The burden of chronic low back pain on society is enormous in terms of both patient suffering and cost (Quebec Task Force on Spinal Disorders, 1987). Numerous treatments for low back pain have been advocated, but not many have been proven to be effective. Epidural steroid injections (ESI) have been used to treat various spinal pathologies generating low back pain. The therapeutic benefits of ESI are attributed to reduction of inflammation caused by the chemicals released from the ruptured disk such as Phospholipase A, which causes nerve root irritation and swelling. The efficacy of ESI, especially in cases without radicular pain, remains controversial. Recently, transforaminal approaches have been used to place corticosteroid with or without a local anesthetic closer to the nerve root. While some authors are reporting a higher success rate especially for radicular pain, the transforaminal approach is not free from complications. Injection of the sacroiliac joint (SIJ) with corticosteroid has long been used to treat patients with sacroilitis. Several studies have demonstrated both short term and long term efficacy of radiologically guided SIJ injections. However, the effectiveness of SIJ remains controversial and controlled perspective studies are needed. Intrathecal drug infusion has been used to treat patients with chronic low back pain secondary to failed back syndrome resistant to conventional treatments such as oral medications, physical therapy, and injections. Traditionally, opioids were used alone in the infusion; however, more recently, combinations of drugs including opioids, local anesthetics, clonidine, and midazolam have been used. These medications seem to act synergistically and decrease opioid side effects including tolerance. While the use of multiple intrathecal agents is now common, few studies that look at the effectiveness of multiple agents in intrathecal infusions have been published. Small patient populations and lack of control groups have been shortcomings of these studies. Spinal cord stimulation (SCS) technique was developed on the basis of the Gate Control Theory of Wall and Melzack. In the studies reviewed, the SCS has been found to be an effective modality for treating nonspecific limb pain, as well as neuropathic pain of nerve root origin. SCS is less effective for the control of allodynia or hyperpathia than for spontaneous pain associated with neuropathic pain syndromes. Radiofrequency (RF) facet nerve rhizotomy has been used for treating facet joint syndrome. Subjective improvement of the patient after a diagnostic block of the facet nerve has been used as a criterion for performing RF ablation of the facet nerve; however, the efficacy of RF ablation of facet joint nerve in managing chronic low back pain remains controversial. In some studies that were reviewed, the authors failed to thoroughly establish the facet joint as the pain generator of the low back pain, which could be responsible for the low success rates. While the RF rhizotomy has traditionally been performed under local anesthesia, some authors have found that using general anesthesia did not decrease their success rate nor did it cause a higher incidence of complications. General anesthesia for RF facet rhizotomy was found to improve patient comfort and reduce operative time by at least 30 minutes. Thorough understanding of the anatomy of the lumbar spine including the pain generators can be helpful in selecting proper patients for specific procedures. The focus of future studies should be on long-term pain relief instead of short-term benefits from these injections.
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