In moving the CLBP patient toward rehabilitation, whether it is with an experienced spine therapist, a work-hardening program, or a multidisciplinary CBT program, more aggressive pain control options may be considered. Various spine injections should be considered a stepping stone to one of these main treatments, not used in isolation. This is one example where the treating physician can be the patient's gatekeeper and help direct care. Many patients find such dramatic relief with a facet joint injection or sacroiliac joint block that they abandon all other treatments until pain returns weeks or months later. They invariably return to the treating clinician's office specifically asking for another ''shot.''
The attractiveness of corticosteroid injections lies in a systemic effect of the steroid causing decreased pain in multiple areas and mild euphoria. There may be a placebo effect of the injection as well. In addition, the injections are thought of as diagnostic tests since placing medication into a facet joint, for example, may lead one to conclude that pain reduction ''proves'' that the injected structure was a pain generator. This is a debatable issue as efficacy data in general are conflicting and of poor quality. Many suggest that variability of techniques used and in particular the lack of image-guidance for epidural injections, is a big factor behind these study results. Looking at the 15 randomized trials on the efficacy of epidural corticoster-oid injections for discogenic radiculopathy, systematic reviews are conflicting.139[I] However, all but two of these studies can be dismissed based on a lack of proper image-guided and contrast-controlled injection technique at the level of the targeted disk.
Overall, there are conflicting or poor quality studies to support the use of epidural, facet joint, sacroiliac joint, radiofrequency procedures, intradiscal electro-thermotherapy (IDET), botulinum toxin injections, pro-lotherapy, trigger point injections, or spinal cord stimulation for patients with CLBP.15[IV] Proper patient selection and wise counseling to set realistic expectations for these procedures is important. They should only be performed with the intent to move along the rehabilitation process, after proper screening for contraindications, and executed in experienced hands. Patients should assume that the effects of injection treatments are temporary (weeks to months).
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