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Management of Chronic Low Back Pain: Rationales, Principles, and Targets of Imaging-guided Spinal Injections¹

¹ From the Departments of Diagnostic Radiology (J.F., S.C., J.W., G.T., C.W.K., C.D.C., P.L.P.), Orthopedic Surgery (T. Niemeyer), and Neuroradiology (T. Nägele), Eberhard-Karls-University, Hoppe-Seyler-Str 3, Tübingen, Germany; and Department of Radiology, Université de Franche Comté, CHU Minjoz, Besancon, France (B.K.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received February 13, 2006; revision requested June 14; final revision received March 23, 2007; accepted March 23. All authors have no financial relationships to disclose. Address correspondence to J.F., Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: jfritz4{at}jhmi.edu).

If low back pain does not improve with conservative management, the cause of the pain must be determined before further therapy is initiated. Information obtained from the patient’s medical history, physical examination, and imaging may suffice to rule out many common causes of chronic pain (eg, fracture, malignancy, visceral or metabolic abnormality, deformity, inflammation, and infection). However, in most cases, the initial clinical and imaging findings have a low predictive value for the identification of specific pain-producing spinal structures. Diagnostic spinal injections performed in conjunction with imaging may be necessary to test the hypothesis that a particular structure is the source of pain. To ensure a valid test result, diagnostic injection procedures should be monitored with fluoroscopy, computed tomography, or magnetic resonance imaging. The use of controlled and comparative injections helps maximize the reliability of the test results. After a symptomatic structure has been identified, therapeutic spinal injections may be administered as an adjunct to conservative management, especially in patients with inoperable conditions. Therapeutic injections also may help hasten the recovery of patients with persistent or recurrent pain after spinal surgery.

© RSNA, 2007