Datta S.,Vanderbilt University |
Gupta S.,Bradford Teaching Hospitals NHS Foundation Trust |
Munglani R.,West Suffolk Hospital NHS |
Bryce D.A.,Advanced Pain Management |
And 5 more authors.
Pain Physician | Year: 2010
Background: Clinical guidelines are a constructive response to the reality that practicing physicians require assistance in assimilating and applying the exponentially expanding, often contradictory, body of medical knowledge. They attempt to define practices that meet the needs of most patients under most circumstances. Ideally, specific clinical recommendations contained within practice guidelines are systematically developed by expert panels who have access to all the available evidence, have an understanding of the clinical problem, and have clinical experience with the procedure being assessed, as well as knowledge of relevant research methods. The recent development of American Pain Society (APS) guidelines has created substantial controversy because of their perceived lack of objective analysis and recommendations perceived to be biased due to conflicts of interest. Objectives: To formally and carefully assess the APS guidelines' evidence synthesis for low back pain for therapeutic interventions using the same methodology utilized by the APS authors. The interventions examined were therapeutic interventions for managing low back pain, including epidural injections, adhesiolysis, facet joint interventions, and spinal cord stimulation. Methods: A literature search by 2 authors was carried out utilizing appropriate databases from 1966 through July 2008. Articles in which conflicts arose were reviewed and mediated by a third author to arrive at a consensus. Selections of manuscripts and methodologic quality assessment was also performed by at least 2 authors utilizing the same criteria applied in the APS guidelines. The guideline reassessment process included the evaluation of individual studies and systematic reviews and their translation into practice recommendations. Results: The conclusions of APS and our critical assessment based on grading of good, fair, and poor, agreed that there is fair evidence for spinal cord stimulation in post lumbar surgery syndrome, and poor evidence for lumbar intraarticular facet joint injections, lumbar interlaminar epidural injections, caudal epidural steroids for conditions other than disc herniation or radiculitis, sacroiliac joint injections, intradiscal electrothermal therapy, endoscopic adhesiolysis, and intrathecal therapy. However, our assessment of APS guidelines for other interventional techniques, utilizing their own criteria, showed fair evidence for therapeutic lumbar facet joint nerve blocks, caudal epidural injections in disc herniation or radiculitis, percutaneous adhesiolysis in post lumbar surgery syndrome, radiofrequency neurotomy, and transforaminal epidural injections in radiculitis. Also it is illustrated that inclusion of latest literature will change the conclusions, with improved grading - caudal epidural, adhesiolysis, and lumbar facet joint nerve blocks from fair to good or poor to fair. The present critical assessment review illustrates that APS guidelines have utilized multiple studies inappropriately and have excluded appropriate studies. Our integrity assessment shows deep concerns that the APS guidelines illustrating significant methodologic failures which raise concerns about transparency, accountability, consistency, and independence. Conclusion: The current reassessment, using appropriate methodology, shows evidence similar to APS guidelines for several procedures, but differs extensively from published APS guidelines for multiple other procedures including caudal epidural injections, lumbar facet joint nerve blocks, lumbar radiofrequency neurotomy, and percutaneous adhesiolysis.
Manchikanti L.,University of Louisville |
Kaye A.D.,Health Science Center |
Boswell M.V.,University of Louisville |
Bakshi S.,Manhattan Spine and Pain Medicine |
And 15 more authors.
Pain Physician | Year: 2015
Background: The therapeutic spinal facet joint interventions generally used for the treatment of axial spinal pain of facet joint origin are intraarticular facet joint injections, facet joint nerve blocks, and radiofrequency neurotomy. Despite interventional procedures being common as treatment strategies for facet joint pathology, there is a paucity of literature investigating these therapeutic approaches. Systematic reviews assessing the effectiveness of various therapeutic facet joint interventions have shown there to be variable evidence ased on the region and the modality of treatment utilized. Overall, the evidence ranges from limited to moderate. Objective: To evaluate and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain. Study Design: A systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain. Methods: The available literature on lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM - QRB) for randomized trials and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM - QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, 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 consumption. Results: A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement. Limitations: The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections. Conclusion: Based on the present assessment for the management of spinal facet joint pain, the evidence for ong-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy. © 2015, American Society of Interventional Pain Physicians. All rights reserved.
Grider J.,University of Kentucky |
Manchikanti L.,University of Louisville |
Carayannopoulos A.,Comprehensive Spine Center at Rhode Island Hospital |
Sharma M.L.,The Walton Center for Neurology and Neurosurgery Foundation Trust |
And 8 more authors.
Pain Physician | Year: 2016
Background: Chronic neuropathic pain has been recognized as contributing to a significant proportion of chronic pain globally. Among these, spinal pain is of significance with failed back surgery syndrome (FBSS), generating considerable expense for the health care systems with increasing prevalence and health impact. Objective: To assess the role and effectiveness of spinal cord stimulation (SCS) in chronic spinal pain. Study Design: A systematic review of randomized controlled trials (RCTs) of SCS in chronic spinal pain. Methods: The available literature on SCS was reviewed. The quality assessment criteria utilized were Cochrane review criteria to assess sources of risk of bias and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM – QRB) criteria for randomized trials. The level of evidence was based on a best evidence synthesis with modified grading of qualitative evidence from Level I to Level V. Data sources included relevant literature published from 1966 through March 2015 that were identified through searches of PubMed and EMBASE, manual searches of the bibliographies of known primary and review articles, and all other sources. Outcome Measures: RCTs of efficacy with a minimum 12-month follow-up were considered for inclusion. For trials of adaptive stimulation, high frequency stimulation, and burst stimulation, shorter follow-up periods were considered. Results: Results showed 6 RCTs with 3 efficacy trials and 3 stimulation trials. There were also 2 cost effectiveness studies available. Based on a best evidence synthesis with 3 high quality RCTs, the evidence of efficacy for SCS in lumbar FBSS is Level I to II. The evidence for high frequency stimulation based on one high quality RCT is Level II to III. Based on a lack of high quality studies demonstrating the efficacy of adaptive stimulation or burst stimulation, evidence is limited for these 2 modalities. Limitations: The limitations of this systematic review continue to require future studies illustrating effectiveness and also the superiority of high frequency stimulation and potentially burst stimulation. Conclusion: There is significant (Level I to II) evidence of the efficacy of spinal cord stimulation in lumbar FBSS; whereas, there is moderate (Level II to III) evidence for high frequency stimulation; there is limited evidence for adaptive stimulation and burst stimulation. © 2016, American Society of Interventional Pain Physicians. All rights reserved.
Al-Mahfoudh R.,the Walton Center for Neurology and Neurosurgery Foundation Trust |
Kirollos R.,Addenbrooks Hospital |
Mitchell P.,the Walton Center for Neurology and Neurosurgery Foundation Trust |
Lee M.,the Walton Center for Neurology and Neurosurgery Foundation Trust |
And 3 more authors.
World Neurosurgery | Year: 2015
Objectives: To assess the clinical outcome, complications, and angiographic outcomes after surgical disconnection of intracranial dural arteriovenous fistulas (DAVFs). Methods: Analysis of prospectively collected data, including clinical presentation, preoperative angiographic findings, postoperative complications, clinical, and angiographic outcomes. Results: Between January 2002 and January 2012, 25 patients underwent surgery for DAVFs. The anatomical locations included tentorial (8), ethmoidal (8), foramen magnum (5), middle fossa (2), torcular (1), and parafalcine (1). All had cortical venous reflux (CVR) and all were treated with craniotomy and disconnection of CVR. Two patients required repeat surgery for residual CVR. One patient had a postoperative seizure. There were no other complications. All patients had complete disconnection of CVR confirmed by digital subtraction angiography. None of the patients have had hemorrhage or recurrence of CVR on follow-up. Conclusions: Surgical disconnection of CVR for high-grade intracranial DAVFs is highly effective and can be performed with very low complication rates. Where embolization cannot be performed safely, surgical disconnection (rather than stereotactic radiosurgery) is the treatment of choice for high grade DAVFs. © 2015 Elsevier Inc.
PubMed | The Walton Center for Neurology and Neurosurgery Foundation Trust
Type: Journal Article | Journal: Acta neurochirurgica | Year: 2014
The rarity and the inconsistent criteria for defining atypical meningioma prior to the WHO 2007 classification made its management and prognostic factors poorly understood. Only few articles have addressed the survival rates of WHO-classified atypical meningiomas. The small number or the disproportionate representation of irradiated patients was a weakness for these articles. This study evaluated whether the extent of surgery and receiving adjuvant radiotherapy after an initial operation along with other patient characteristics influenced the recurrence and survival rates of atypical meningiomas.The clinical and surgical notes of the 79 patients with grade II atypical meningioma treated at our center over 13 years were retrospectively evaluated. The histology grading was consistent with WHO 2007 classification. The Simpson grading system was used to assess the extent of surgical resection. Kaplan Meier analysis, Cox multivariate regression analysis, and the Log-rank test were conducted using STATA statistical package.The average age at the time of initial operation was 58 years, and 54 % were males. The mean follow-up period was 50 months. In Cox multivariate analysis, only Simpson grading was predictive of recurrence (hazard ratio = 2.22 / 1 increase in Simpson grade. p=0.003). Simpson grade I patients had a relapse-free survival rate of 97 and 74 % at one and five years, respectively, compared with 88 and 32 % in the subtotal resection group (Simpson grades II to IV). There was no statistically significant correlation between recurrence and subjecting patients to postoperative radiotherapy. Apart from Simpson grade I patients, there was a general trend for worse outcome in irradiated patients.The most important prognostic factor in determining recurrence was Simpson grading. There was no statistically significant impact of adjuvant radiotherapy on the recurrence of atypical meningiomas. Meta-analysis for the existing literature is needed.