Influence of prior opioid exposure on diagnostic facet joint nerve blocks

Laxmaiah Manchikanti, MD; Mark V. Boswell, MD, PhD; Rajeev Manchukonda, BDS; Kimberly A. Cash, RT; James Giordano, PhD

doi:10.5055/jom.2008.0039

Authors

Laxmaiah Manchikanti, MD
Mark V. Boswell, MD, PhD
Rajeev Manchukonda, BDS
Kimberly A. Cash, RT
James Giordano, PhD

DOI:

https://doi.org/10.5055/jom.2008.0039

Keywords:

chronic spinal pain, facet joint pain, controlled diagnostic blocks, facet joint blocks, lidocaine, bupivacaine, prevalence, false-positive rates, opioids

Abstract

Objective: To determine the influence of prior opioid use on the diagnostic validity of controlled comparative local anesthetic blocks in the diagnosis of facet joint involvement in chronic spinal pain.
Methods: Data were evaluated from 438 patients with chronic spinal pain who underwent diagnostic facet joint nerve blocks. Patient data were divided into four groups based on the level of opioid use: group I (no opioid use), group II (low opioid use), group III (moderate opioid use), and group IV (high opioid use). Facet joint involvement was diagnosed utilizing controlled comparative local anesthetic blocks with 1 percent preservative- free lidocaine and 0.25 percent preservative-free bupivacaine.
Results: Prior and current opioid use did not show relationship to the diagnostic validity of controlled comparative local anesthetic blocks. Among patients not using opioids (group I), the prevalence of facet joint pain was shown to be 33 percent in the cervical spine, 40 percent in the thoracic spine, and 18 percent in the lumbar spine, with false-positive results with a single lidocaine block of 53 percent, 33 percent, and 54 percent, respectively. Facet joint involvement in patients with opioid use ranged from 37 percent to 53 percent in the cervical spine, 13 percent to 67 percent in the thoracic spine, and 28 percent to 33 percent in the lumbar spine.
Conclusions: Overall, this evaluation demonstrated that current or prior opioid use is not associated with interference of the validity of controlled comparative local anesthetic blocks in diagnosing spinal facet jointrelated pain.

Author Biographies

Laxmaiah Manchikanti, MD

Medical Director, Pain Management Center of Paducah, Paducah, Kentucky; Associate Clinical Professor of Anesthesiology and Perioperative Medicine, University of Louisville, Kentucky.

Mark V. Boswell, MD, PhD

Chairman of Department of Anesthesiology and Director of the Messer Racz Pain Center, Department of Anesthesiology, Texas Tech. University Health Sciences Center, Lubbock, Texas.

Rajeev Manchukonda, BDS

Research Assistant, Pain Management Center of Paducah, Paducah, Kentucky.

Kimberly A. Cash, RT

Radiological Technologist and Research Coordinator, Pain Management Center of Paducah, Paducah, Kentucky.

James Giordano, PhD

Departments of Medicine and Neuroscience at Georgetown University Medical Center, Washington DC, and Senior Fellow and Director of the Center for Neurotechnology Studies, Potomac Institute for Policy Studies, Arlington, VA.

References

Trescot AM, Boswell MV, Atluri SL, et al.: Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006; 9(1): 1-40.

Manchikanti L: National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician. 2007; 10(3): 399-424.

Boswell MV, Trescot AM, Datta S, et al.: Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007; 10(2): 7-111.

Cohen SP, Raja SN: Pathogenesis, diagnosis and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007; 106(3): 591-614.

Hogan QH, Abram SE: Neural blockade for diagnosis and prognosis: A review. Anesthesiology. 1997; 86(1): 216-241.

Cohen SP, Larkin T, Chang A, et al.: The causes of false-positive medial branch blocks in soldiers and retirees. Mil Med. 2004; 169(10): 781-786.

Bogduk N: International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Clin J Pain. 1997; 13(4): 285-302.

Manchikanti L, Singh V, Pampati V, et al.: Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001; 4(4): 308-316.

Manchikanti L, Boswell MV, Singh V, et al.: Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004; 28(5): 15.

Manchukonda R, Manchikanti KN, Cash KA, et al.: Facet joint pain in chronic spinal pain: An evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007; 20(7): 539-545.

Schwarzer AC, Aprill CN, Derby R, et al.: Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine. 1994; 19(10): 1132-1137.

Schwarzer AC, Aprill CN, Derby R, et al.: The relative contributions of the disc and zygapophysial joint in chronic low back pain. Spine. 1994; 19(7): 801-806.

Schwarzer AC, Wang SC, Bogduk N, et al.: Prevalence and clinical features of lumbar zygapophysial joint pain: A study in an Australian population with chronic low back pain. Am Rheum Dis. 1995; 54(2): 100-106.

Manchikanti L, Pampati V, Fellows B, et al.: Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician. 1999; 2(3): 59-64.

Manchikanti L, Pampati V, Fellows B, et al.: The diagnostic validity and therapeutic value of medial branch blocks with or without adjuvant agents. Curr Rev Pain. 2000; 4(5): 337-344.

Manchikanti L, Pampati V, Fellows B, et al.: The inability of the clinical picture to characterize pain from facet joints. Pain Physician. 2000; 3(2): 158-166.

Manchikanti L, Hirsch JA, Pampati V: Chronic low back pain of facet (zygapophysial) joint origin: Is there a difference based on involvement of single or multiple spinal regions? Pain Physician. 2003; 6(4): 399-405.

Manchikanti L, Singh V, Pampati V, et al.: Is there correlation of facet joint pain in lumbar and cervical spine? Pain Physician. 2002; 5(4): 365-371.

Manchikanti L, Manchukonda R, Pampati V, et al.: Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007; 88(4): 449-455.

Barnsley L, Lord SM, Wallis BJ, et al.: The prevalence of chronic cervical zygapophyseal joint pain after whiplash. Spine. 1995; 20(1): 20-26.

Lord SM, Barnsley L, Wallis BJ, et al.: Chronic cervical zygapophysial joint pain with whiplash: A placebo-controlled prevalence study. Spine. 1996; 21(15): 1737-1745.

Manchikanti L, Singh V, Rivera J, et al.: Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002; 5(3): 243-249.

Speldewinde GC, Bashford GM, Davidson IR: Diagnostic cervical zygapophyseal joint blocks for chronic cervical pain. Med J Aust. 2001; 174(4): 174-176.

Manchikanti L, Singh V, Falco FJ, et al.: Cervical medial branch blocks for chronic cervical facet joint pain: A randomized double-blind, controlled trial with one-year follow-up. Spine. 2008; 33(17): 1813-1820.

Manchikanti L, Singh V, Pampati V, et al.: Evaluation of the prevalence of facet joint pain in chronic thoracic pain. Pain Physician. 2002; 5(4): 354-359.

Schwarzer AC, Aprill CN, Derby R, et al.: The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994; 58(2): 195-200.

Barnsley L, Lord S, Wallis B, et al.: False-positive rates of cervical zygapophysial joint blocks. Clin J Pain. 1993; 9(2): 124-130.

Carragee EJ, Haldeman S, Hurtwitz E: The pyrite standard: The Midas touch in the diagnosis of axial pain syndromes. Spine J. 2007; 7(1): 27-31.

Carragee EJ: Is lumbar discography a determinate of discogenic low back pain: Provocative discography reconsidered. Curr Rev Pain. 2000; 4(4): 301-308.

Carragee EJ, Chen Y, Tanner CM, et al.: Provocative discography in patients after limited lumbar discectomy. A randomized study of pain response in symptomatic and asymptomatic subjects. Spine. 2000; 25(23): 3065-3071.

Carragee EJ, Tanner CM, Khurana S, et al.: The rates of falsepositive lumbar discography in select patients without low back symptoms. Spine. 2000; 25(11): 1373-1381.

Cohen SP, Mullings R, Abdi S: The pharmacologic treatment of muscle pain. Anesthesiology. 2004; 101(2): 495-526.

Manchikanti L, Singh V, Pampati V, et al.: Provocative discography in low back pain patients with or without somatization disorder: A randomized, prospective evaluation. Pain Physician. 2001; 4(3): 227-239.

Manchikanti L, Pampati V, Fellows B, et al.: Influence of psychological factors on the ability of diagnose chronic low back pain of facet joint origin. Pain Physician. 2001; 4(4): 349-357.

Manchikanti L, Damron KS, Rivera J, et al.: Evaluation of effect of sedation as a confounding factor in the diagnostic validity of lumbar facet joint pain: A prospective, randomized, double-blind, placebo-controlled evaluation. Pain Physician. 2004; 7(4): 411-417.

Manchikanti L, Pampati V, Damron KS, et al.: A randomized, prospective, double-blind, placebo-controlled evaluation of the effect of sedation on diagnostic validity of cervical facet joint pain. Pain Physician. 2004; 7(3): 301-309.

Manchikanti L, Pampati V, Damron KS, et al.: The effect of sedation on diagnostic validity of facet joint nerve blocks: An evaluation to assess similarities in population with involvement in cervical and lumbar regions. Pain Physician. 2006; 9(1): 47-52.

Manchikanti L, Pampati V, Damron K: The role of placebo and nocebo effects of perioperative administration of sedatives and opioids in interventional pain management. Pain Physician. 2005; 8(4): 349-355.

Andersen G, Sjogren P, Hansen SH, et al.: Pharmacological consequences of long-term morphine treatment in patients with cancer and chronic nonmalignant pain. Eur J Pain. 2004; 8(3): 263-271.

Ballantyne J, Mao J: Opioid therapy for chronic pain. N Engl J Med. 2003; 349(20): 1943-1953.

Ballantyne JC: Opioid analgesia: Perspectives on right use and utility. Pain Physician. 2007; 10(3): 479-491.

Mao J, Price DD, Mayer DJ: Mechanisms of hyperalgesia and opiate tolerance: A current view of their possible interactions. Pain. 1995; 62(3): 259-274.

Mao J, Price DD, Mayer DJ: Thermal hyperalgesia in association with the development of morphine tolerance in rats: Roles of excitatory amino acid receptors and protein kinase C. J Neurosci. 1994; 14(4): 2301-2312.

Angst MS, Koppert W, Pahl I, et al.: Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain. 2003; 106(1/2): 49-57.

Wilson GR, Reisfield GM: Morphine hyperalgesia: A case report. Am J Hosp Palliat Care. 2003; 20(6): 459-461.

Kissin I: Tolerance to opioid analgesia: Why do we differ from rats? Anesth Anal. 2005; 101(6): 1727-1729.

Van Elstraete AC, Sitbon P, Trabold F, et al.: A single dose of intrathecal morphine in rats induces long-lasting hyperalgesia: The protective effect of prior administration of ketamine. Anesth Analg. 2005; 101(6): 1750-1756.

Mao J: Opioid-induced abnormal pain sensitivity: Implications in clinical opioid therapy. Pain. 2002; 100(3): 213-217.

Mercadante S, Ferrera P, Villari P, et al.: Hyperalgesia: An emerging iatrogenic syndrome. J Pain Symptom Manag. 2003; 26(2): 769-775.

Angst MS, Clark JD: Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiol. 2006; 104(3): 570-587.

Mayer DJ, Mao J, Holt J, et al.: Cellular mechanisms of neuropathic pain, morphine tolerance, and their interactions. PNAS, USA. 1999; 96(14): 7731-7736.

Belanger S, Ma W, Chabot JG, et al.: Expression of calcitonin gene-related peptide, substance P and protein kinase C in cultured dorsal root ganglion neurons following chronic exposure to mu, delta and kappa opiates. Neuroscience. 2002; 115(2): 441-453.

Gardell LR, Wang R, Burgess SE, et al.: Sustained morphine exposure induces a spinal dynorphin-dependent enhancement of excitatory transmitter release from primary afferent fibers. J Neurosci. 2002; 22(15): 6747-6755.

Sharar RG. General principles of epidemiology. In Cassens BJ (ed.): Preventive Medicine and Public Health. Baltimore: Williams & Wilkins, 1992, pp 1-28.

Boswell MV, Trescot AM, Datta S, et al.: Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007; 10(1): 7-111.

Manchikanti L, Damron KS, McManus CD, et al.: Patterns of illicit drug use and opioid abuse in patients with chronic pain at initial evaluation: A prospective, observational study. Pain Physician. 2004; 7(4): 431-437.

Vogt MT, Kwoh CK, Cope DK, et al.: Analgesic usage for low back pain: Impact on health care costs and service use. Spine. 2005; 30(9): 1075-1081.

Mahmud MA, Webster BS, Courtney TK, et al.: Clinical management and the duration of disability for work-related low back pain. J Occup Environ Med. 2000; 42(12): 1178-1187.

Webster BS, Verma SK, Gatchel RJ: Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007; 32(19): 2127-2132.

Sehgal N, Shah RV, McKenzie-Brown AM, et al.: Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: A systematic review of evidence. Pain Physician. 2005; 8(2): 211-224.

Sehgal N, Dunbar EE, Shah RV, et al.: Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: An update. Pain Physician. 2007; 10(1): 213-228.

Barnsley L, Bogduk N: Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993; 18(6): 343-350.

Dreyfuss P, Schwarzer AC, Lau P, et al.: Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine. 1997; 22(8): 895-902.

Kaplan M, Dreyfuss P, Halbrook B, et al.: The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint. Spine. 1998; 23(17): 1847-1852.

Bogduk N, Lord S: Cervical zygapophysial joint pain. Neurosurg Q. 1998; 8(2): 107-117.

Bonica JJ, Buckley FP (eds.): Regional analgesia with local anesthetics. In The Management of Pain. Philadelphia: Lea & Febiger, 1990, pp 1883-1966.

Boas RA: Nerve blocks in the diagnosis of low back pain. Neurosurg Clin N Am. 1991; 2(4): 806-816.

Barnsley L, Lord S, Bogduk N: Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joints pain. Pain. 1993; 55(1): 99-106.

Lord SM, Barnsley L, Bogduk N: The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain. 1995; 11(3): 208-213.

Manchikanti L, Singh V, Derby R, et al.: Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. Pain Physician. 2008; 11(4): 393-482.