Interventional Spine: Beyond the Physical Examination

Outcomes

As a result of participating in this activity, learners will be better able to:

• make a differential diagnosis of source of pain
• set realistic expectation with patients
• provide treatment options for patients

Overview

• Prevalence of axial pain generators
• Determining the predictive nature of diagnostic tests
• Accuracy and utility of lumbar discography 
• Discogenic pain: Imaging correlates
• Diagnosing zygapophyseal joint pain
• Predictability of radiofrequency denervation for lumbar and cervical facet joints
• Diagnostic value of nerve blocks
• Diagnosing painful sacroiliac joints

Accreditation & Designation

Release date: This activity was released 8/19/2022.

Termination date: The content of this activity remains eligible for CME Credit until 8/18/2025, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

California Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill
AB487 requires physicians licensed in California to complete a one-time CME activity for 12 hours of credits that addresses both pain management and the appropriate care and treatment of the terminally ill. This activity contributes to achievement of requirements with AB487.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Aaron Calodney discloses the following financial relationships within the past 24 months: Research support & Consulting: Medtronic, Boston Scientific, Nevro, Stryker, Saluda, Nalu

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• DePalma, M. J. (2015). Diagnostic nihilism toward low back pain: What once was accepted, should no longer be. Pain Medicine, 16(8), 1453-1454.
• Schwarzer, A. C., Aprill, C. N., Derby, R., Fortin, J., Kine, G., & Bogduk, N. (1994). Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?. Spine, 19(10), 1132-1137.
• DePalma, M., Ketchum, J., Saullo, T., & Schofferman, J. (2011). Structural etiology of chronic low back pain due to motor vehicle collision. Pain medicine, 12(11), 1622-1627.
• Cohen, S. P., Bajwa, Z. H., Kraemer, J. J., Dragovich, A., Williams, K. A., Stream, J., ... & Hurley, R. W. (2007). Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis. Regional Anesthesia & Pain Medicine, 32(6), 495-503.
• Cohen, S. P., Hurley, R. W., Buckenmaier, C. C., Kurihara, C., Morlando, B., & Dragovich, A. (2008). Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. The Journal of the American Society of Anesthesiologists, 109(2), 279-288.
• Maigne, J. Y., Aivaliklis, A., & Pfefer, F. (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine, 21(16), 1889-1892.
• Manchikanti, L., Benyamin, R. M., Singh, V., Falco, F., Hameed, H., Derby, R., ... & Cohen, S. P. (2013). An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain. Pain Physician, 16(2S), SE55.
• DePalma, M. J., Ketchum, J. M., Trussell, B. S., Saullo, T. R., & Slipman, C. W. (2011). Does the location of low back pain predict its source?. PM&R, 3(1), 33-39.
• DePalma, M. J., Ketchum, J. M., & Saullo, T. (2011). What is the source of chronic low back pain and does age play a role?. Pain medicine, 12(2), 224-233.
• Hancock, M. J., Maher, C. G., Latimer, J., Spindler, M. F., McAuley, J. H., Laslett, M., & Bogduk, N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European Spine Journal, 16(10), 1539-1550.
• Bogduk, N., Aprill, C., & Derby, R. (2013). Lumbar discogenic pain: state-of-the-art review. Pain Medicine, 14(6), 813-836.
• Lotz, J. C., Gornet, M. F., Peacock, J. C., Hu, S. S., Schranck, F. W., Stewart, D., & Berven, S. H. (2013). Single voxel MR spectroscopy distinguishes nonherniated painful from herniated painful and non-painful lumbar discs. The Spine Journal, 13(9), S101.
• Falco, F., Manchikanti, L., Datta, S., Sehgal, N., Geffert, S., Onyewu, O., ... & Hirsch, J. A. (2012). An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain physician, 15(6), E869.
• Schwarzer, A. C., Wang, S. C., Bogduk, N., McNaught, P. J., & Laurent, R. (1995). Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Annals of the rheumatic diseases, 54(2), 100-106.
• Hancock, M. J., Maher, C. G., Latimer, J., Spindler, M. F., McAuley, J. H., Laslett, M., & Bogduk, N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European Spine Journal, 16(10), 1539-1550.
• Manchikanti, L., Pampati, V., Fellows, B., & Baha, A. G. (2000). The inability of the clinical picture to characterize pain from facet joints. Pain Physician, 3(2), 158-66.
• Schwarzer, A. C., Wang, S. C., O'Driscoll, D., Harrington, T., Bogduk, N., & Laurent, R. (1995). The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine, 20(8), 907-912.
• Cohen, S. P., Hurley, R. W., Christo, P. J., Winkley, J., Mohiuddin, M. M., & Stojanovic, M. P. (2007). Clinical predictors of success and failure for lumbar facet radiofrequency denervation. The Clinical journal of pain, 23(1), 45-52.
• De Maeseneer, M., Lenchik, L., Everaert, H., Marcelis, S., Bossuyt, A., Osteaux, M., & Beeckman, P. (1999). Evaluation of lower back pain with bone scintigraphy and SPECT. Radiographics, 19(4), 901-912.
• Holder, L. E., Machin, J. L., Asdourian, P. L., Links, J. M., & Sexton, C. C. (1995). Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. Journal of Nuclear Medicine, 36(1), 37-44.
• Pneumaticos, S. G., Chatziioannou, S. N., Hipp, J. A., Moore, W. H., & Esses, S. I. (2006). Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology, 238(2), 693-698.
• Jain, A., Jain, S., Agarwal, A., Gambhir, S., Shamshery, C., & Agarwal, A. (2015). Evaluation of efficacy of bone scan with SPECT/CT in the management of low back pain. The Clinical Journal of Pain, 31(12), 1054-1059.
• Derby, R., Melnik, I., Lee, J. E., & Lee, S. H. (2012). Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome. Pain medicine, 13(12), 1533-1546.
• Cohen, S. P., Strassels, S. A., Kurihara, C., Griffith, S. R., Goff, B., Guthmiller, K., ... & Nguyen, C. (2013). Establishing an optimal “cutoff” threshold for diagnostic lumbar facet blocks: a prospective correlational study. The Clinical journal of pain, 29(5), 382-391.
• Pampati, S., Cash, K. A., & Manchikanti, L. (2009). Accuracy of diagnostic lumbar facet joint nerve blocks: A 2-year follow-up of 152 patients diagnosed with controlled diagnostic blocks. Pain Physician, 12(5), 855.
• Derby, R., Melnik, I., Choi, J., & Jeong-Eun, L. (2013). Indications for repeat diagnostic medial branch nerve blocks following a failed first medial branch nerve block. Pain Physician, 16(5), 479.
• Cohen, S. P., Williams, K. A., Kurihara, C., Nguyen, C., Shields, C., Kim, P., ... & Strassels, S. A. (2010). Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. The Journal of the American Society of Anesthesiologists, 113(2), 395-405.
• Fortin, J. D., & Falco, F. J. (1997). The Fortin finger test: an indicator of sacroiliac pain. American journal of orthopedics (Belle Mead, NJ), 26(7), 477-480.
• Dreyfuss, P., Michaelsen, M., Pauza, K., McLarty, J., & Bogduk, N. (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine, 21(22), 2594-2602.
• Slipman, C. W., Lipetz, J. S., Plastaras, C. T., Jackson, H. B., Vresilovic, E. J., Lenrow, D. A., & Braverman, D. L. (2001). Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. American journal of physical medicine & rehabilitation, 80(6), 425-432.
• Duhon, B. S., Bitan, F., Lockstadt, H., Kovalsky, D., Cher, D., Hillen, T., & SIFI Study Group. (2016). Triangular titanium implants for minimally invasive sacroiliac joint fusion: 2-year follow-up from a prospective multicenter trial. International journal of spine surgery, 10.
• Kennedy, D. J., Engel, A., Kreiner, D. S., Nampiaparampil, D., Duszynski, B., & MacVicar, J. (2015). Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: a systematic review. Pain Medicine, 16(8), 1500-1518.