Physical Medicine and Rehabilitation Clinics of North America
Epidemiology of Spine Care: The Back Pain Dilemma
Section snippets
Prevalence of LBP
Despite the vast amount of research devoted to LBP, the epidemiology of this condition is not well understood, and the overall prevalence of LBP in the United States is unclear. There are several techniques for estimating the prevalence of spine problems, including survey techniques as well as the use of medical billing claims data. Each method has its strengths and weaknesses. Retrospective surveys obtain information directly from affected individuals but may be subject to recall bias.
The use of interventional spine procedures
Interventional spine procedures have been used for many decades for a variety of spinal disorders and range from percutaneous injections to surgery. For a variety of reasons, there has been a recent proliferation in the number of techniques available for use and marked increases in the use rates for many of the procedures. Percutaneous interventions include epidural steroid injections (ESIs) via several different approaches, facet/zygapophysial joint (z-joint) procedures, spinal cord
Epidural steroid injections
Although ESIs for the treatment of lumbosacral radicular pain were first introduced in the early 1950s,22 there has been a lot of interest recently in the use of these injections as an alternative to more invasive surgical procedures for treating spinal pain. Since the introduction pf ESIs, many investigators have examined them for the treatment of lumbosacral radiculopathy as well as axial (nonradicular) spinal pain syndromes.23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Although most studies
Understanding the increase in use
One of the more optimistic explanations available for the disproportionately escalating rate of ESI use could be improvements in health care delivery, including more effective management of spinal pain in the general population. If these improvements are occurring, improvements in measures of health or disability or a decrease in rates of surgical intervention for specific spine problems might be expected. The available data do not seem to indicate that this is the case. Paradoxically, measures
Z-joint Injections and RFN
There are fewer epidemiologic data examining the use of z-joint intraarticular steroid injections and RFN (ie, radiofrequency ablation of the z-joint medial branch nerve) than there are for ESIs. There is good evidence to indicate that z-joints are potential sources of back pain.63, 64, 65, 66 Injection of these joints with corticosteroids, as is performed for many peripheral joints, is believed to have the potential to transiently relieve pain. In addition, these joints are innervated by the
Discussion
Individuals with LBP are receiving an increasing number of interventional treatments for pain without any available evidence to support a substantial overall improvement in functional status. This situation presents a challenging dilemma for health care providers. There is a vast and ever-expanding array of potential treatment options for LBP, many of which have some evidence of efficacy in select patients but none of which has offered long-term benefit for most patients with LBP. There are
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