Epidural Steroid Facet Joint Injections Augment the Outcomes of Percutaneous Lumbar Spinal Fixation for Post-discectomy Failed Surgery through Local Immunomodulation

Dear Editor, We read with interest the comprehensive literature review and commentary by Dr. Epstein of the risks of epidural and transforaminal steroid injections in the spine.[5] While this manuscript appears to be comprehensive, we are concerned with the lack of evidence in the opinions offered. We disagree with Dr. Epstein's understanding of the literature and makes unusual claims discrediting all interventional techniques even though the title says “epidural and transforaminal steroid injections in the spine.” Further, the author appears to not recognize that transforaminal injections and caudal epidural injections are in facet epidural injections.[8,9] Dr. Epstein has selected all the negative studies and provided seemingly erroneous interpretations of other literature leading to what we believe are best termed inappropriate conclusions. It would appear that her focus may have been on the contaminated epidural steroid injections resulting in meningitis. However, she postulated a multitude of other issues based on incidence of infection from contaminated steroids, projecting that epidural injections are typically short-acting and ineffective over the long-term, exposing patients to major risks and complications, with delay in surgery. Even the very unusually high and unimaginable complications she is describing in these manuscripts of adhesive arachnoiditis of 6-16%, intravascular injections, etc., along with other life-threatening complications are not based on the literature she has reviewed. Even with the extraordinary statements re: Complications in interventional pain procedures, they may well be less when compared with the risks of intraspinous fusion devices in which Dr. Epstein described maximal complication rates of 38%, reoperation rates of 85%, poor outcomes in 77%, along with high costs of the device.[7] Additionally, per Dr. Epstein many operations that are recommended are not necessary or are too complex.[6] The author, in the description of complications and outcomes of interlaminar and transforaminal epidural injections, seems to use the manuscript of facet joint nerve blocks by Manchikanti et al.[20] alleging 11.4% intravascular injury and 76.3% bleeding. This would be a gross misinterpretation of that study. There was no intravascular injury described in this manuscript by Manchikanti et al.,[20] which rather described intravascular entry, unrelated to epidural injections. An assessment of outcomes should describe at least all randomized trials. Instead Dr. Epstein appears to have picked only a few studies with negative results. Based on inadequate utilization of literature, she describes that patients are subject to major life-threatening risks, while delaying potential requisite surgery. Per above, prior reports by Dr. Epstein of surgical complications are enormous.[7] Overall this manuscript would be appropriate for describing the infectious complications based on contaminated steroid injection. Multiple manuscripts in literature[8,10,11,12,13,14,15,16,18,19,21,22,23,24,25,26] have shown equal effectiveness of epidural injections on a long-term basis, along with facet joint nerve blocks, even though that was not the subject of this review, and have shown significant improvement with outcomes of at least 50% pain relief with functional status improvement of 50% over a period of 2 years. A recent systematic review also confirmed these findings.[3] Multiple complications related to transforaminal epidural injections are justifiable;[8,9] however, these complications are related to mainly cervical epidural injections and based on the radicular entry and injection of particulate steroids. The author seems to make multiple statements not substantiated by literature. This trend extended to the clinical effectiveness, complications, and also costs and provides misinterpretations. She quotes Manchikanti et al.[20] as providing a multitude of data, which was not related to this manuscript or to other manuscripts.[17] The author has also made multiple statements regarding financial incentives not described in any of the manuscripts. The author also describes two major types of epidural spinal injections, translaminar and transforaminal; however, there is also a caudal epidural injection. In assessment of the efficacy of epidural injections, one would review all the literature; however, this review is lacking focus on selective literature and using the literature related to the complications in the efficacy. She also described one study by Manchikanti;[14] which was a positive study, and made no comments. Parr et al.[27] is cited in reference to short-term pain relief for disc herniation and radiculitis and evidence was lacking for both short- and long-term treatment from an earlier systematic review published in 2009 rather than using the manuscript published by Benyamin et al.[1] In fact, recent guidelines[8] and multiple systematic reviews[1,2,4,9,28] have provided similar evidence for interlaminar epidural injections, caudal epidural injections, and lumbar transforaminal epidural injections performed in interventional pain management settings under fluoroscopy with proper selection of patients. However, there is no evidence for transforaminal cervical epidural injections. Overall, this manuscript is confusing. It is our opinion that it provides multiple elements of misinformation rather than evidence-based opinions.

Background: Since the late 1940s, corticosteroids have been a mainstay class of agents in multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive effects. Epidural injections, with or without steroids, have been extensively used throughout the world. There are reports of epidural injections starting in 1901, with steroids being added to the local anesthetic since 1952, when steroids were administered into the sacral foramen. Purpose: Due to the extensive side effects of steroids in various injections, some have proposed limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the multiple side effects of the steroids have elevated the level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from common expressions of the day, the term “steroid distancing” began to be used and proposed for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and feasibility of steroid distancing in interventional pain management. Methods: This focused review of local anesthetics and steroids utilized in interventional pain management for epidural injections, peripheral nerve blocks, and intraarticular injections by multiple database searches. This is a focused narrative review and not a systematic review. Consequently, evidence synthesis was not performed traditionally, but was based on an overview of the available evidence. Results: No significant difference was identified based on whether steroids are added to local anesthetic or not for epidural as well as facet joint injections. However, there was not enough evidence to compare these 2 groups for peripheral intraarticular injections. Limitations: The present review is limited by the paucity of literature with bupivacaine alone or bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee, hip, shoulder and other joints, and intraarticular facet joint injections. Conclusion: This review shows an overall lack of significant difference between lidocaine alone and lidocaine with steroids in epidural injections. However, available evidence is limited for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate patient selection and steroids reserved for non-responsive patients with local anesthetic and with significant radiculitis. Key words: Steroid distancing, chronic pain, steroids, epidural injections, local anesthetic alone, local anesthetic with steroid, steroid distancing, physical distancing

Revisión del tratamiento con corticoides en el dolor de espalda según la medicina basada en la evidencia

Treatment of lumbosacral radiculopathy with epidural steroids.

Inadvertent lumbar facet joint injection during an interlaminar epidural steroid injection (ESI) is rare when using the loss-of-resistance technique. The pattern of contrast material on the lateral view can mimic that of a successful ESI. The purpose of this study is to illustrate the imaging features of this event. From 2001 to 2009, 6,631 interlaminar lumbar ESIs were performed. Cases in which facet joint injection was recognized by the radiologist were identified by a text search of the report for the term "facet" and corroborated by review of the case images and the patients' medical records. Forty-two positive events were identified. Imaging features are characteristic and include sigmoid-shaped area of contrast material projecting over the posterior elements on the lateral view and an ovoid area of contrast material projecting over the facet joints on the anteroposterior (AP) view. Thirty-one out of 42 events were recognized by the operator during the procedure. In 17 cases, the final images documented the appropriate location of the needle tip within the epidural space. In 9 cases, simultaneous epidural and facet joint injection occurred. In 16 cases, epidural contrast material was not documented. Lumbar facet joint injection has a characteristic appearance and can be distinguished from epidural injection. However, since this event can simulate the appearance of a successful ESI, it may be unrecognized during the procedure. Therefore, the true incidence is likely higher than that suggested by this study. Recognizing the imaging features of this event permits the operator to further manipulate the needle tip and increase the success rate of ESIs.

Background: The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, starting in 1901 with local anesthetic alone, conflicting recommendations have been provided, despite the extensive literature. Recently Chou et al performed a technology assessment review for Agency for Healthcare Research and Quality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multiple other publications have supported the efficacy and use of epidural injections. Purpose: To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic and separate facts from opinions. Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed through August 2015. Study Selection: Randomized trials, either placebo or active control, of epidural injections for lumbar radiculopathy and spinal stenosis. Data Extraction: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis. Data Synthesis: Thirty-nine randomized controlled trials met inclusion criteria. There were 9 placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid. Results A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy. A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months. Limitations: The review was restricted to the data available with at least 3 months of followup, which excluded some studies. The inclusion criteria were restricted to English language studies. Conclusion: Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective. Key Words: Epidural injections, epidural steroids, lumbar radiculopathy, spinal stenosis, lidocaine, steroids, bupivacaine

BackgroundLumbar spinal stenosis is one of the most common causes of low back pain among older adults and can cause significant disability. Despite its prevalence, treatment of spinal stenosis symptoms remains controversial. Epidural steroid injections are used with increasing frequency as a less invasive, potentially safer, and more cost-effective treatment than surgery. However, there is a lack of data to judge the effectiveness and safety of epidural steroid injections for spinal stenosis. We describe our prospective, double-blind, randomized controlled trial that tests the hypothesis that epidural injections with steroids plus local anesthetic are more effective than epidural injections of local anesthetic alone in improving pain and function among older adults with lumbar spinal stenosis.MethodsWe will recruit up to 400 patients with lumbar central canal spinal stenosis from at least 9 clinical sites over 2 years. Patients with spinal instability who require surgical fusion, a history of prior lumbar surgery, or prior epidural steroid injection within the past 6 months are excluded. Participants are randomly assigned to receive either ESI with local anesthetic or the control intervention (epidural injections with local anesthetic alone). Subjects receive up to 2 injections prior to the primary endpoint at 6 weeks, at which time they may choose to crossover to the other intervention.Participants complete validated, standardized measures of pain, functional disability, and health-related quality of life at baseline and at 3 weeks, 6 weeks, and 3, 6, and 12 months after randomization. The primary outcomes are Roland-Morris Disability Questionnaire and a numerical rating scale measure of pain intensity at 6 weeks. In order to better understand their safety, we also measure cortisol, HbA1c, fasting blood glucose, weight, and blood pressure at baseline, and at 3 and 6 weeks post-injection. We also obtain data on resource utilization and costs to assess cost-effectiveness of epidural steroid injection.DiscussionThis study is the first multi-center, double-blind RCT to evaluate the effectiveness of epidural steroid injections in improving pain and function among older adults with lumbar spinal stenosis. The study will also yield data on the safety and cost-effectiveness of this procedure for older adults.Trial RegistrationClinicaltrials.gov NCT01238536

Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing spinal pain. To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. In managing lumbar radicular pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.

Multistate Outbreak of Fungal Infection Associated With Injection of Methylprednisolone Acetate Solution From a Single Compounding Pharmacy—United States, 2012

Regenerative injection-based therapy has established itself as a therapeutic option for the management of a variety of painful musculoskeletal conditions. The aim of this work was to review the current literature regarding regenerative injection therapy for axial/radicular spine pain. A comprehensive literature review was conducted on the use of regenerative medicine for axial/radicular spine pain. Eligible articles analyzed the therapeutic injection effects of platelet-rich plasma (PRP), prolotherapy, or mesenchymal signaling cells (MSCs) via intradiscal, facet joint, epidural, or sacroiliac joint delivery. Regarding intradiscal PRP, there are level I/IV studies supporting its use. Regarding intradiscal prolotherapy, there are level III to IV studies supporting its use. Regarding intradiscal MSCs, there are level I/IV studies supporting its use with the exception of one level IV study that found no significant improvement at 12 months. Regarding facet joint injections with PRP, there are level I/IV studies supporting its use. Regarding facet joint injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate any statistical significance supporting its use. Regarding epidural injections with PRP, there are level I/IV studies supporting its use. Regarding epidural injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate statistical significance beyond 48 hours. Regarding sacroiliac joint injections with PRP, there are level I/IV studies supporting its use. Regarding sacroiliac joint injections with prolotherapy, there are level I/III studies supporting its use. Currently, there are level I studies to support the use of PRP and MSC injections for discogenic pain; facet joint injections with PRP; epidural injections of autologous conditioned serum and epidural prolotherapy; and PRP and prolotherapy for sacroiliac joint pain. One level I study showed that facet joint prolotherapy has no significant benefit. Notably, no intervention has multiple published level I studies.

Injection with anaesthetics and/or steroids is one of the treatment modalities used in patients with chronic low back pain which needs evaluation with respect to the effectiveness on short and long term pain relief. To evaluate the effectiveness of injection therapy in patients with low back pain lasting longer than one month. We distinguished between three injection sites: facet joint, epidural or local injections. We searched the Medline and Embase databases up to 1996 and other search methods as advocated by the Back Review Group search strategy. Abstracts and unpublished studies were not included. Randomized controlled trials of injection therapy for pain relief (although additional treatments were allowed) in patients with benign low back pain lasting longer than one month and not originating from cancer. Two authors independently assessed the trials for methodological quality. Subgroup analyses were made between trials with different control groups (placebo and active injections), with different injection site (facet joint, epidural and local injection), and timing of outcome measurement (short and long term). Within the resulting 12 subcategories of studies (2*3*2), the overall relative risks and corresponding 95% confidence intervals were estimated, using a random effects model (DerSimonian and Laird). In the case of trials in which control groups were active injections, we refrained from pooling the results. Twenty-one randomized trials were included in this review. All studies involved patients with low back pain lasting longer than one month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: only 8 studies had a methodologic score of 50 or more points. There were only three well designed explanatory clinical trials: one on injections into the facet joints with a short-term RR of 0.89 (95% CI: 0.65-1.21) and a long-term RR of 0.90 (95% CI: 0.69-1.17); one on epidural injections with a short-term RR of 0.94 (95% CI: 0.76-1.15) and a long-term RR of 1.00 (95% CI: 0.71-1.41); and one on local injections with a long-term RR of 0.79 (95% CI: 0.65-0.96). Within the 6 subcategories of explanatory studies the pooled RRs with 95% confidence intervals were: facet joint, short-term: RR=0.89 (0.65-1.21); facet joint, long-term: RR=0.90 (0.69-1.17); epidural, short-term: RR=0.93 (0.79-1.09); epidural, long-term: RR=0.92 (0.76-1.11); local, short-term: RR=0.80 (0.40-1.59); local, long-term: RR=0.79 (0.65-0.96). Convincing evidence is lacking on the effects of injection therapies for low back pain. There is a need for more, well designed explanatory trials in this field.

Injection with anaesthetics and/or steroids is one of the treatment modalities used in patients with chronic low back pain which needs evaluation with respect to the effectiveness on short and long term pain relief. To evaluate the effectiveness of injection therapy in patients with low back pain lasting longer than one month. We distinguished between three injection sites: facet joint, epidural or local injections. We searched the Medline and Embase databases up to 1996 and other search methods as advocated by the Back Review Group search strategy. Abstracts and unpublished studies were not included. Randomized controlled trials of injection therapy for pain relief (although additional treatments were allowed) in patients with benign low back pain lasting longer than one month and not originating from cancer. Two reviewers independently assessed the trials for methodological quality. Subgroup analyses were made between trials with different control groups (placebo and active injections), with different injection site (facet joint, epidural and local injection), and timing of outcome measurement (short and long term). Within the resulting 12 subcategories of studies (2*3*2), the overall relative risks and corresponding 95% confidence intervals were estimated, using a random effects model (DerSimonian and Laird). In the case of trials in which control groups were active injections, we refrained from pooling the results. Twenty-one randomized trials were included in this review. All studies involved patients with low back pain lasting longer than one month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: only 8 studies had a methodologic score of 50 or more points. There were only three well designed explanatory clinical trials: one on injections into the facet joints with a short-term RR of 0.89 (95% CI: 0.65-1.21) and a long-term RR of 0.90 (95% CI: 0.69-1.17); one on epidural injections with a short-term RR of 0.94 (95% CI: 0.76-1.15) and a long-term RR of 1.00 (95% CI: 0.71-1.41); and one on local injections with a long-term RR of 0.79 (95% CI: 0.65-0.96). Within the 6 subcategories of explanatory studies the pooled RRs with 95% confidence intervals were: facet joint, short-term: RR=0.89 (0.65-1.21); facet joint, long-term: RR=0.90 (0.69-1.17); epidural, short-term: RR=0.93 (0. 79-1.09); epidural, long-term: RR=0.92 (0.76-1.11); local, short-term: RR=0.80 (0.40-1.59); local, long-term: RR=0.79 (0.65-0. 96). Convincing evidence is lacking on the effects of injection therapies for low back pain. There is a need for more, well designed explanatory trials in this field.

Aim The study aims to examine the long-term outcomes of foraminal epidural injection and facet joint injection therapies in patients over the age of 60 who have been recommended for surgical intervention for degenerative spinal diseases but have declined surgical treatment due to comorbidities, anesthesia risks, and surgical risks. Methods Between 2018-2019, patients over the age of 60 diagnosed with Degenerative Spinal Disease who declined the recommended surgical treatment and underwent foraminal epidural and facet joint injection therapies were retrospectively evaluated. Patients were assessed using the visual pain scale and MacNab classifications during an average follow-up period of 57.14 (45-68) months. Inclusion criteria for the study included patients being continuously followed up and treated at the same center, regularly attending check-up examinations, and not having emergency surgical indications. Results The study included 35 patients with an average follow-up period of 57.14 months. Patients were treated with either facet joint or foraminal epidural injections in a single session based on their symptoms and complaints. The most striking result of our study is that the visual pain scale and MacNab classification outcomes after spinal injection therapy can be used as indicators for long-term results. Conclusion Sharing the outcomes of commonly practiced spinal injection therapies in the literature more frequently will provide guidance for the treatment planning of challenging conditions, especially like degenerative spinal disease.

It Is Time to Abandon Atlanto-Axial Joint Injections: Do No Harm!

Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is limited. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is limited. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for shortterm relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. Conclusion: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.” Key words: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions, epidural injections, epidural adhesiolysis, discography, radiofrequency, disc decompression, vertebroplasty, kyphoplasty, spinal cord stimulation, intrathecal implantable systems