Abstract

The annual prevalence of chronic low back pain ranges from 15% to 45%, with a point prevalence of 30%. Low-back pain is associated with significant economic, social, and health impact. The number of patients receiving spinal interventional techniques such as needle placement of drugs in targeted areas, ablation of targeted nerves, and implantation of spinal cord stimulators increase every year. This increase in utilization parallels the rising prevalence of low back pain, advancement of new and innovative fluoroscopic injection techniques and the evolution of new interventional pain management modalities. Lumbar intervertebral discs, facet joints, sacroiliac joint, ligaments, fascia, muscles, and nerve root dura have been shown to be capable of transmitting pain in the lumbar spine with resulting symptoms of low back pain and lower extremity pain. Diagnostic and therapeutic spinal interventional techniques in the management of low-back pain include facet joint interventions, sacroiliac joint interventions, epidural injections, lumbar epidural adhesiolysis, discography and intradiscal therapies, mechanical disc decompression, and implantable therapies. The diagnostic blocks applied in the precision diagnosis of chronic low back pain include lumbar facet joint nerve blocks, lumbar provocation discography, and sacroiliac joint blocks. Faset joint pain prevalence is 21% to 40% in heterogenous population with chronic low back pain and 16% in post lumbar surgery syndrome. Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain. Primary discogenic pain is reported in 26% of patients suffering with chronic low back pain. Discography is a procedure that is used to characterize the pathoanatomy/architecture of the intervertebral disc and to determine if the intervertebral disc is a source of chronic low back pain. Lumbar discography may help to identify symptomatic and pathological intervertebral discs. The prevalence of sacroiliac joint pain is estimated to range between 10% and 38%. Due to the inability to make the diagnosis of sacroiliac joint-mediated pain with non-invasive tests, sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis. Controlled sacroiliac joint blocks with placebo or controlled comparative local anesthetic blocks are recommended when indications are satisfied. After diagnostic local anesthetic blocks, facet joint pain may be managed by intraarticular injections, medial branch blocks, or neurolysis of medial branches. Percutaneous neurotomy of medial branches may be performed by radiofrequency (RF) thermoneurolysis utilizing conventional RF (heat destroys nerves and blocks pain transmission) or pulsed RF (heat never exceeds 42^o C preventing damage to the tissues and the nerves). After diagnostic blocks, sacroiliac joint pain may be managed with intraarticular injections and L5-S3 medial branch RF (Conventional RF, Pulsed RF and Cooled RF). Multiple intradiscal therapies described to manage either discogenic pain or IDD include Intradiscal RF Thermocoagulation (IRFT), Intradiscal electrothermal therapy (IDET), Intradiscal Thermal Annuloplasty (IDTA), Intradiscal Biaculoplasty (IDB), Intradiscal dual RF (IDRF), Intradiscal Pulsed RF (IPRF). RF of the communicant ramus and sympathetic ganglions may be performed for discogenic segmental pain. Caudal, epidural transforaminal steroid injections, epidural neuroplasty, dorsal root ganglion (DRG) pulsed RF may be performed for radicular pain and failed back surgery syndrome (FBSS). Interventional pain management is a rapidly growing field. The importance of spinal interventional techniques in managing chronic spinal pain has been established on the basis of advances in imaging, neuroanatomic findings, and the development of precision diagnostic and therapeutic injection techniques. Numerous new procedures or modifications of old procedures are being introduced nearly every year in the last two decades. There is increasing evidence supporting the use of spinal interventional techniques in managing spinal pain.

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