The role of thoracic medial branch blocks in managing chronic mid and upper back pain: a randomized, double-blind, active-control trial with a 2-year followup

Laxmaiah Manchikanti, Vijay Singh, Frank J E Falco, Kimberly A Cash, Vidyasagar Pampati, Bert Fellows, Laxmaiah Manchikanti, Vijay Singh, Frank J E Falco, Kimberly A Cash, Vidyasagar Pampati, Bert Fellows

Abstract

Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections. Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids. Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup. Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin.

Figures

Figure 1
Figure 1
Schematic presentation of participant flow at 2-year followup.
Figure 2
Figure 2
Proportion of patients with significant reduction in numeric rating score and Oswestry Disability Index (≥50% reduction from baseline).

References

    1. Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20–71 years of age. BMC Musculoskeletal Disorders. 2009;10, article 39
    1. Occhipinti E, Colombini D, Grieco A. Study of distribution and characteristics of spinal disorders using a validated questionnaire in a group of male subjects not exposed to occupational spinal risk factors. Spine. 1993;18(9):1150–1159.
    1. Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Manual Therapy. 1997;2(3):132–143.
    1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskeletal Disorders. 2009;10(1, article 77)
    1. Stolker RJ, Vervest ACM, Groen GJ. Percutaneous facet denervation in chronic thoracic spinal pain. Acta Neurochirurgica. 1993;122(1-2):82–90.
    1. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders. 2004;5, article 15
    1. Manchukonda R, Manchikanti KN, Cash KA, Pampati V, Manchikanti L. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. Journal of Spinal Disorders and Techniques. 2007;20(7):539–545.
    1. Manchikanti L, Pampati V, Fellows B, et al. Characteristics of chronic low back pain in patients in an interventional pain management setting: a prospective evaluation. Pain Physician. 2001;4(2):131–142.
    1. Manchikanti L, Pampati V. Research designs in interventional pain management: is randomization superior, desirable or essential? Pain Physician. 2002;5(3):275–284.
    1. Manchikanti L, Pampati V, Singh V, Boswell MV, Smith HS, Hirsch JA. Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data. BMC Health Services Research. 2010;10, article 84
    1. Manchikanti L, Pampati V, Boswell MV, Smith HS, Hirsch JA. Analysis of the growth of epidural injections and costs in the medicare population: a comparative evaluation of 1997, 2002, and 2006 data. Pain Physician. 2010;13(3):199–212.
    1. Specialty Utilization data files from CMS.
    1. Manchikanti L, Singh V, Boswell MV. Interventional pain management at crossroads: the perfect storm brewing for a new decade of challenges. Pain Physician. 2010;13(2):E111–E140.
    1. Benyamin RM, Datta S, Falco FJE. A perfect storm in interventional pain management: regulated, but unbalanced. Pain Physician. 2010;13(2):109–116.
    1. Atluri S, Datta S, Falco FJE, Lee M. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician. 2008;11(5):611–629.
    1. Singh V, Manchikanti L, Shah RV, Dunbar EE, Glaser SE. Systematic review of thoracic discography as a diagnostic test for chronic spinal pain. Pain Physician. 2008;11(5):631–642.
    1. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13(5):401–435.
    1. Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician. 2011;14(2):91–121.
    1. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12(4):699–802.
    1. Zhang HQ, Lin MZ, Shen KY, et al. Surgical management for multilevel noncontiguous thoracic spinal tuberculosis by single-stage posterior transforaminal thoracic debridement, limited decompression, interbody fusion, and posterior instrumentation (modified TTIF) Archives of Orthopaedic and Trauma Surgery. 2012;132(6):751–757.
    1. Manchikanti L, Singh V, Pampati V, Beyer CD, Damron KS. Evaluation of the prevalence of facet joint pain in chronic thoracic pain. Pain Physician. 2002;5(4):354–359.
    1. Manchikanti L, Manchikanti KN, Manchukonda R, Pampati V, Cash KA. Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. Pain Physician. 2006;9(2):97–105.
    1. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V. Effectiveness of thoracic medial branch blocks in managing chronic pain: a preliminary report of a randomized, double-blind controlled trial; Clinical Trial NCT00355706. Pain Physician. 2008;11(4):491–504.
    1. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V, Fellows B. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. 2010;13(6):535–548.
    1. Manchikanti L, Singh V, Falco FJE, Cash KA, Fellows B. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. 2010;13(5):437–450.
    1. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. International Journal of Medical Sciences. 2010;7(3):124–135.
    1. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. A preliminary report of a randomized double-blind, active controlled trial of fluoroscopic thoracic interlaminar epidural injections in managing chronic thoracic pain. Pain Physician. 2010;13(6):E357–E369.
    1. Manchikanti L, Cash KA, McManus CD, Pampati V, Smith HS. One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis. Pain Physician. 2011;14(1):25–36.
    1. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. Preliminary results of a randomized, double-blind, controlled trial of fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar discogenic pain without disc herniation or radiculitis. Pain Physician. 2010;13(4):E279–E292.
    1. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Cervical epidural injections in chronic-discogenic neck pain without disc herniation or radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4):E265–E278.
    1. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine (Phila Pa 1976) 36(23):1897–1905.
    1. Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4):343–355.
    1. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. The effectiveness of fluoroscopic cervical interlaminar epidural injections in managing chronic cervical disc herniation and radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(3):223–236.
    1. Chou R, Huffman L. Guideline for the Evaluation and Management of Low Back Pain: Evidence Review. Glenview, Ill, USA: American Pain Society; 2009.
    1. Manchikanti L, Datta S, Derby R, Wolfer LR, Benyamin RM, Hirsch JA. A critical review of the American pain society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010;13(3):E141–E174.
    1. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American pain society clinical practice guidelines for interventional techniques: part 2. therapeutic interventions. Pain Physician. 2010;13(4):E215–E264.
    1. Carragee EJ, Haldeman S, Hurwitz E. The pyrite standard: the Midas touch in the diagnosis of axial pain syndromes. Spine Journal. 2007;7(1):27–31.
    1. Bogduk N. In defense of King etal.: the validity of manual examination in assessing patients with neck pain. Spine Journal. 2007;7(6):749–752. author reply (Carragee EJ) pp. 752-753.
    1. Cohen SP, Williams KA, Kurihara C, et al. 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. Anesthesiology. 2010;113(2):395–405.
    1. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician. 2009;12(4):E71–E121.
    1. Pampati S, Cash KA, Manchikanti L. Accuracy of diagnostic lumbar facet joint nerve blocks: a 2-year follow-up of 152 patients diagnosed with controlled diagnostic blocks. Pain Physician. 2009;12(5):855–866.
    1. Manchikanti L, Pampati S, Cash KA. Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks: an assessment of the implications of 50% relief, 80% relief, single block, or controlled diagnostic blocks. Pain Physician. 2010;13(2):133–143.
    1. Rubinstein SM, van Tulder M. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Practice and Research. 2008;22(3):471–482.
    1. Manchikanti L, Singh V, Falco FJE, Cash KM, Fellows B. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine. 2008;33(17):1813–1820. Spine (Phila Pa 1976), vol. 34, no. 10, pp. 1116, 2009.
    1. Manchikanti L, Singh V, Falco FJE, Cash KM, Fellows B. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine. 2008;33(17):1813–1820. author reply, vol. 34, pp. 1116-1117, 2009.
    1. Manchikanti L, Shah RV, Datta S, Singh V. Critical evaluation of interventional pain management literature provides inaccurate conclusions. Spine Journal. 2009;9(8):706–708.
    1. Manchikanti L, Pampati V, Damron K. The role of placebo and nocebo effects of perioperative administration of sedatives and opioids in interventional pain management. Pain Physician. 2005;8(4):349–355.
    1. Manchikanti L, Giordano J, Fellows B, Hirsch JA. Placebo and nocebo in interventional pain management: a friend or a foe—or simply foes? Pain Physician. 2011;14(2):E157–E175.
    1. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Annales of Internal Medicine. 2001;134(8):663–694.
    1. Merskey H, Bogduk N. Task Force on Taxonomy of the International Association of the Study of Pain. 2nd edition. Seattle, Wash, USA: IASP Press; 1994. Classification of chronic pain. Descriptions of chronic pain syndromes and definition of pain terms.
    1. Jensen MP, Karoly P. Self-report scales and procedures for assessing pain in adults. In: Turk CD, Melzack R, editors. Handbook of Pain Assessment. 2nd edition. New York, NY, USA: Guilford Press; 2001. pp. 15–34.
    1. Fairbank JCT, Pynsent PB. The oswestry disability index. Spine. 2000;25(22):2940–2953.
    1. Manchikanti L, Hirsch JA, Smith HS. Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: part 2: randomized controlled trials. Pain Physician. 2008;11(6):717–773.
    1. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Management of pain of post lumbar surgery syndrome: one-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections. Pain Physician. 2010;13(6):509–521.
    1. Manchikanti L, Cash KA, McManus CD, Pampati V, Fellows B. Fluoroscopic caudal epidural injections with or without steroids in managing pain of lumbar spinal stenosis: one-year results of randomized, double-blind, active-controlled trial. Journal of Spinal Disorders and Techniques. 2012;25(6):226–234.
    1. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic epidural injections in cervical spinal stenosis: preliminary results of a randomized, double-blind, active control trial. Pain Physician. 2012;15(1):E59–E70.
    1. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic cervical interlaminar epidural injections in managing chronic pain of cervical post-surgery syndrome: preliminary results of a randomized, double-blind active control trial. Pain Physician. 2012;15(1):13–26.
    1. Pereira J, Lawlor P, Vigano A, Dorgan M, Bruera E. Equianalgesic dose ratios for opioids: a critical review and proposals for long-term dosing. Journal of Pain and Symptom Management. 2001;22(2):672–687. Narcotic analgesic converter, Global-RPh Inc., .
    1. Lord SM, Barnsley L, Wallis BJ, Mcdonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. The New England Journal of Medicine. 1996;335(23):1721–1726.
    1. Van Kleef M, Barendse GAM, Kessels A, Voets HM, Weber WEJ, De Lange S. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine. 1999;24(18):1937–1942.
    1. Iversen T, Solberg K, Romner B, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. British Medical Journal. 2011;343, article d5278
    1. Gharibo C, Varlotta G, Rhame E, Liu EJ, Bendo J, Perloff M. Interlaminar versus transforaminal epidural steroids for the treatment of sub-acute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician. 2011;14(6):499–511.
    1. Koes BW, Scholten RJPM, Mens JMA, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain. 1995;63(3):279–288.
    1. Chou R, Atlas SJ, Loeser JD, Rosenquist RW, Stanos SP. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? Journal of Pain. 2011;12(8):833–839.
    1. Manchikanti L, Benyamin RM, Falco FJE, Caraway D, Datta S, Hirsch JA. Guidelines warfare over interventional techniques: is there a lack of discourse or straw man? Pain Physician. 2012;15(1):E1–E26.
    1. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. The New England Journal of Medicine. 1991;325(14):1002–1007.
    1. Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. The New England Journal of Medicine. 1997;336(23):1634–1640.
    1. Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine. 2001;26(9):1059–1067.
    1. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Medicine. 2010;11(8):1149–1168.
    1. Pham Dang C, Lelong A, Guilley J, et al. Effect on neurostimulation of injectates used for perineural space expansion before placement of a stimulating catheter normal saline versus dextrose 5% in water. Regional Anesthesia and Pain Medicine. 2009;34(5):398–403.
    1. Tsui BCH, Kropelin B, Ganapathy S, Finucane B. Dextrose 5% in water: fluid medium for maintaining electrical stimulation of peripheral nerves during stimulating catheter placement. Acta Anaesthesiologica Scandinavica. 2005;49(10):1562–1565.
    1. Indahl A, Kaigle AM, Reikerås O, Holm SH. Interaction between the porcine lumbar intervertebral disc, zygapophysial joints, and paraspinal muscles. Spine. 1997;22(24):2834–2840.
    1. Indahl A, Kaigle A, Reikeras O, Holm S. Electromyographic response of the porcine multifidus musculature after nerve stimulation. Spine. 1995;20(24):2652–2658.
    1. Manchikanti L, Falco FJE, Boswell MV, Hirsch JA. Facts, fallacies, and politics of comparative effectiveness research: part I. Basic considerations. Pain Physician. 2010;13(1):E23–E54.
    1. Manchikanti L, Falco FJE, Boswell MV, Hirsch JA. Facts, fallacies, and politics of comparative effectiveness research: part 2—implications for interventional pain management. Pain Physician. 2010;13(1):E55–E79.
    1. Manchikanti L, Falco FJE, Benyamin R, Helm S, Parr AT, Hirsch JA. The impact of comparative effectiveness research on interventional pain management: evolution from Medicare modernization act to patient protection and affordable care act and the patient-centered outcomes research institute. Pain Physician. 2011;14(3):E249–E282.
    1. Manchikanti L, Singh V, Caraway DL, Benyamin RM, Hirsch JA. Medicare Physician payment systems: impact of 2011 schedule on interventional pain management. Pain Physician. 2011;14(1):E5–E33.
    1. Hayashi N, Weinstein JN, Meller ST, Lee HM, Spratt KF, Gebhart GF. The effect of epidural injection of betamethasone or bupivacaine in a rat model of lumbar radiculopathy. Spine. 1998;23(8):877–885.
    1. Lee HM, Weinstein JN, Meller ST, Hayashi N, Spratt KF, Gebhart GF. The role of steroids and their effects on phospholipase A2: an animal model of radiculopathy. Spine. 1998;23(11):1191–1196.
    1. Johansson A, Hao J, Sjölund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibres. Acta Anaesthesiologica Scandinavica. 1990;34(5):335–338.
    1. Pasqualucci A, Varrassi G, Braschi A, et al. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion. Clinical Journal of Pain. 2007;23(7):551–557.
    1. Lavoie PA, Khazen T, Filion PR. Mechanisms of the inhibition of fast axonal transport by local anesthetics. Neuropharmacology. 1989;28(2):175–181.
    1. Bisby MA. Inhibition of axonal transport in nerves chronically treated with local anesthetics. Experimental Neurology. 1975;47(3):481–489.
    1. Katz WA, Rothenberg R. Section 3: the nature of pain: pathophysiology. Journal of Clinical Rheumatology. 2005;11(2, supplement):S11–S15.
    1. Cassuto J, Sinclair R, Bonderovic M. Anti-inflammatory properties of local anesthetics and their present and potential clinical implications. Acta Anaesthesiologica Scandinavica. 2006;50(3):265–282.
    1. Arnér S, Lindblom U, Meyerson BA, Molander C. Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies. Pain. 1990;43(3):287–297.
    1. Melzack R, Coderre TJ, Katz J, Vaccarino AL. Central neuroplasticity and pathological pain. Annals of the New York Academy of Sciences. 2001;933:157–174.
    1. Sato C, Sakai A, Ikeda Y, Suzuki H, Sakamoto A. The prolonged analgesic effect of epidural ropivacaine in a rat model of neuropathic pain. Anesthesia and Analgesia. 2008;106(1):313–320.
    1. Tachihara H, Sekiguchi M, Kikuchi SI, Konno SI. Do corticosteroids produce additional benefit in nerve root infiltration for lumbar disc herniation? Spine. 2008;33(7):743–747.

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