Interventional Procedures for Spinal Pain Management

Indications and Guidelines

• The American College of Rheumatology conditionally recommends local glucocorticoid injections for patients with active sacroiliitis and enthesitis despite NSAID treatment, with a strength of evidence based on population-level data 1, 2
• The ASAS/EULAR guidelines state that "glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered" for patients with axial pain and imaging evidence of spondylosis and facet DJD/arthritis 3, 4
• The Pan American League of Associations for Rheumatology and the American College of Rheumatology recommend sacroiliac joint glucocorticoid injections for patients with active sacroiliitis, noting improvement in pain for up to 9 months 5, 2

Patient Selection and Criteria

• Patients with axial pain, positive facet tenderness, and imaging evidence of spondylosis and facet DJD/arthritis are suitable candidates for facet joint injections 1, 3, 4
• Patients with sacroiliac joint pain for greater than 3 months, tenderness over the SIJ, and previous injections providing almost complete relief are considered suitable candidates for SIJ injection, as recommended by the Pan American League of Associations for Rheumatology 5
• Patients who have tried conservative treatments, including physical therapy, NSAIDs, and previous injections, may be considered for SIJ injection, according to the American College of Rheumatology 2
• Patients with chronic pain (>3 months) and radicular symptoms, who have failed conservative management, may be considered for a nerve root block as a first-line interventional treatment, before considering SI joint injections 6

Treatment Outcomes and Expectations

• Facet joint injections can provide pain relief in patients with chronic nonradicular low back pain, with significant improvement in a majority of patients immediately after the procedure and at 24 weeks 3, 4
• SIJ injections can produce pain relief for up to 9 months, with some patients experiencing relief for over 3 months, as reported by the American College of Rheumatology 2
• A patient's documented 75% pain relief from the therapeutic procedure itself is clinically significant and represents a "small but important pain relief", according to a study 7
• Patients should be informed that SIJ injections typically provide temporary relief and may need to be repeated, as noted by the American College of Rheumatology 2

Procedure and Technique

• Image guidance (fluoroscopy or CT) is recommended for accurate needle placement, and local anesthetic with corticosteroid is typically injected into or around the affected facet joints 3, 4
• Transforaminal epidural steroid injections (TFESI) are recommended as the first-line interventional treatment for radicular symptoms, according to a reputable medical society, before considering SI joint injections 8
• The following stepped approach is recommended:

• Cooled radiofrequency ablation (C-RFA) may be considered for potentially larger lesion size and improved outcomes 7
• Medial branch blocks are recommended as a diagnostic procedure before considering radiofrequency denervation for patients with chronic lower back pain and imaging evidence of facet joint arthropathy, with a positive response defined as ≥80% pain relief, supported by the 2020 NICE guidelines and the British Pain Society 7, 9, 10

Post-Procedure Assessment and Management

• Patients should be assessed for pain relief at 1 hour post-procedure, then at 1, 4, and 12 weeks, and considered for radiofrequency denervation if significant but temporary relief is achieved 3, 4
• Assessing pain relief and functional improvement at 1, 3, and 6 months post-procedure is recommended, using standardized pain scales and functional assessments 11
• Physical rehabilitation focusing on paraspinal muscle strengthening is recommended for managing back pain, especially with comprehensive assessment of the patient's condition 9
• Repeat radiofrequency neurolysis may be considered if pain returns after a successful period of relief, but not additional diagnostic blocks at the same levels 11

Risks and Complications

• Potential risks of nerve root blocks include infection, bleeding, nerve damage, and temporary pain flare, although these are rare 6, 7
• Small risk of infection, bleeding, or nerve damage associated with medial branch blocks, sacroiliac joint injection, and rhizolysis, as well as temporary post-procedure pain flare and variable duration of pain relief (typically 6-11 months) 7, 11, 12
• Anticoagulation management is crucial in patients on medications like Plavix to minimize bleeding risk, and should be addressed prior to the procedure 7