11. Stiles EG. Osteopathic manipulation in a hos-
pital environment. J Am Osteopath Assoc.
12. Wallace E, McPartland JM, Jones JM III, Kuchera
WA, Buser BR. In: Ward RC, ed. Foundations for Advanced concepts in
Osteopathic Medicine. Philadelphia, Pa: Williams &
Wilkins; 1997; pp 945, 947.
interventional spine care
13. Borsook D, ed. The Massachusetts General Hos-
pital Handbook of Pain Management. Boston, GERALD E. DWORKIN, DO
Mass: Little Brown; 1996.
14. Raj PP. Practical Management of Pain. St Louis,
Mo: Mosby; 2000.
15. Guyton AC, Hall JE. Textbook of Medical Phys-
iology. 10th ed. Philadelphia, Pa: WB Saunders Co;
2000; pp 274-277.
16. West JB. Best and Taylor’s Physiologic Basis of This review of interventional treatment of the spine emphasizes the need for
Medical Practice. 11th ed. Baltimore, Md: Williams aggressive pain control as a means of preventing persistent pain. The use and
& Wilkins; 1985; pp 322, 323.
application of lumbar epidural injections, facet blocks/denervation, lysis of
17. Kuchera ML, Kuchera WA. Osteopathic Con- epidural adhesions, thermal annuloplasty, radiofrequency neurotomy, and
siderations in Systemic Dysfunction. Columbus, nucleoplasty are the treatment options described. These descriptions are not
Ohio: Greyden Press; 1994.
all-inclusive of advanced treatment options for patients with spine pain.
18. Herman EP. Postoperative adynamic ileus: its (Key words: disk disruption, disk herniation, facet syndrome, failed
prevention and treatment by osteopathic manip- back surgery syndrome, leg pain, lysis of adhesions, nonsteroidal anti-inflam-
ulation. The DO. October 1965;(6):163-164.
matory drugs [NSAIDs], nucleoplasty coablation, radiofrequency neurotomy,
19. Millard FP. Applied Anatomy of the Lymphatics. spine pain, thermal annuloplasty)
Kirksville, Mo: The Journal Printing Co; 1922.
20. Steele KM. Treatment of the acutely ill hospi-
talized patient. In: Ward RC, ed. Foundations for
Osteopathic Medicine. Philadelphia, Pa: Williams &
Wilkins; 1997; p 1045.
21. Radjieski JM. Effect of osteopathic manipula-
C are of the individual with painful
spine conditions has evolved over
many years. The founder, Andrew
any given time. Although it is true that
60% to 90% of that number have self-
limiting or short-term pain, 1-year follow-
tive treatment on length of stay for pancreatitis: a
randomized pilot study. J Am Osteopath Assoc. Taylor Still, MD, DO, and the early prac- up will show that up to 50% will report
1998;98:264-272. titioners of osteopathic medicine real- recurrence. A recent study showed that
22. Tong D, Frances C. Postoperative pain control ized that the spine represented an inter- 13% to 50% will have moderate to severe
in ambulatory surgery. Surg Clin North Am. woven structure with a dynamic chronic pain and, importantly, 31% of
1999;79:401-430. relationship between spinal compo- patients with chronic back pain have had
23. Goldstein FJ, Jeck S, Nicholas A, Berman MA, nents. They understood how abnormal spine surgery.1 The long-term functional
Lerario M. Effect of pre-operative morphine and preexisting structural conditions can be sequela of persistent spinal pain is related
postop osteopathic manipulative treatment [OMT] exacerbated by injury, leading to fur- to the cumulative effects of mechanical
upon postop pain after total abdominal hysterec-
tomy [abstract]. J Am Osteopath Assoc. ther structural dysfunction. As osteo- dysfunction, chronic inflammatory medi-
2001;101:471. pathic physicians and diagnosticians, ators, and central pain mechanisms.2
our skill lies in identifying the primary The lumbar spine undergoes uni-
24. Andersson GB. A comparison of osteopathic
spinal manipulation with standard care for patients spine diagnosis as well as secondary versal degenerative changes.3 This degen-
with low back pain. N Engl J Med. 1999;341:1426- diagnoses that may be caused by the eration occurs over time, even without
1431. primary process. Tertiary diagnostic cat- obvious insult or injury. Etiologic factors
egories will present themselves as a are complex but interrelated. The spine
result of chronicity of primary and sec- segment that is composed of a three-joint
ondary processes. Overall, our goal is complex, including the two facet joints
to limit pain and promote functional and the intervertebral disk, is prone to
restoration. interrelated degenerative changes. These
Low back pain remains one of the changes occur regardless of which region
most common ailments, responsible for suffers initially. For example, synovial
more than 5 million sufferers of pain at injury in the facet joint can lead to facet
capsular laxity and instability that causes
additional stress on the intervertebral
Correspondence to Gerald E. Dworkin, DO, Well-
ness Center—2nd Floor, 1503 Lansdowne Ave, disk. This stress results in radial annular
Darby, PA 19023. tears and internal disk disruption (IDD).
S8 • JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 Dworkin • Advanced concepts in interventional spine care
This cascading process generally results Lumbar stenosis
in bony enlargement of the articular pro- The second radicular syndrome involves
cesses and osteophytes at the vertebral Checklist lumbar canal stenosis and often affects
bodies (ie, spinal stenosis). This process elderly individuals. It is characterized by
is greatly accelerated in the face of spinal pain during walking with relief during
pain syndromes with their resultant per- Radicular syndromes rest, and it must be distinguished from
sistent inflammatory mediators.4 Fur- Disk herniation vascular claudication.
ther, chronic spinal inflammatory con- Failed back surgery syndrome The pathophysiology of spinal
ditions following disk herniation, spine stenosis is best understood in terms of
surgery, or trauma can lead to epidural Nonradicular syndromes the degenerative cascade. Chronic stress
fibrosis, adhesions, and scar formation.5 Facet syndrome and injury to the facet joints and inter-
Internal disk disruption
The resultant irritability of the nerve root vertebral disk lead to combined lesions
contributes to persistent pain states. that produce simultaneous central and
It is useful to characterize back pain Figure. Conditions included in radicular syn- lateral spinal stenosis. There is often loss
into either radicular (nerve irritation) syn- dromes and in nonradicular syndromes. of disk height. The superior facet of the
dromes (Figure), accounting for 5% to lower vertebrae moves upward and for-
15% of cases of spinal pain, or nonradic- ward on the inferior facet of the upper
ular (without nerve compression) syn- widely used. Medications, however, are vertebrae, thereby narrowing the inter-
dromes (Figure), accounting for the preferentially distributed in the dorsal vertebral foramen and causing radicular
remaining 85% to 95% of such patients. aspect of the spinal canal away from symptoms.3
Specific spinal conditions may fit into inflammatory reactions occurring in ven- Physical therapy is used to main-
this classification, and their respective tral aspects of the canal. In addition, tain flexibility; assistive devices are used
interventional treatment protocols serve much of the medication will flow cra- for safe ambulation. Response to ESIs,
to illustrate use of advanced treatment niad and may miss the primary site of especially via the caudal approach, may
techniques. inflammation.8 be good, particularly early in the clinical
Many pain practitioners believe that course. Surgical treatment is by decom-
Disk herniation the caudal technique is the initial epidural pressive laminectomy.
The pathophysiology of leg pain after injection of choice. It remains quite safe
disk herniation involves large amounts of and preferentially affects the epidural Failed back surgery syndrome
inflammatory mediators that are released space around L5-S1, but may also allow Failed back surgery syndrome typically
on disruption of the disk. These inflam- anti-inflammatory effect as high up as involves radicular symptoms that are
matory mediators increase the sensitivity L3-4. If an initial caudal epidural or observed after failed back surgery;
and firing of the dorsal root ganglion.6 translaminar epidural method is not suc- epidural adhesions are present. Even
In addition, the inflamed nerve root is cessful after one or two injections, a trans- after successful back surgery, several
painful when pressed or stretched. foraminal epidural injection should be related effects to the surgery itself occur,
strongly considered.8 This approach including perineural fibrosis, some
Illustrative case study requires image guidance using fluo- degree of persistent chemical irritation,
A 35-year-old man, after lifting, has pain pri- roscopy with improved target specificity and often venous congestion with
marily into his legs, associated with numb- over other ESIs. It will also provide diag- reduced nutrient delivery to neural struc-
ness, tingling, and worsening with bending nostic information because of its selec- tures.5,11 These side effects, often related
and lifting. Physical examination revealed tivity.9 In addition to image guidance, to the appearance of scars and adhesions,
positive straight leg raising with restricted contrast is mandatory to verify that the may be of low clinical importance or may
flexion of the lumbar spine, decreased sensa- epidural injection spreads ventrally and cause severe radicular pain. In the event
tion in the S1 distribution. The magnetic res- ensure that the injection is not intravas- of significant radicular pain after spine
onance imaging (MRI) study confirmed disk cular. surgery, an interventional treatment may
herniation at L5-S1. Using a combination of exercise sta- include lysis of adhesions procedures.
Conservative treatment includes bilization program and ESIs, Saal et al10 There are several treatment tech-
short-term bed rest (ie, less than 2 to 3 had 45 of 52 patients responding with niques described in the literature.5,8,11
days), along with nonsteroidal anti- good to excellent outcomes. Further, One common method includes intro-
inflammatory drugs (NSAIDs) and pain serial MRIs demonstrated significant res- duction of a flexible catheter through a
medicine as needed. Physical therapy olution of the disk herniation at 1 year. caudal approach via an introducer
can be initiated to restore range of Adverse effects of ESIs can include needle.11 This procedure is done under
motion, reduce muscle spasm, and main- headache (especially if there is dural image guidance, allowing the flexible
tain mobility and muscle strength. damage), as well as infection, bleeding, a catheter to be directed toward regions
If epidural steroid injections (ESIs) 7- to 10-day increase in blood sugar (from of clinical relevance and scar formation.
are to be considered, there are three major use of cortisone), hypertension, pedal Contrast may be used to see regions
routes.7 The translaminar approach is edema, and congestive heart failure. where scar tissue appears. These regions,
Dworkin • Advanced concepts in interventional spine care JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 • S9
when approached with the catheter, can ture of a degenerative disk and often a high- pathologic process clearly established by
be infiltrated by relatively large volumes intensity zone, which correlates with annular diskography and who have had a failed
of fluid, including saline solution, corti- rupture and disk degeneration. Often, how- response to at least 6 months of conser-
sone, and anesthetic agents. ever, MRI is nondiagnostic with minimal vative therapy and are facing surgery as
Hyaluronidase, an enzyme useful findings. the sole therapeutic option. Additional
in reducing adhesiveness of scar tissue, This patient has IDD, which is dif- criteria include largely preserved disk
may be added before instillation of fluid. ferentiated from disk herniation by the height, back pain greater than leg pain,
Overall, the process seems to reduce lack of findings on MRI. Intolerance to sit- intolerance of sitting, good tolerance of
fibrosis and inflammation and increase ting and lack of significant findings on standing, posterior annular deficit, high
neural mobility. This process is enhanced MRI (other than loss of height) make one motivation with no significant psychi-
by the use of specific stretching exercises suspect IDD. A definitive diagnosis, how- atric history, and no demonstrable facet
given to patients after the procedure. ever, requires diskography.12 disease.20
Two types of nonradicular (or axial) The pathophysiology of painful IDD Proposed mechanisms for thermal
back pain include facet syndrome (15% of involves innervation of the outer annuloplasty include thermal modifica-
those presenting with axial spine pain), annulus16; this region is densely inner- tion of collagen, thermocoagulation of
and IDD (accounting for 39% of cases).12 vated, and disrupted portions of the disk annular nociceptors, and volume con-
become infiltrated with neurovascular traction of the disk itself. Postprocedure
Facet syndrome bundles. Inflammatory mediators care includes 6 weeks with no signifi-
The facet syndrome is associated with heighten nociception and sensitize the cant bending, twisting, or lifting; wearing
posttraumatic facet synovitis. Physical nerve endings. Pressurizing the disk, vis- a corset for the first 2 weeks; and aggres-
findings include back pain, worsened à-vis sitting or lifting, will provoke pain. sive stabilization exercises beginning
with extension. Pain radiates locally, gen- The use of diskography can be quite week 3 or 4.
erally across the back and often into the helpful in diagnosing IDD.17 Indications For patients whose leg pain is
proximal aspect of the thigh, groin, and include equivocal disk disease on MRI greater than that of the back but who
upper lumbar region. This important or computed tomography (CT) scans, have minimal disk herniation on MRI
cause for axial spine pain is difficult to multiple-level disk disease, postsurgical and who have had a failed response to 6
determine radiologically. Often, diag- spine with pain, and painful disk in con- months of conservative treatment, an
nostic medial branch or facet joint blocks junction with posterior fusion. Diskog- additional percutaneous mode of therapy
can be done under image guidance.13 raphy is also used as a preliminary test for is available. Nucleoplasty coablation uses
Resolution of symptoms after introduc- spinal fusion to evaluate disks above and radiofrequency technology to ablate and
tion of a local anesthetic such as bupiva- below the contemplated fusion region.18 coagulate soft tissue within the nucleus
caine hydrochloride to the facet joint or During diskography, needles are of the involved disk. This procedure acts
its nerve is diagnostic. This pain can placed under image guidance into each to decompress contained herniated disk
resolve, albeit temporarily, after medial disk under study and then pressurized material percutaneously. Postprocedure
branch blocks or injections into the facet to provoke pain. Familiar or concordant therapy is similar to that for thermal
joints.14 A more definitive treatment pain is highly correlated with a signifi- annuloplasty.
modality includes radiofrequency neu- cant pain-generating disk. Postdiskog-
rotomy of the nerve to the facet joint.15 An raphy CT scans, as well as plain film x-ray Comment
electrode is placed along the medial studies, will demonstrate annular tears Preventing the disabling sequelae of per-
branch nerve under fluoroscopic guid- within the disk.18 Recording disk pres- sistent low back pain is of great impor-
ance. Radiofrequency current is then sure during the test can be helpful in clas- tance. An organized approach is helpful,
applied to the distal tip of the probe, sifying IDD. Medical histories of IDD have particularly when many therapeutic
causing an increase in temperature that been evaluated in several studies. In one options are included. This article by no
denervates the nerve for up to 6 months. such investigation, after 1-year follow-up, means accounts for all advanced treat-
Internal disk disruption accounts for 14 of 17 patients with IDD had worsened ment options but may serve as a resource
a large percentage of individuals with pain if no interventions were offered.12 for both patient and practitioner.
nonradicular pain syndromes, ie, pain If individuals have undergone con-
without nerve compression. servative treatment for several months References
and have failed to improve, other options 1. Manchikanti L, Pampati V, Fellows B, Beyer CD,
Illustrative case study must be considered. Minimally invasive Damron KS, Barnhill RC, et al. Characteristics of
chronic low back pain in patients in an interven-
A 42-year-old male attorney with a history of procedures include thermal annuloplasty tional pain management setting: A prospective
low back pain off and on for 5 years has a utilizing radiofrequency. Other thermal evaluation. Pain Physician. 2001;4(2):131-142.
severe episode of pain 1 week before the office annuloplasty techniques include resis- 2. Weinstein J. Recent advances in the neurophys-
visit. He presents with minimal leg pain, tive heating such as intradiskal electro- iology of pain. Physical Medicine and Rehabilitation:
localized back pain, and significant intolerance thermography.19 State of the Art Reviews. 1990;4(2):201-220.
to sitting more than 15 minutes. Lying down Candidates for thermal annuloplasty 3. Kirkald-Willis WH, Bernard T Jr. Pathology and
lessens his pain. The MRI study shows a pic- include patients who have a diskogenic pathogenis of the low back pain. In: Managing
S10 • JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 Dworkin • Advanced concepts in interventional spine care
Low Back Pain. 4th ed. Philadelphia,Pa: Churchill Liv-
ingstone; 1999; pp 65-95.
4. Saal J. The role of inflammation in lumbar pain.
Physical Medicine and Rehabilitation: State of the
Art Reviews. 1990;4(2):191-200.
Opioid “mythstakes”: Opioid
5. Manchikanti L, Pampati V, Fellows B, Rivera J,
Beyer CD, Damron KS. Role of one day epidural analgesics—current clinical and
adhesiolysis in management of chronic low back
pain: A randomized clinical trial. Pain Physician.
6. Olmarker K, Rydebik B. Pathophysiology of sci- WILLIAM VILENSKY, DO, RPH
atica. Orthop Clin North Am. 1991;22(2):223-234.
7. Woodward J, Herring S, Windsor R, Dreyer S,
Lester J, Lagattula F. Epidural procedures in spine
pain management. In: Lennard T, ed. Physiatric
Procedures and Clinical Practice. Philadelphia, Pa:
Hanley & Belfus, Inc; 1995; pp 260-291.
8. Manchikanti L, Singh V, Kloth D, Slipman CW,
Jasper JF, Trescot AM, et al. Interventional tech- Barriers to appropriate prescribing of opioids include the deficit in educating
niques in the management of chronic pain: Part 2.0. medical students in core curricula. Other barriers include physicians’ lack of
Pain Physician. 2001;4(1):24-96.
knowledge of pain management, failure to educate their patients or include
9. Slipman CW, Zacharia I. The role of diagnostic them in treatment options, and failure to take adequate medical histories and
selective nerve root blocks in the management of
spinal pain. Pain Physician. 2001;4(3):214-226. obtain records of their patients’ previous treatment. In addition, physicians often
10. Saal JA. Intervertebral disc herniation: Advances
lack the ability to distinguish the patient who is suffering pain from the addict.
in nonoperative treatment. Physical Medicine and Patients, too, may fear that opioid therapy may cause addiction. This article pro-
Rehabilitation: State of the Art Reviews. vides an overview of guidelines and federal regulations for prescribing opioids,
along with some caveats, in the hope that physicians and patients alike will
11. Racz G, et al. Lysis of Adhesions in the Epidural appreciate that pain management is an integral part of treatment. And, that treat-
Space: Techniques of Neurolysis. Boston, Mass:
Kluwer Academic; 1989; pp 57-72. ment is aimed at decreasing or eradicating pain and maintaining patients’
12. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine
function to the greatest possible degree while monitoring and treating side
G, Bogduk N. The prevalence and clinical features effects.
of internal disc disruption in patients with chronic (Key words: addiction myths, analgesics, federal regulations, morphine,
low back pain. Spine. 1995;20:1878-1883. opioids, pain management, prescription guidelines)
13. Dreyfuss P, Lagattuta F, Kaplansky B, Heller B.
Zygapophyseal joint injection techniques in the
spinal axis. In: Lennard T, ed. Physiatric Procedures
and Clinical Practice. Philadelphia, Pa: Hanley &
Belfus, Inc; 1995.
14. Manchikanti L, Pampati V, Bakhit CE, Rivera JJ,
P ain management in the United
States has labored under “myths”
regarding use of morphine, a natural
Myths have made their way into medical
practice, causing both physicians and
Beyer CD, Damron KS, et al. Effectiveness of lumbar alkaloid of the opium plant, and syn- patients to become wary and weary of
facet joint nerve blocks in chronic low back pain:
A randomized clinical trial. Pain Physician. thetic analgesics (opioids) that have sim- using opioids for pain management. The
2001;4(1):101-117. ilar characteristics. During the past 15 term pain management should now be
15. Windsor R, Dreyer S. Facet joint nerve abla- years, physicians in both pain and used instead of pain treatment. Treatment
tion. In: Lennard T, ed. Physiatric Procedures and addiction medicine have recognized implies that the pain exists and the physi-
Clinical Practice. Philadelphia, Pa: Hanley & Belfus, and heralded the need for change in cian has to fight the battle to quell the
attitudes in treating patients in pain as pain; management refers to addressing
16. Nachemson AL. Causes and cure of low back
pain and sciatica, April, 1991: The lumbar spine: an well as those who suffer from the neu- the pathologic process causing the pain
orthopedic challenge. Spine. 1976;1:59-61. robiologic disease of addiction. Those and preventing its appearance.
17. Bogduk N, Aprilo C, Darby R. Discography. In: myths have raised the prescribing In a 1954 JAMA report, Rayport1
White AH, Schofferman JA, eds. Spine Care. St stakes that in the past escalated physi- stated that 27% of patients who were
Louis, Mo: Mosby-Year Book; 1995; pp 219-239. cians’ fears and governmental restrictive given morphine for pain had become
18. Fortin J. Lumbar and thoracic discography with regulations. addicted. In 1980, changes in attitude
CT and MRI correlations. In: Lennard T, ed. Physi- were seen in a study by Porter and Jeck2
atric Procedures and Clinical Practice. Philadelphia,
Pa: Hanley & Belfus, Inc; 1995. that concluded that only 4 of 11,882
19. Saal JA, Saal JS. Intradiscal electrothermal treat- Dr Vilensky is a clinical associate professor of psy- patients given opioids in the hospital had
ment for chronic discogenic low back pain. Spine. chiatry at the University of Medicine and Den- difficulty in discontinuing such use. In
2000;25:2622-2627. tistry of New Jersey–New Jersey Medical School, in
Newark, NJ. 1982, Perry and Heidrich3 found that
20. Saal JA, Saal JS. Intradiscal electrothermal treat- Correspondence to William Vilensky, DO, RPh, none of approximately 10,000 burn
ment for chronic discogenic low back pain with Executive Medical Director, Forensic & Educational
two year follow-up. Proceedings of the North
patients became addicted to opioids used
Consultants, 110 S Nassau Ave, Margate, NJ 08402-
American Spine Society. 15th Annual Meeting, 2520. in their management of pain. In lecturing
New Orleans, La, September 5-7, 2000; pp 5-7. E-mail: firstname.lastname@example.org and questioning physicians and nurses
Vilensky • Opioid analgesics—current clinical and regulatory perspectives JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 • S11