Axial Low Back Pain Research Articles

Twelve-month results from a randomized controlled trial comparing differential target multiplexed spinal cord stimulation and conventional spinal cord stimulation in subjects with chronic refractory axial low back pain not eligible for spine surgery

BackgroundSuccessful treatments for intractable chronic low back pain (CLBP) in patients who are not eligible for surgical interventions are scarce. The superior efficacy of differential target multiplexed spinal cord stimulation (DTM SCS) to conventional SCS (Conv-SCS) on the treatment of CLBP in patients with persistent spinal pain syndrome (PSPS) who have failed surgical interventions (PSPS-T2) motivated the evaluation of DTM SCS versus Conv-SCS on PSPS patients who are non-surgical candidates (PSPS-T1). MethodsThis is a prospective, open label, crossover, post-market randomized controlled trial in 20 centers across the United States. Eligible patients were randomized to either DTM SCS or Conv-SCS in a 1:1 ratio. Primary endpoint was CLBP responder rate (percentage of subjects with ≥50% CLBP relief) at 3-month in randomized subjects who completed trialing (modified intention-to-treat population). Patients were followed up to 12 months. Secondary endpoints included change of CLBP and leg pain, responder rates, changes in disability, quality of life, patient satisfaction and global impression of change, and safety profile. An optional crossover was available at 6-month to all patients. Results121 PSPS-T1 subjects with CLBP and leg pain mostly associated with degenerative disc disease and radiculopathy and who were not eligible for spine surgery were randomized. CLBP responder rate with DTM SCS (93.5%) was superior to Conv-SCS (36.4%) at the primary endpoint. Superior CLBP responder rates (88.1-90.5%) were obtained with DTM SCS at all other timepoints. Mean CLBP reduction with DTM SCS (6.52 cm) was superior to that with Conv-SCS (3.01 cm) at the primary endpoint. Similar CLBP reductions (6.23-6.43 cm) were obtained with DTM SCS at other timepoints. DTM SCS provided significantly better leg pain reduction and responder rate, improvement of disability and quality of life, and better patient satisfaction and global impression of change. 90.9% of Conv-SCS subjects who crossed over were CLBP responders at completion of the study. Similar safety profiles were observed between the two groups. ConclusionDTM SCS for chronic CLBP in non-surgical candidates is superior to Conv-SCS. Improvements were sustained and provided significant benefits on the management of these patients.

Potential Cost Savings with 60-day Peripheral Nerve Stimulation Treatment in Chronic Axial Low Back Pain.

Chronic axial low back pain (CLBP) that is not responsive to medication management or physical therapy often requires significant clinical intervention. Several interventional pain management options exist, including a 60-day peripheral nerve stimulation (PNS) treatment. This economic evaluation investigated the potential for projected cost savings associated with prioritizing 60-day PNS treatment relative to a 'standard of care' (SOC) approach (where patients do not have access to 60-day PNS). A decision tree (supervised machine learning) model tracked treatment progression across two hypothetical cohorts of US patients with CLBP in whom non-interventional options were ineffective (Cohort A: treatment starting with 60-day PNS followed by any additional interventional and surgical treatments versus Cohort B: standard of care interventional and surgical treatments without access to 60-day PNS). Treatment efficacy estimates were based on published success rates. Conditional on treatment failure, up to two additional interventions were considered within the 12-month time frame in both cohorts. SOC treatment options included epidural injection, radiofrequency ablation (RFA), basivertebral nerve ablation (BVNA), PNS permanent implant (PNS-PI), spinal cord stimulator (SCS) trial/implant, and spinal fusion surgery. Treatment choice probabilities in both cohort algorithms were based on clinician interviews. Costs were based on national Medicare reimbursement levels in the ambulatory surgery center (ASC) setting. Savings reflected the difference in projected costs between cohorts. A Monte Carlo simulation and sensitivity analyses were conducted to generate confidence intervals and identify important inputs. The treatment algorithm which prioritized initial 60-day PNS treatment was projected to save $8056 (95% CI $6112-$9981) per patient during the first year of interventional treatment relative to the SOC approach. Use of the 60-day PNS treatment as an initial interventional treatment in patients with CLBP may result in significant savings for Medicare. Projected savings may be even larger for commercial payers covering non-Medicare patients.

European randomized controlled trial evaluating differential target multiplexed spinal cord stimulation and conventional medical management in subjects with persistent back pain ineligible for spine surgery: 24-month results.

Differential target multiplexed spinal cord stimulation (DTM SCS) was shown to be superior to conventional SCS for treating chronic low back pain (CLBP) in subjects with persistent spinal pain syndrome with previous spinal surgery (PSPS-T2) or ineligible for it (PSPS-T1). This study reports 24-month efficacy and safety of DTM SCS vs. conventional medical management (CMM) in PSPS-T1 subjects across four European countries. This is a prospective, multicenter, open-label, randomized, controlled trial with optional crossover. Subjects randomized 1:1 to DTM SCS or CMM. Primary endpoint was responder rate (% subjects reporting ≥50% CLBP relief) at 6 months. A superiority test compared responder rates between treatments. CLBP and leg pain levels, functional disability, quality of life (QoL), patient satisfaction and global impression of change were evaluated for 24 months. A Composite Responder Index (CRI) was obtained using CLBP relief, disability and QoL. Incidence of study-related adverse events evaluated safety. A total of 55 and 57 subjects were randomized to DTM SCS and CMM respectively. DTM SCS was superior, with CLBP responder rates ≥80% and CLBP relief >5.6 cm (>70% reduction) through the 24-month follow-up. Improvements with DTM SCS in other outcomes were sustained. The CRI was >80% for DTM SCS through 24 months. Opioid medication intake decreased in subjects treated with DTM SCS. Most patients treated with DTM SCS felt satisfied and improved at the end of the study. Safety was congruent with other studies. DTM SCS is efficacious and safe during 24 months for the treatment of CLBP and leg pain in PSPS-T1 patients ineligible for spine surgery. This randomized controlled trial shows that Differential Target Multiplexed SCS (DTM SCS) is an effective and safe long-term treatment for PSPS type 1 patients suffering from axial low back pain with or without leg pain and who are ineligible for spinal surgery. Currently, CMM treatments are their only option and provide limited benefits. Besides superior pain relief, DTM SCS provides significant improvements in functional disability, quality of life, high levels of satisfaction and perceived impression of change.

Surgical treatment of refractory low back pain using implanted BurstDR spinal cord stimulation (SCS) in a cohort of patients without options for corrective surgery: Findings and results from the DISTINCT study, a prospective randomized multi-center-controlled trial

Background: Low back pain (LBP) is a highly prevalent, disabling condition affecting millions of people. Patients with an identifiable anatomic pain generator and resulting neuropathic lower extremity symptoms often undergo spine surgery, but many patients lack identifiable and/or surgically corrective pathology. Nonoperative treatment options often fail to provide sustained relief. Spinal cord stimulation (SCS) is sometimes used to treat these patients, but the lack of level 1 evidence limits its widespread use and insurance coverage. The DISTINCT RCT study evaluates the efficacy of passive recharge burst SCS compared to conventional medical treatment (CMM) in alleviating chronic, refractory axial low back pain. MethodsThis prospective, multicenter, randomized, study with an optional 6-month crossover involved patients who were not candidates for lumbar spine surgery. The primary and secondary endpoints evaluated improvements in low back pain intensity (NRS), back pain-related disability (ODI), pain catastrophizing (PCS), and healthcare utilization. Patients were randomized to SCS therapy or CMM at 30 US study sites. ResultsThe SCS arm reported a 85.3% NRS responder rate (≥ 50% reduction) compared to 6.2% (5/81) in the CMM arm. After the 6M primary endpoint, SCS patients elected to remain on assigned therapy and 66.2% (49/74) of CMM patients chose to trial SCS (crossover). At the 12M follow-up, SCS and crossover patients reported 78.6% and 71.4% NRS responder rates. Secondary outcomes indicated significant improvements in ODI, PCS, and reduced healthcare utilization. Six serious adverse events were reported and resolved without sequelae. ConclusionDISTINCT chronic low back pain patients with no indication for corrective surgery experienced a significant and sustained response to burst SCS therapy for up to 12 months. CMM patients who crossed over to the SCS arm reported profound improvements after 6 months. This data advocates for a timely consideration of SCS therapy in patients unresponsive to conservative therapy.

Vacuum Disc Phenomenon Turned Gassy Disc Herniation: A Case Report

BACKGROUND: The vacuum phenomenon is a radiologic finding that results from gas accumulation within degenerated discs, joints, or vertebrae. This gas can herniate, causing back pain and/or radiculopathy. Asymptomatic imaging abnormalities can be coincidental and/or non-concordant with clinical presentation therefore warranting close evaluation. CASE REPORT: This 45-year-old man, previously diagnosed with lumbar facet arthropathy, returned to the clinic for left-sided axial low back pain. Imaging revealed that a gas filled mass in the right lateral recess was affecting the traversing right L5 and S1 nerve roots. Given the exclusive axial symptoms consistent with lumbar zygapophyseal joint arthropathy, the patient was treated with a repeat L3-4 medial branch and L5 dorsal ramus radiofrequency ablation and experienced subsequent near-complete pain resolution. CONCLUSIONS: Careful consideration must be taken when conducting clinical evaluation, imaging, diagnosis, and treatment of patients with low back pain given the significant frequency of abnormal, often nonconcordant, radiological findings. KEY WORDS: Pneumorrhachis, vacuum disc phenomenon, low back pain, case report

Intradiscal Steroid Injections for Degenerative Disc Disease With Modic Changes: A Retrospective Study of Therapeutic and Diagnostic Features.

Anterior column pain refers to axial low back pain (LBP) originating from the intervertebral disc or vertebral endplates (discogenic or vertebrogenic pain). We sought to assess the safety and effectiveness of intradiscal steroid injection (IDSI) in diagnosing and treating patients with LBP arising from the anterior column. This is a retrospective chart review of 66 patients who underwent 77 injections in an outpatient, private practice setting for the treatment of chronic lower back with history and physical exam findings indicating an origin within the anterior column and magnetic resonance imaging (MRI) findings of Modic changes associated with disc degeneration of grade 4 or above on the modified Pfirrmann scale. Patients reported pain as measured by the numerical rating scale (NRS) before the injection, at the time of their follow-up, and their maximum pain relief. The primary outcome was the change in NRS before and after the injections. The secondary outcome determined if the changes in the subjects' NRS met the minimal clinically important change (MCIC) criteria for LBP. We conducted a statistical analysis using a paired sample t-test. There was a statistically significant difference between the pre-injection and follow-up NRS scores (p < 0.001) and a significant difference between pre-injection and maximum relief NRS scores (p < 0.001). Most subjects (55/77, 71.4%) met the MCIC to relieve their chronic LBP at the time of the follow-up evaluation. For patients with chronic LBP and degenerative endplate changes, IDSIs provided these patients with significant short-term pain relief from pain arising from the anterior column.

Long-term effects of lumbar flexion versus extension exercises for chronic axial low back pain: a randomized controlled trial

This study aimed to compare the long-term effects of flexion- and extension-based lumbar exercises on chronic axial low back pain (LBP). This was a 1-year follow-up of a prospective, assessor-blind, randomized controlled trial. Patients with axial LBP (intensity ≥ 5/10) for > 6 months allocated to the flexion or extension exercise group. Patients underwent four sessions of a supervised treatment program and were required to perform their assigned exercises daily at home. Clinical outcomes were obtained at baseline, 1, 3, 6 months, and 1-year. A total of 56 patients (age, 54.3 years) were included, with 27 and 29 in the flexion and extension groups, respectively. Baseline pain and functional scales were similar between both groups. The mean (± standard deviation) baseline average back pain was 6.00 ± 1.00 and 5.83 ± 1.20 in the flexion and extension groups, respectively. At 1-year, the average pain was 3.78 ± 1.40 and 2.26 ± 2.62 (mean between-group difference, 1.52; 95% confidence interval 0.56–2.47; p = 0.002), favoring extension exercise. The extension group tended to have more improvements in current pain, least pain, and pain interference than the flexion group at 1-year. However, there was no group difference in worst pain and functional scales. In this controlled trial involving patients with chronic axial LBP, extension-based lumbar exercise was more effective in reducing pain than flexion-based exercises at 1-year, advocating lumbar extension movement pattern as a component for therapeutic exercise for chronic LBP.Clinical Trial Registration No.: NCT02938689 (Registered on www.clinicaltrial.gov; first registration date was 19/10/2016).

Comparison of the efficacy of lumbar erector spinae plane block for chronic axial low back pain in geriatric and younger patients: Results of a retrospective study

Introduction: The lumbar erector spinae plane block is one of the interventional procedures for chronic low back pain. This study aimed to compare the efficacy of lumbar erector spinae plane block for chronic axial low back pain due to disc protrusion/bulging in geriatric and younger patients and to evaluate clinical, demographic, and radiological characteristics that may be associated with treatment success. Materials and Method: The clinical and demographic data of patients who underwent ultrasound-guided lumbar erector spinae plane block for chronic axial low back pain between November 2022 and July 2023 were retrospectively evaluated. Patients were divided into two groups, ≥65 and &lt;65 years of age, and treatment efficacy at the third month after the procedure was evaluated and compared. Results: A total of 147 patients (75 patients aged &lt;65 years and 72 patients aged ≥65 years) were included in the analysis, and a successful treatment response (at least 50% pain relief) was achieved in 44.4% of geriatric patients and 62.6% of younger patients (p=0.027). In addition BMI, comorbidity, opioid use, and lumbar paraspinal fatty infiltration were significantly higher in geriatric patients than in younger patients (p&lt;0.05). Conclusion: The results of this study demonstrate that lumbar erector spinae plane block for chronic axial low back pain provides significantly less pain relief in geriatric patients than in younger patients at three-month follow-up. Keywords: Lower back pain; Aged; Injection; Ultrasound imaging

Lumbar Dorsal Root Ganglion Pulsed Radiofrequency for Spinal Stenosis with an Atypical Fluoroscopic Neurogram: A Case Study

Background: We present a case of an atypical fluoroscopic neurogram pattern for complex chronic axial low back pain during a lumbar dorsal root ganglia (DRG) pulsed radiofrequency stimulation. Case Report: A 70 year old female with a history of complex chronic axial low back pain with radicular leg pain. Initially her pain was described as intermittent, burning, and sharp with an intensity of 9/10 on the Numeric Rating Scale (NRS). This pain worsens with ambulation, lumbar extension, turning, weight bearing and spinal loading activities. MRI imaging noted lumbar anterolisthesis, moderate to severe central spinal stenosis, and mild bilateral neural foraminal space narrowing. From these findings, her pain is likely secondary to components of sacroiliac (SI) joint dysfunction, lumbar facetogenic pain, lumbar radiculitis, and spinal stenosis with neurogenic claudication. A multimodal and multidisciplinary rehabilitation approach involving minimally invasive interventional procedures and medication management was implemented with varying pain relief. She responded to L5 transforaminal epidural nerve root injections, SI joint prolotherapy, and sacral lateral branch radiofrequency ablation. She completed bilateral L5 DRG pulsed radiofrequency stimulation, which did not provide radicular pain relief. We performed a unilateral L4 DRG pulsed radiofrequency stimulation, which revealed an atypical L4 fluoroscopic neurogram pattern. At the 3 month follow up she reported the pain severity to have a NRS between 7-8/10. At 4 months, the pain severity was reported to have a NRS between 4-6/10 with subjective improvements with her daily activities. Conclusion: In a normal transforaminal epidural fluoroscopic neurogram, the anteroposterior view should demonstrate contrast spread medially around the pedicle and laterally following the exiting nerve root. In the case of this patient the combined anatomical presentation of anterolisthesis, central spinal canal stenosis, and circumferential disc bulging are all potential reasons for insufficient contrast passage resulting in the atypical neurogram.

Systematic Review and Meta-Analysis of Effectiveness of Therapeutic Sacroiliac Joint Injections

BACKGROUND: The sacroiliac joint is one of the proven causes of low back and lower extremity pain, ranging from 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis. Despite the difficulty of diagnosis, multiple therapeutic modalities including surgical and nonsurgical interventions have been utilized. Among the interventional modalities, intraarticular injections are commonly utilized. OBJECTIVE: To evaluate the therapeutic effectiveness of intraarticular injections in the sacroiliac joint. STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies of the therapeutic effectiveness of intraarticular injections of the sacroiliac joint utilizing the Preferred Reporting Items For Systematic Reviews And Meta-Analyses (PRISMA) checklist. METHODS: The available literature on therapeutic sacroiliac joint intraarticular injections was reviewed. The quality assessment criteria utilized were the Cochrane review criteria to assess risk of bias, the Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials, and the Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for nonrandomized studies. The level of evidence was based on best evidence synthesis with modified grading of qualitative evidence from Level I to Level V. Data collection was performed including literature published from 1966 through December 2022, as well as manual searches of the bibliographies of known articles. OUTCOME MEASURES: Primary outcome measures include pain relief and improvement in functional status at 3 months for a single intervention. Only the studies performed under fluoroscopic guidance, with at least 3 months of follow-up were included. Duration of relief was categorized as short-term (&lt; 6 months) and long-term (&gt; 6 months). RESULTS: Based on the qualitative and quantitative analyses with a single-arm meta-analysis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, and the inclusion of 11 RCTs (5 positive, 6 negative) and 3 observational studies (2 positive, one negative), the evidence was Level III or fair in managing low back pain of sacroiliac joint origin with sacroiliac joint injections. LIMITATIONS: This systematic review and meta-analysis are limited by lack of eligible studies, inconsistencies among the available studies, variations in techniques, variable diagnostic standards for inclusion criteria, and finally, the inability to correlate the results and perform an optimal systematic review and meta-analysis. CONCLUSION: The present systematic review and meta-analysis show an inability to perform conventional dual-arm analysis, whereas a single-arm meta-analysis demonstrated a difference of approximately 3 points on the Numeric Rating Scale (NRS) and 8 points on the Oswestry Disability Index (ODI). However, there were no studies that considered &gt;= 50% relief as the criterion standard. Overall, the qualitative and quantitative evidence combined shows Level III or fair evidence for therapeutic sacroiliac joint injections for managing low back pain of sacroiliac joint origin. KEY WORDS: Chronic low back pain, sacroiliac joint pain, sacroiliac joint dysfunction, sacroiliitis, sacroiliac joint injection, sacroiliac joint nerve blocks, radiofrequency ablation, conventional radiofrequency, pulsed radiofrequency

3. Pain originating from the lumbar facet joints.

Pain originating from the lumbar facets can be defined as pain that arises from the innervated structures comprising the joint: the subchondral bone, synovium, synovial folds, and joint capsule. Reported prevalence rates range from 4.8% to over 50% among patients with mechanical low back pain, with diagnosis heavily dependent on the criteria employed. In well-designed studies, the prevalence is generally between 10% and 20%, increasing with age. The literature on the diagnosis and treatment of lumbar facet joint pain was retrieved and summarized. There are no pathognomic signs or symptoms of pain originating from the lumbar facet joints. The most common reported symptom is uni- or bilateral (in more advanced cases) axial low back pain, which often radiates into the upper legs in a non-dermatomal distribution. Most patients report an aching type of pain exacerbated by activity, sometimes with morning stiffness. The diagnostic value of abnormal radiologic findings is poor owing to the low specificity. SPECT can accurately identify joint inflammation and has a predictive value for diagnostic lumbar facet injections. After "red flags" are ruled out, conservatives should be considered. In those unresponsive to conservative therapy with symptoms and physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic medial branch block can be performed which remains the most reliable way to select patients for radiofrequency ablation. Well-selected individuals with chronic low back originating from the facet joints may benefit from lumbar medial branch radiofrequency ablation.

Quantification of needle angles for lumbar medial branch denervation targeting the posterior half of the superior articular process: an osteological study.

Lumbar medial branch radiofrequency ablation (RFA) is a common intervention to manage chronic axial low back pain originating from the facet joints. A more parasagittal approach targeting the posterior half of the lateral neck of superior articular process (SAP) was previously proposed. However, specific needle angles to achieve parallel placement at this target site have not been investigated. To quantify and compare the needle angles, on posterior and lateral views, to achieve parallel placement of electrodes along the medial branch at the posterior half of the lateral neck of SAP at each lumbar vertebral level (L1-L5) and sacrum. Osteological Study. Twelve disarticulated lumbosacral spines (n = 72 individual bones) were used in this study. Needles were placed along the periosteum of the posterior half of the lateral neck of SAP, bilaterally and photographed. Mean needle angles for each vertebral level (L1-L5) and sacrum were quantified, and statistical differences were analyzed. The posterior view provided the degrees of lateral displacement from the parasagittal plane (abduction angle), while the lateral view provided the degrees of declination (cranial-to-caudal angle) of the needle. Mean needle angles at each level varied, ranging from 5.63 ± 5.76° to 14.50 ± 14.24° (abduction angle, posterior view) and 40.17 ± 7.32° to 64.10 ± 9.73° (cranial-to-caudal angle, lateral view). In posterior view, a < 10-degree needle angle interval was most frequently identified (57.0% of needle placements). In lateral view, the 40-50-degree (L1-L2), 50-60-degree (L3-L5), and 60-70-degree (sacrum) needle angle intervals occurred most frequently (54.2%, 50.0%, and 41.7% of needle placements, respectively). Targeting the posterior half of the lateral neck of SAP required <10-degree angulation from parasagittal plane in majority of cases. However, variability of needle angles suggests a standard "one-size-fits-all" approach may not be the optimal technique.

ID: 214211 Spinal Cord Stimulation for Treatment of Horizontal Low Back Pain: A Retrospective Analysis

Chronic pain resulting from injury to the lumbar disc is often vaguely described as “axial low back pain” (ALBP). ALBP implies a vertical pain surrounding the axial spine, however patients with true ALBP often have pain that is reproducible on exam with either percussion and/or direct pressure. In addition, in our experience, patients with complaints of Horizontal LBP (HLBP) appear to have consistent radiological evidence of lumbar degenerative disc disease (DDD) and/or injury. Moreover, HLBP putatively exhibits a referred pain-pattern associated with lumbar disc pathology. Here, we describe a single-site, observational analysis of patients diagnosed with horizontal, low back pain (LBP) with radiographically-confirmed lumbar DDD who were treated using Spinal Cord Stimulation (SCS).

ID: 222376 Far-Contralateral Oblique (FCO) Sacroiliac Joint Injection: Description of a Novel Technique

Axial low back pain (LBP) has been one of the primary causes of years lived with a disability, and it continues to be an expanding burden on health systems as the global population continues to grow. Though some patients experience LBP originating from facet mediated and vertebrogenic pain, about 15-25% of patients with LBP have pain originating primarily from the sacroiliac joint (SIJ). As the treatments offered for SIJ mediated pain continue to evolve, appropriately diagnosing this diarthrodial joint as the primary pain mediator becomes even more critical. Traditionally, the intra-articular SIJ injections are targeted towards the inferior 1/3 of the SIJ. Due to patients’ variable anatomy and pathological changes that occur with time, accessing the joint from this area may become challenging. For the objective of our study, we propose entering the superior ⅓ of the SIJ, by way of an alternative far-contralateral oblique approach. Furthermore, to promote future studies on the efficacy of this approach and possibly comparing it with the traditional approach.

ID: 203311 Dorsal Root Ganglion Stimulation Outcomes for The Treatment Of Osteoarthritic Mechanical Knee Pain

DRG stimulation (DRG-S) is a form of neuromodulation used to treat CRPS type I or II (causalgia) of the groin and lower extremities. However, there is growing evidence that this therapy works for other chronic pain conditions such as chronic axial low back pain, which is mechanical or mixed mechanical/neuropathic type pain. In addition, DRG-S has demonstrated analgesic effectiveness in osteoarthritic preclinical rat pain models of the knee with peripheral pathologic origins. This pilot study will evaluate outcomes of patients trialed and implanted with the ProclaimTM DRG System to treat mechanical knee pain secondary to osteoarthritis.

ID: 220389 SCS in Patients Without Options for Corrective Surgery; Results From DISTINCT, a Prospective RCT Trial

Low back pain (LBP) is a highly prevalent, costly condition affecting millions of people worldwide across all sociodemographic classes. Those with an identifiable anatomic pain generator may undergo back surgery and achieve relief, but many are not candidates as they lack an identifiable surgically corrective pathology. Standard non-operative strategies include physiotherapy, oral analgesics, and image guided injections; these may not provide durable relief. Spinal cord stimulation is sometimes used to treat these patients but level I evidence is sparse. We present results from DISTINCT (NCT04479787), the largest RCT to date, comparing passive recharge burst SCS to conventional medical management (CMM) in patients suffering from chronic, refractory axial low back pain, who have not had lumbar spine surgery and for whom corrective surgery is not an option.

ID: 207032 Durability of Relief Following 60-day Percutaneous Medial Branch PNS Treatment for Chronic Low Back Pain

For patients with chronic axial low back pain (LBP), there is often clinical evidence of central nervous system sensitization and finding a clear source of nociceptive input or damage to the somatosensory system can be challenging. Conventional therapies that mask the pain can fail to address centrally-mediated, underlying causes of pain. Sixty-day percutaneous peripheral nerve stimulation (PNS) applied to medial branch nerves offers a non-opioid, non-destructive, and non-surgical treatment designed to restore the balance of peripheral inputs to the central nervous system and reverse maladaptive changes in central pain processing, which can be applied earlier in the treatment continuum than permanently-implanted neurostimulation systems. The objective of this large multicenter clinical trial was to characterize the responses to medial branch PNS in a prospective multicenter case series study in patients recalcitrant to multiple non-surgical treatments. Additional goals of the clinical trial were to determine which low back pain patient phenotypes may be more or less likely to respond to PNS.

Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management.

There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.

Боль в крестцово-подвздошном суставе

Pain originating in the sacroiliac joint (SIJ) is one of the potential causes of axial low back pain. A quarter of low back pain cases can be associated with the SIJ damage. The review presents the causes and current clinical data associated with the SIJ dysfunction, describes specific (provocation) tests used to detect the SIJ syndrome. Diagnostic tests and their effectiveness for differential diagnosis are described. The methods of instrumental diagnostics, conservative treatment, including manual therapy, and interventional options for treating patients with pain in the SIJ zone are described in detail.

The Effectiveness of Intraosseous Basivertebral Nerve Ablation in the Treatment of Nonradiating Vertebrogenic Pain: A Systematic Review.

Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This systematic review aims to determine the efficacy of intraosseous basivertebral nerve radiofrequency ablation in treating nonradiating axial chronic LBP compared to standard therapy, sham, or without contrast. The population of interest is individuals greater than or equal to 18 years old with chronic nonradiating vertebrogenic pain. The key outcome was the percentage of patients with greater than or equal to 50% pain reduction, greater than or equal to 10-point improvement in function and disability measured by the Oswestry Disability Index (ODI), greater than or equal to two-point pain reduction in the visual analog scale (VAS) or numerical pain rating scale, and a decrease in opioid utilization by 10 morphine milligram equivalents. Three databases, PubMed, MEDLINE, and Google Scholar, were used to retrieve the studies for the review. Two independent reviewers assessed the studies for inclusion using the validated tools for quality appraisal.There were 286 articles in total; however, only 11 publications with extensive data on 413 participants matched the inclusion criteria and were used for this review.At three months, a majority of theparticipants reported greater than or equal to 10-point improvement in the ODI, a measure of functional and disability improvement on a 10-point scale, and greater than or equal to two-point improvement in the VAS. A good number of patients in the basivertebral nerve ablation (BVNA) arm reported complete pain resolution demonstrating therapy success and the superiority of BVNA over sham and standard treatment. Basivertebral nerve radiofrequency ablation, among other criteria, is a safe and minimally invasive therapy that significantly lowers pain and impairment in individuals with vertebrogenic pain with distinct Modic type 1 and 2 changes at lumbar vertebra three-sacral vertebra one (L3-S1) vertebral levels. Proper patient selection and exact procedural methods are essential to the success of basivertebral nerve neurotomy. The findings of the existing investigations require confirmation by nonindustry-funded, large-scale, high-quality trials using generalizable study participants.