ABSTRACT
INTRODUCTION: The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS: The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS: The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION: The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
Subject(s)
Electric Stimulation Therapy/methods , Ganglia, Spinal , HumansABSTRACT
BACKGROUND: The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks. STUDY DESIGN: A systematic review of diagnostic and therapeutic sacroiliac joint interventions. OBJECTIVE: To evaluate the accuracy of diagnostic sacroiliac joint interventions and the utility of therapeutic sacroiliac joint interventions. METHODS: The literature search was carried out by searching the databases of PubMed, EMBASE, and Cochrane reviews. Methodologic quality assessment of included studies was performed using the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria for diagnostic accuracy and observational studies, whereas randomized trials were evaluated utilizing the Cochrane review criteria. Only studies with scores of 50 or higher were included for assessment. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria. OUTCOME MEASURES: For diagnostic interventions, the outcome criteria included at least 50% pain relief coupled with a patient's ability to perform previously painful maneuvers with sustained relief using placebo-controlled or comparative local anesthetic blocks. For therapeutic purposes, outcomes included significant pain relief and improvement in function and other parameters. Short-term relief for therapeutic interventions was defined as 6 months or less, whereas long-term effectiveness was defined as greater than 6 months. RESULTS: The indicated level of evidence is II-2 for the diagnosis of sacroiliac joint pain utilizing comparative, controlled local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 38% using a double block paradigm in the study population. The false-positive rate of single, uncontrolled, sacroiliac joint injections is 20% to 54%. The evidence for provocative testing to diagnose sacroiliac joint pain is Level II-3 or limited. For radiofrequency neurotomy the indicated evidence is limited (Level II-3) for short- and long-term relief. LIMITATIONS: The limitations of this systematic review include the paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodological flaws. CONCLUSIONS: The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3).