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An update of evaluation of therapeutic thoracic facet joint interventions

PainSci » bibliography » Manchikanti et al 2012
updated
Tags: treatment, back pain, injections, neurology, pain problems, spine, medicine

Three articles on PainSci cite Manchikanti 2012: 1. Complete Guide to Low Back Pain2. The Complete Guide to Neck Pain & Cricks3. Do Nerve Blocks Work for Neck Pain and Low Back Pain?

PainSci commentary on Manchikanti 2012: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This tiny review was based on extremely limited evidence: just four studies (three non-randomized), and “The only positive studies were of medial branch blocks performed by the same group of authors” (e.g. Manchikanti 2008) … who also happen to be the authors of this review. That doesn’t mean they are wrong, of course, but it’s an important caveat. The word they chose to describe this level of evidence was “fair.” I’m not sure that’s fair! They are mostly just re-reporting the positive results of their own trials.

They also concluded there wasn’t enough evidence about intraarticular injections and radiofrequency neurotomy. They probably should have concluded the same about medial branch blocks!

This paper is very similar to Falco et al, regarding the cervical spine (again involving some of the same researchers).

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of patients based on responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of thoracic medial branches.

STUDY DESIGN: Systematic review of therapeutic thoracic facet joint interventions.

OBJECTIVE: To determine the clinical utility of therapeutic thoracic facet joint interventions in the therapeutic management of chronic upper back and mid back pain.

METHODS: The available literature for the utility of facet joint interventions in the therapeutic management of thoracic facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term> 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake.

RESULTS: For this systematic review, 13 studies were identified. Of these, 7 studies were excluded, and a total of 4 studies (after removal of duplicate publication) met inclusion criteria for methodological quality assessment with one randomized trial and 3 non-randomized studies. The evidence is fair for therapeutic thoracic facet joint nerve blocks, limited for thoracic radiofrequency neurotomy, and not available for thoracic intraarticular injections.

LIMITATIONS: The limitation of this systematic review includes a paucity of literature. The only positive studies were of medial branch blocks performed by the same group of authors. «The authors of this review!»

CONCLUSION: The evidence for therapeutic facet joint interventions is fair for medial branch blocks, whereas it is not available for intraarticular injections, and limited for radiofrequency neurotomy due to lack of literature.

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