Chronic Axial Low Back Pain Research Articles

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.

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 <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 <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<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.

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: 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: 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.

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.

Endoscopic transection of right L3 and L4 medial branch nerves and L5 dorsal ramus: A 2-dimensional operative video

Zygapophyseal joints in the lumbar spine are innervated by medial branches of the dorsal rami of spinal nerves and have been implicated in the generation of axial low back pain. Percutaneous radiofrequency ablation procedures target bony landmarks under fluoroscopic guidance near the anticipated location of medial branches and dorsal rami. In contrast, endoscopic visualization allows for surgical transection of the targeted nerves through either direct visualization or dissection and ablation of the tissues surrounding the expected trajectory of the nerves. Endoscopic transection of medial branches and dorsal rami has been suggested as a possible alternative to percutaneous radiofrequency lesioning although further research is needed to define indications, explore relative risks and benefits, and evaluate efficacy by directly comparing these two techniques. In this video, we present a case of a female with chronic axial low back pain that was refractory to conservative care including physical therapy, exercise, facet steroid injections, and analgesic medications. After positive response to blocking the L3, L4 medial branch nerves and the L5 dorsal ramus, the patient underwent multiple percutaneous radiofrequency ablations, which provided progressively shorter duration of relief. With her persistent symptoms suggestive of facet-mediated lumbar back pain, endoscopic transection was offered as an alternative approach. We provide an operative video including discussion of imaging, target anatomy and operative steps for endoscopically-visualized transection of the L3 and L4 medial branch nerves and the L5 dorsal ramus on the right side.

Epidural Steroid Injection Versus Conservative Measures in Treatment of Chronic Axial Low Back Pain, A Prospective Randomized Controlled Study

Chronic low back pain (CLBP) is a very common disorder with various management strategies. There is still debate regarding treatment alternatives for axial CLBP. This study aimed to compare the effect of epidural steroid injection (ESI), interferential current (IFC) therapy and core strengthening exercises in a prospective randomized controlled manner. Hence, sixty patients complaining of axial CLBP were included and randomly assigned into either a group of ESI and exercises (group A) or IFC and exercises (group B) or exercises only (group C); each group was of 20 patients. Outcomes were visual analogue scale (VAS) for pain, Oswestry disability index (ODI) for function and Beck's depression inventory (BDI) for depression, assessed at baseline and 3-, 6- and 12-week follow-ups. At the start of the study, there were no significant differences between the three groups in age, gender, cause and duration of CLBP, body mass index, abdominal muscle power, muscle spasm or tenderness (p &gt; 0.05). Significant improvement in VAS and ODI at 3-, 6- and 12-weeks was observed compared to baseline assessment in the three studied groups. The improvement was higher for group A compared to B and C. BDI was significantly improved in group A and C at 3 weeks, and in all groups at 6- and 12-weeks compared to baseline. However, at the end of the study, there was no significant difference in the BDI between the three groups. From this study and over a period of 3 months, all studied groups showed improvement in pain, function, and depression but the group who received epidural steroid injection with core strengthening exercises was statistically better than the other two groups, with significant improvement in pain and function, but not in depression. Early effective assessment and dealing with depression, even prophylactic treatment and cognitive behavioral therapy should be addressed. Trial registration: The Pan African Clinical Trial Registry (www.pactr.org) identification number is PACTR201901523042787 on 16 January 2019.

The Role of Exercise in Treating Low Back Pain.

The purpose of this review is to highlight the role of exercise in preventing and managing acute and chronic axial low back pain (LBP). LBP is one of the leading contributors to years lived with disability as well as health care expenditures in the United States. With an expected increase in prevalence due to an aging population, sports medicine providers have a unique opportunity to provide effective treatment strategies incorporating exercise advice and prescription. Although the majority of individuals with acute LBP will have their symptoms resolve spontaneously, almost 40% will have recurrence or develop chronic LBP within 1 year. No single exercise method has been shown to be more effective than another. The evidence for walking programs, aerobic exercise, yoga, Pilates, and tai chi for LBP is discussed. Our review summarizes the beneficial role of a personalized exercise program and related counseling strategies in the prevention and management of LBP.

Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review.

Chronic low back pain remains highly prevalent, costly, and the leading cause of disability worldwide. Symptoms are complex and treatment involves an interdisciplinary approach. Due to diverse anatomical etiologies, treatment outcomes with interventional options are highly variable. A novel approach to treating chronic axial low back pain entails the use of peripheral nerve stimulation to the lumbar medial branch nerve, and this review examines the clinical data of the two different, commercially available, non-spinal neuromodulation systems. This review provides the clinician a succinct narrative that presents up-to-date data objectively. Our review found ten clinical studies, including one report of two cases, six prospective studies, and three randomized clinical trials published to date. Currently, there are different proposed mechanisms of action to address chronic axial low back pain with different implantation techniques. Evidence suggests that peripheral nerve stimulation of the lumbar medial branch nerve may be effective in improving pain and function in patients with chronic axial low back pain symptoms at short and long term follow up, with good safety profiles. Further long-term data is needed to consider this intervention earlier in the pain treatment algorithm, but initial data are promising.

Significant other interactions in people with chronic low back pain: Subgrouping and multidimensional profiles.

Background: Back pain is complex. Social support and significant other interactions influence the pain experience. Purpose: To statistically derive subgroups of people with chronic low back pain based upon their interactions with significant others, and profile subgroups across multidimensional variables. Research Design: Longitudinal cohort study. Study Sample: People with chronic axial low back pain (n = 262). Data Collection and Analysis: Latent class analysis of significant other interaction data was used to derive subgroups of people with chronic low back pain. Subgroups were profiled across baseline multidimensional variables and one-year follow-up pain intensity, disability and bothersomeness. Results: Three clusters were identified: Cluster 1 (7.6%) characterised by the lowest distracting, punishing and solicitous interactions. Cluster 2 (16.0%) characterised by the highest distracting and solicitous responses and social support. Cluster 3 (76.3%) characterised by the highest punishing and lowest social support. Cluster 1 reported less disability than Clusters 2 and 3. Mindfulness was significantly different across all subgroups with Cluster 1 being most mindful and Cluster 3 least mindful. Depression, anxiety and stress were significantly higher in Cluster 3 than Cluster 1. Pain catastrophising was higher for Cluster 2 than Clusters 1 and 3. Cluster 2 had lower pressure pain threshold than Clusters 1 and 3. Conclusions: These results support the association between significant other interactions and the experience of back pain. Considering significant other interactions in clinical practice may be important for managing some people's presentation.

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study.

BackgroundThe objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments.Materials & MethodsParticipants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress.ResultsClinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment.ConclusionGiven the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.

Current Perspectives on Neurostimulation for the Management of Chronic Low Back Pain: A Narrative Review.

Neurostimulation techniques for the treatment of chronic low back pain (LBP) have been rapidly evolving; however, questions remain as to which modalities provide the most efficacious and durable treatment for intractable axial symptoms. Modalities of spinal cord stimulation, such as traditional low-frequency paresthesia based, high-density or high dose (HD), burst, 10-kHz high-frequency therapy, closed-loop, and differential target multiplexed, have been limitedly studied to determine their efficacy for the treatment of axial LBP. In addition, stimulation methods that target regions other than the spinal cord, such as medial branch nerve stimulation of the multifidus muscles and the dorsal root ganglion may also be viable treatment options. Here, current scientific evidence behind neurostimulation techniques have been reviewed with a focus on the management of chronic axial LBP.

P128. Spinal cord stimulation decreases pain and disability in patients with non-radicular, nonoperative chronic axial low back pain

BACKGROUND CONTEXT Low back pain (LBP) continues to be a costly problem in the United States. Unfortunately, current treatment options are limited when patients have predominantly LBP without instability or radicular symptoms. Neuromodulation has been shown to be effective, particularly in patients with chronic pain conditions such as failed back surgery and chronic regional pain syndrome. As such, the field of neuromodulation is evolving and spinal cord stimulator (SCS) implantation may provide a benefit to individuals who have chronic otherwise non-operable LBP. Considering SCS continues to advance with respect to stimulation parameters (eg, frequency, burst), combined with recent reports of improvements in both radicular lower extremity pain and axial LBP, further investigation into how SCS may benefit individuals experiencing chronic non-operative axial LBP is warranted. PURPOSE The purpose of this study was to determine the effects of SCS implantation on reducing pain and disability in chronic axial LBP patients who failed conservative treatment. STUDY DESIGN/SETTING Retrospective pre-test/post-test observational study design. PATIENT SAMPLE Twenty-four patients with chronic axial LBP who underwent SCS implantation. OUTCOME MEASURES Pain (Visual Analog Scale-VAS) and Disability (Oswestry Disability Index-ODI). METHODS A total of 24 patients with chronic axial LBP underwent SCS implantation and 1-year followup. All patients were diagnosed with chronic axial LBP with minimal or no radicular pain and had failed conservative treatment for a minimum of 12 months. All patients had >70% reduction of pain with trial stimulator before referral for placement of permanent implant. Patients were excluded if their primary complaint was radicular leg pain, had previous lumbar surgeries, no response to trial stimulator, RESULTS Baseline (pre-SCS implantation) measures for VAS and ODI were 7.9±1.5 and 24.2±10.2, respectively. At 1-year follow-up (post-SCS implantation), VAS and ODI were 3.4±2.6 and 12.0±10.9, respectively. These findings represent statistically significant effect sizes and clinically meaningful improvements in both pain (56.6% reduction in VAS, P CONCLUSIONS Patients with axial non-operable LBP demonstrated significant improvements in pain and disability at 1-year post-SCS implantation as VAS and ODI scores both surpassed minimal clinically important difference thresholds. This demonstrates that neuromodulation may play an important role in decreasing the burden that chronic LBP places on society. As SCS implantation technology improves, there is an increasing role for spine surgeons to understand the role of neuromodulation in the management of patients with spinal conditions. Further randomized controlled trials are needed to compare SCS implantation to other treatment interventions for chronic axial LBP. FDA DEVICE/DRUG STATUS Boston Scientific Coverage Lead with Precision Spectra Spinal Cord Stimulator System (Approved for this indication)

Lumbar Radiofrequency Ablation: Procedural Technique.

Lumbar radiofrequency ablation is indicated for the treatment of chronic axial low back pain that is mediated by facet arthropathy which has failed more conservative treatment options. This article details proper equipment and medications, patient positioning and setup, step-by-step instructions for multiplanar fluoroscopic visualization, cannula placement, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A90) accompanies this paper.

Percutaneous Peripheral Nerve Stimulation (PNS) for the Treatment of Chronic Low Back Pain Provides Sustained Relief

The objective of this study was to evaluate the use of percutaneous peripheral nerve stimulation (PNS) for the treatment of chronic low back pain (LBP). Percutaneous PNS offers the potential to provide an effective neuromodulation therapy using a system and fine-wire leads designed specifically for percutaneous use with history of an excellent safety profile. Subjects with chronic axial LBP received percutaneous PNS leads targeting the medial branch of the dorsal ramus in the region of LBP. Lead placement was guided using ultrasound and confirmed by selective activation of the lumbar multifidus and patient-reported sensations. The percutaneous fine-wire leads remained in place for the 30-day therapy. A majority of subjects reported statistically and clinically significant reductions in both average pain intensity (BPI-5) and worst pain intensity (BPI-3) scores with PNS treatment, which continued long term at the four-month follow-up visit. Subject-reported reductions in pain intensity were substantiated by concomitant and sustained reductions in analgesic medication usage. Subjects also reported clinically significant reductions in patient-centric outcomes of disability (Oswestry Disability Index), pain interference (BPI-9), and patient global impression of change (PGIC). This work demonstrates the potential value of percutaneous PNS for the treatment of chronic LBP. Improvements in pain, medication, and patient-centric outcomes, which were sustained long term after the removal of PNS leads, demonstrate the significance of this innovative approach to treat chronic LBP.

Evaluation of the Neuropathic Component of Chronic Low Back Pain.

Assessment of neuropathic pain in chronic low back syndromes is important. However, there is currently no gold standard for its diagnosis. The aim of this observational cross-sectional study was to assess the neuropathic component of pain in various chronic low back pain syndromes using a range of diagnostic tests. Included in this study were 63 patients with chronic axial low back pain (ALBP), 48 patients with chronic radicular syndromes (CRS) comprising 23 with discogenic compression (CDRS) and 25 with lumbar spinal stenosis (LSS), and 74 controls. PainDETECT questionnaire (PDQ), quantitative sensory testing (QST), and skin biopsy with evaluation of intraepidermal nerve fiber density (IENFD) were used to assess the neuropathic pain component. Positive PDQ (≥19) was obtained more frequently in patients with CDRS and LSS (26.1% and 12.0%, respectively) compared with patients with ALBP (1.6%, P<0.001). The proportion of patients with sensory loss confirmed by QST was lowest in the ALBP subgroup (23.8%) compared with CDRS (47.8%), and LSS (68.0%) subgroups (P<0.001). A reduction in IENFD was disclosed in a proportion of up to 52.0% of affected roots in patients with CRS. Neuropathic pain is quite frequent in CRS, and QST reveals sensory loss as a frequent abnormality in patients with CRS. Using a cut-off value of 19, PDQ identified a neuropathic component in a relatively low proportion of patients with CRS. CRS may be associated with a reduction in IENFD.

Fluoroscopic-guided sacroiliac, joint injections for treatment of chronic axial low back pain in a tertiary Hospital in Nigeria: a preliminary study.

The injection of mixture of plain bupivacaine and triamcinolone acetonide into the sacroiliac joint (SIJ) to relieve chronic low back pain is uncommon in the West African sub-region. The objective of this study was to demonstrate the efficacy or otherwise of fluoroscopic-guided SI joint injection in the management of chronic axial low back pain in Nigeria. This was a prospective observational interventional study. The study was carried out at a tertiary hospital in Nigeria. Twenty-six patients with SI joint pain, based on IASP diagnostic criteria, who presented to our unit over 36 months from March 2012 to March 2015 and. Fluoroscopic-guided injections of 5mls mixture of bupivacaine and triamcinolone acetonide into the sacro-iliac (SI) joints of 26 patients with SI joint pain out of 116 patients who were offered different interventions for chronic low back pain. The patients were followed up for year and pain intensity and functional status were assessed at 3-, 6- and 12 months post-intervention. Pain relief and functional improvement were the main outcome measures. The mean numeric rating score (NRS) and Oswestry Disability index (ODI) score in 14 (53.9%) patients at 12 months post-interventions were significantly lower compared with baseline values; 3.19 ± 1.10 vs 8.54 ±1.14 p=0.000 and 25.35 ± 5.40 vs 37.54 ±8.41, p=0.000 respectively. Fluoroscopic-guided steroid injection into the SI joint resulted into reduction in pain intensity and improved physical function in the majority of patients with SI joint pain. Not declared.