Background: Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use. Objectives: To provide guidance for the prescription of opioids for the management of chronic non-cancer pain, to develop a consistent philosophy among the many diverse groups with an interest in opioid use as to how appropriately prescribe opioids, to improve the treatment of chronic non-cancer pain and to reduce the likelihood of drug abuse and diversion. These guidelines are intended to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique. Methods: The methodology utilized included the development of objectives and key questions. The methodology also utilized trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various specialties and groups. The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed, with a best evidence synthesis of the available literature, and utilized grading for recommendation as described by the Agency for Healthcare Research and Quality (AHRQ).

Background: Chronic axial spinal pain is one of the major causes of significant disability and health care costs, with facet joints as one of the proven causes of pain. Objective: To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. Methods: The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of facet joint interventions, was reviewed, with a best evidence synthesis of available literature and utilizing grading for recommendations. Summary of Evidence and Recommendations: Non-interventional diagnosis: • The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. • The level of evidence is IV for accurate diagnosis of facet joint pain with physical examination based on symptoms and signs, with weak strength of recommendation. Imaging: • The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. • The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . • The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT) . Interventional Diagnosis: Lumbar Spine: • The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. • Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of ≥ 80% were included. • The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥ 80% pain relief.Limitations: The limitations of these guidelines include a paucity of high-quality studies in the majority of aspects of diagnosis and therapy. Conclusions: These facet joint interventions guidelines were prepared with a comprehensive review of the literature with methodologic quality assessment with determination of level of evidence and strength of recommendations Key words: Chronic spinal pain, interventional techniques, diagnostic blocks, therapeutic interventions, facet joint nerve blocks, intraarticular injections, radiofrequency neurolysis

The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET.

No abstract

Background: 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. Objective: 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. Study Design: 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. Methods: 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). Outcome Measures: 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. Results: 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. Conclusion: 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. Key words: Spinal pain, low back pain, cervicalgia, epidural steroids, interlaminar, caudal, transforaminal, radiculopathy, axial pain, postlaminectomy syndrome, failed back surgery syndrome.