the Disc in the Low-Back)

a. In 2008, researchers from the Cochrane Collaboration published a review of published studies about Surgery for slipped Lumbar Discs.

Different surgical techniques were compared: Open Discectomy, Microdiscectomy, and other Minimally Invasive types of Discectomy. An “Open Discectomy” makes a larger incision in the spine to be able to remove a disc herniation. A “Microdiscectomy” is a Minimally Invasive surgery which uses a small incision and small instruments to remove a disc herniation. Often a Microscope is used to see the disc herniation. Other Minimally Invasive Discectomies include Percutaneous Discectomies which are done with needles and small instruments through the skin.

This review study only looked at the most scientific studies, called “clinical trials” which were published until 2007. They reviewed the data from 42 clinical trials with a total of 5,197 patients.

The results of the review showed that:

1. Surgery for Sciatica from Lumbar Disc Herniations in carefully selected patients provides faster relief than conservative care (Physical Therapy, Injections, Medications, etc.). However it is unclear if surgery or conservative care are better for the disc disease in the long term.

2. The results from a Microdiscectomy and Open Discectomy for Lumbar (low-back) discs are approximately the same.

b. In 2008, researchers from the Division of Neurosurgery at the Albany Medical Center in New York published a study in the Journal “Neurosurgical Focus”.

This study compared the results of different types of surgeries for Lumbar (low-back) Disc Herniations. Specifically, they compared Microdiscectomies to other Minimally Invasive Discectomies.

The Microdiscectomy uses a small incision and removes the muscle attachments of the spine to see the disc herniation. The surgical retractors are open the spine wider than in a Minimally Invasive Discectomy.

The Minimally Invasive Discectomy uses a small incision but then splits the muscle fibers rather than removing the muscle attachments to the spine. The surgical retractors are small tubes through which the surgery is performed.

This study reviewed the results from 172 patients who underwent either surgical technique. None of the patients had previous spine surgery.

c. In 2008, researchers from the Department of Orthopaedics at the Dartmouth Medical School in New Hampshire published a study in the Journal “Spine”.

This study was one part of a very large study, called “Sport”. “SPORT” stands for “Spine Patient Outcomes Research Trial”. This part of the “Sport” study evaluated Lumbar (low-back) Disc Herniations. Specifically, patients who received surgery as a treatment were compared to those who did not. The specific surgery was an Open Discectomy, which is a standard treatment for disc herniations. More minimally invasive surgeries such as Microdiscectomies were not included.

A total of 1,244 patients were studied at 13 different spine centers. The patients were evaluated for 4 years after they were enrolled into the study to see what the differences were between those who had received surgery and those who did not. They were primarily evaluated for bodily pain, physical function, and disability.

The results showed that the patients who received surgery had less pain, functioned better physically, and were less disabled than patients who did not receive surgery.

In summary, the data from the SPORT trial seems to indicate that patients with lumbar disc herniations who have a Discectomy surgery do better after 4 years than those who do not have surgery.

2. Minimally Invasive Lumbar Surgery (Minimally Invasive Surgery of the Low-Back)

a. In 2007, researchers from the Universite Francois-Rabelais de Tours in France published a review study in the Journal “Seminars in Arthritis and Rheumatism”.

The review study examined published studies about the use of Percutaneous (through the skine) Laser Disc Decompressions for Lumbar (low-back) disc herniations. They looked at studies published between 1980 and 2006.

The results of the review study showed that Percutaneous Laser Disc Decompressions for Disc Herniations of the low-back lack scientific proof.

b. In 2009, physicians from the Pain Management Center of Paducah, Kentucky published a review study in the Journal “Pain Physician”.

This review study examined the usefulness of Nucleoplasty Disc Decompressions for Lumbar (low-back) Disc Herniations. The physicians reviewed studies which were published until 2008. The main goal of the review was to find out if patients received pain relief of sciatica pain from the disc herniation.

The result of the review study showed that there is some evidence that Nucleoplasty Disc Decompressions can produce relief of sciatic pain from disc herniations, however this evidence is not very scientific. Better studies such as Clinical Trials are needed.

c. In 2009, researchers from the Massachusetts General Hospital and Harvard Medical School published a review study in the Journal “Pain Physician”.

This study examined the effectiveness of “Automated Percutaneous Lumbar Discectomies” (Nucleotome type devices) for Lumbar Disc Herniations which had not broken through the outer ring (annulus) of the Disc.

The researchers examined the results for studies which were published in the English language. The primary focus of the results were pain relief.

The results of this review study showed that there was a moderate degree of evidence that Automated Percutaneous Lumbar Discectomies provided pain relief for Disc Herniations of the low-back which had not broken through the outer ring (annulus) of the disc. More clinical trials are needed to examine this type of Disc Procedure further.

3. Lumbar Spinal Stenosis Surgery (Surgery of a Narrowed Spinal Canal in the Low-Back)

In June of 2010, researchers from the Department of Orthopaedics at the Dartmouth Medical School in New Hampshire published a study in the Journal “Spine”.

This study was part of a larger study called “SPORT”, which stands for “Spine Patient Outcomes Research Trial”. “SPORT” is a larger long-term study which evaluates the outcomes of Spinal Surgery. This specific part of the study looked at patients with Lumbar Spinal Stenosis (narrowing of the nerve canal in the low-back). Patients who received surgery were compared with those who did not. The specific surgery studied was a Laminectomy (removal of the Lamina bone to free up the trapped spinal nerves).

A total of 654 patients were part of the study. They were evaluated over the course of 4 years at 13 different Spine Clinics. The patients were primarily evaluated for bodily pain, physical function, and disability.

The results showed that the patients who received surgery had less pain, functioned better physically, and were less disabled than patients who did not receive surgery.

In summary, the SPORT study seems to show that patients with Lumbar Spinal Stenosis have better outcomes 4 years after Surgery (Laminectomy) than those who did not have surgery.

IV. Sacral Spine (Tailbone)

A. Sacroiliac Joint Procedures (Tail-Bone Joint Procedures)

a. In 2008, physicians from the “Pioneer Spine and Sports Physicians” practice in Springfield, MA published an study in the “Archives of Physical Medicine and Rehabilitation”.

The study evaluated different techniques of steroid injections for Sacroiliac Joint pain. The standard technique injected the medication directly into the joint, the modified technique injected some medication into the joint and some around the joint.

The study followed 120 patients. All patients had prior Physical Therapy with no relief of pain. After receiving either the standard injection or the modified injection, patients were evaluated at 1 hour after the injection, 3 weeks and 3 months for pain relief and improved function. A positive response to the injection was determined to be at least a 50% drop in pain scores (i.e. from 6/10 to 3/10 or better).

The results showed that at 3 months only 12.50% of the patients who received the standard injection had a positive response, whereas 31.25% of the modified injection patients had a positive response.

In summary, this study showed that injecting medication into and around the Sacroiliac Joint to relieve chronic pain is better than just injecting into the joint alone.

b. In 2003, researchers from the Interventional Pain Associates of Bellingham, Washington published a study in the Journal “Spine”.

The goal of the study was to evaluate the usefulness of Radiofrequency Nerve Disruptions (Rhizotomies) of the nerves traveling to the Sacroiliac Joints, using a new technique.

The new technique was based on the study of human cadavers where the specific nerves traveling to the Sacroiliac Joints were analyzed. Based on this analysis, the researchers developed a new technique of where in the spine to disrupt the nerves.

14 patients who underwent the new technique of Radiofrequency Disruption of the Sacroiliac Joint nerves were studied for 6 months after the procedure was performed. The procedure was deemed a success if more than 60% of the pain was relieved consistently.

9 of the 14 patients (64%) experienced a successful outcome from the procedure. 5 of the 14 patients (36%) had complete relief of their pain.

In summary, this study introduced a new technique of how to perform Radiofrequency Disruptions of the Sacroiliac Joints which appears to be useful in providing long lasting relief in some patients. The study did not compare their technique to others.

c. In 2007 researchers from several different academic institutions published an article in the Journal “Pain Physician”. This article was a review of all published studies on treatments for Sacroiliac Joint Pain between 1966 and 2006.

The studies were then analyzed for their data. The data from all these studies were then combined to create an overall picture of how useful certain interventions are.

The evidence of the results has 5 categories:

- Conclusive evidence (proof)

- Strong evidence

- Moderate evidence

- Limited

- Indeterminate (not enough evidence)

Here are the conclusions from this extensive review:

1. There is moderate evidence that injections of the Sacroiliac Joints using Local Anesthetic. This injection is typically done to anesthetize the joints to see if they are responsible for the patient’s pain.

2. There is limited evidence that injections with Steroids are useful.

3. There is limited evidence that Radiofrequency Disruptions (Rhizotomies) are useful.

In summary, this review article showed that anesthetizing Sacroiliac Joints to make a diagnosis is moderately useful, while Steroid Injections and Radiofrequency Rhizotomies have limited evidence of usefulness.

d. In 2002, researchers from the Department of Radiology at the University of Witten/Herdecke in Bochum, Germany published an article in the European Journal of Radiology.

The study evaluated how useful Radiofrequency Disruptions (Rhizotomies) of the Sacroiliac Joints were when done with the help of a Cat Scan Machine.

38 patients were chosen, who had temporary relief of their Sacroiliac Joint pain from steroid and local anesthetic injections. All 38 patients then had a CT-guided Radiofrequency Disruption of the Sacroiliac Joints.

3 months later the patients were reevaluated:

13 of the 38 patients (34%) had complete relief of pain.

12 of the 38 patients (32%) reported substantial relief.

7 of the 38 patients (18%) had only slight relief.

3 of the 38 patients (8%) had no relief.

3 patients had no data.

In summary, using a Cat Scan machine to perform Radiofrequency Disruptions of Sacroiliac Joints appears to be a useful technique for some patients. The data was not compared to other techniques which use X-Rays to guide the procedure (fluoroscopic) and have less radiation.

V. Implanted Pain Relief Devices

1. Spinal Cord Stimulation (Electrical Stimulation of the Spinal Cord for Pain Relief)

a. In 2011, researchers from the University of Maastricht in the Netherlands published an article in the European Journal of Pain.

The article reviewed studies which were done to see if Spinal Cord Stimulation was an effective and safe treatment for nerve pain from Diabetes. They reviewed studies which were published between 1980 and 2010. Only the most scientific studies were used for the review. They found 4 studies that met these criteria. The data from the studies was then analyzed to draw conclusions.

The results from this review article showed that after 1 year of Spinal Cord Stimulation for nerve pain from Diabetes, 63% of the patients had more than 50% relief of pain. At the same time 60% of patients were able to stop using pain medication for the nerve pain. There were no major complications from the implantation of the Spinal Cord Stimulation systems.

In summary, this study showed that Spinal Cord Stimulation for diabetic nerve pain can be helpful. The researchers recommended that more detailed scientific studies should be conducted to provide further proof about the effectiveness of Spinal Cord Stimulation for diabetic nerve pain.

b. In 2004, researchers from the University of Texas Southwestern Medical School in Dallas published an article in the Journal of Neurosurgery.

This article reviewed studies which were published about the safety and effectiveness of Spinal Cord Stimulation for chronic pain. The authors reviewed all studies that were published over a 20 year period. Only the most scientific studies were included. They found 68 studies which totaled 3679 patients.

The results showed that Spinal Cord Stimulation was effective for the long term treatment of pain from angina, leg pain due to insufficient blood flow, nerve pain, and chronic low back pain.

In summary, this review article found that published studies found Spinal Cord Stimulation to be effective for a number of chronic pain conditions, including low back pain.

c. In 2009, researchers from the Advanced Pain Management and Spine Specialists practice in Fort Myers, Florida published a review article in the Journal Pain Physician.

This article reviewed studies on the use of Spinal Cord Stimulation for patients with chronic low back pain from Failed Back Surgery. Studies published in English between 1966 and 2008 were examined. The researchers looked at the following data:

- pain relief

- improved function

- improved psychological health

- how many patients returned to work

- if the treatment resulted in less pain medication use

The results of the review of the studies showed that there was good evidence that Spinal Cord Stimulation was effective as a long-term treatment for patients with chronic low back pain from Failed Back Syndrome.

2. Intrathecal Pain Pumps (Implanted Pain Pumps)

a. In 2001, researchers from the Section of Neurosurgery of the University of Saskatchewan published a study in the Journal “Surgical Neurology”.

The goal of the study was to evaluate the usefulness of Morphine Pain Pumps for chronic pain not related to cancer.

25 patients with severe chronic non-cancer pain were given an injection of Morphine into the spinal fluid. 16 of the 25 patients had more than 50% relief after the injection. These 16 patients then had a Morphine Pain Pump implanted. The patients were then followed for an average of over 2 years (29 months) to see how they did over the long term.

After 6 months, the average patient had a 67% relief of pain. After an average of 29 months, the average patient reported a 57% relief of pain.

In the end, 12 patients (75%) were considered a success and 4 patients 925%) a failure. Of the 4 patients who failed the treatment, 2 patients did not get satisfactory pain relief, and 2 patients had to have the pumps removed due to side effects.

In summary, this study showed that Morphine Pain Pumps can be effective for patients with chronic non-cancer pain if the patients are carefully screened and selected.

b. In 2009, physicians from ACMI Pain Care published an article in the Journal “Pain Physician”.

This article reviewed published studies about the use of Intrathecal Pain Pumps for the relief of chronic pain not related to cancer.

The physicians reviewed the published studies on this subject from 1966 to 2008. The quality of each study was analyzed and the most scientific studies were given the most weight.

The studies were analyzed with regard to how much pain relief patients received, how well they functioned, their psychological health, whether they were able to return to work, and if they were able to take less pain medication by mouth.

The results of the study showed that there was limited evidence from published studies that Intrathecal Pain Pumps were effective for the control of non-cancer pain.