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Farrell S, Smith A, Schneider B, Schneider G, Grondin D, Gelley G, Bobos P, Maher CG, Gross AR. Glucocorticoid facet joint injection for chronic back or neck pain. Cochrane Database Syst Rev 2024; 11:CD015354. [PMID: 39569679 PMCID: PMC11580111 DOI: 10.1002/14651858.cd015354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The primary objective is to assess the benefits and harms of glucocorticoid facet joint injections in adults with chronic back or neck pain that is presumed to be facet joint-mediated. The secondary objective is to assess whether the effects differ by diagnostic method for facet joint-mediated pain.
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Affiliation(s)
- Scott Farrell
- RECOVER Injury Research Centre & NHMRC Centre for Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Australia
| | - Ashley Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Byron Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Tennessee, Kentucky, USA
| | - Geoff Schneider
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Diane Grondin
- Canadian Memorial Chiropractic College, Toronto, Canada
| | - Geoffrey Gelley
- Private Practice, Gelley Chiropractic Clinic, Winnipeg, Canada
| | - Pavlos Bobos
- Faculty of Health Sciences, Department of Health and Rehabilitation Sciences, Western University, London, Canada
| | | | - Anita R Gross
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
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Donati D, Vita F, Amoruso V, Origlio F, Tedeschi R, Castagnini F, Stella SM, Miceli M, Faldini C, Galletti S. The Effectiveness of Ultrasound-Guided Infiltrations Combined with Early Rehabilitation in the Management of Low Back Pain: A Retrospective Observational Study. Diagnostics (Basel) 2024; 14:2087. [PMID: 39335766 PMCID: PMC11431475 DOI: 10.3390/diagnostics14182087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/16/2024] [Accepted: 09/17/2024] [Indexed: 09/30/2024] Open
Abstract
Background and Aims: Low back pain is a prevalent condition affecting 60-85% of individuals during their lifetime. Despite various proposed mechanisms, the etiology of low back pain remains unclear. This study aims to evaluate the effectiveness of combining ultrasound-guided infiltrations with early rehabilitation in reducing pain and improving functional limitations in patients with chronic nonspecific low back pain. Methods: A retrospective observational study was conducted, reviewing data from January to April 2024 involving 40 patients with chronic nonspecific low back pain. Each patient received two cycles of ultrasound-guided lidocaine and corticosteroid infiltrations at the level of the posterior lower iliac spine, followed by 10 rehabilitation sessions. Patients were assessed at baseline (T0), after the first treatment cycle (T1), and after the second cycle (T2) using the Oswestry Disability Index, Quebec Back Pain Disability Scale, Roland Disability Questionnaire, and Numeric Rating Scale. Results: Significant improvements were observed across all assessment scales. The ODI scores decreased from 33.5 at baseline to 3.5 after treatment (p < 0.001). Similar reductions were noted in the QBPDS (from 61.5 to 10.3), RDQ (from 18 to 3.4), and NRS (from 7.4 to 1.3). The combination of ultrasound-guided infiltrations and early rehabilitation resulted in a significant reduction in pain and disability, with the most notable improvements occurring after the second treatment cycle. Conclusions: The integration of ultrasound-guided infiltrations with early rehabilitation is highly effective in managing chronic nonspecific low back pain, significantly reducing both pain and functional limitations.
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Affiliation(s)
- Danilo Donati
- Physical Therapy and Rehabilitation Unit, Policlinico di Modena, 41125 Modena, Italy;
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Fabio Vita
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, 40136 Bologna, Italy
| | - Vincenza Amoruso
- Rehabilitation Unit Santa Corona Hospital, 17027 Pietra Ligure, Italy
| | - Flavio Origlio
- Physical Therapy and Rehabilitation Unit, IRCCS Rizzoli Orthopedic Institute, University of Bologna, 40136 Bologna, Italy
| | - Roberto Tedeschi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40136 Bologna, Italy
| | - Francesco Castagnini
- SC Ortopedia e Traumatologia e Chirurgia Protesica e dei Reimpianti di Anca e Ginocchio, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Salvatore Massimo Stella
- SIUMB Advanced School for Musculoskeletal Ultrasound, Department of Clinical and Experimental Medicine, University Post-Graduate Course, Santa Chiara University Hospital, 56121 Pisa, Italy
| | - Marco Miceli
- IRCCS Istituto Ortopedico Rizzoli, Diagnostic and Interventional Radiology, 40136 Bologna, Italy
| | - Cesare Faldini
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, 40136 Bologna, Italy
| | - Stefano Galletti
- Musculoskeletal Ultrasound School, Italian Society for Ultrasound in Medicine and Biology, 40136 Bologna, Italy
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Arora P, Kanthed P, Vyas N, Dey S. Minimally invasive pain and spine interventions for low backache. INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_122_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Gündoğdu Z, Öterkuş M, Karatepe Ü. Evaluation of the Effect of Radiofrequency Denervation on Quality of Life of Patients with Facet Joint Syndrome by Oswestry Disability Index Score and Visual Analogue Scale Score. Prague Med Rep 2021; 122:278-284. [PMID: 34924105 DOI: 10.14712/23362936.2021.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
In this study, we aimed to investigate the effect of radiofrequency denervation procedure on pain and quality of life of patients with facet joint syndrome. Forty-seven patients who were admitted to our hospital with low back pain and diagnosed with facet joint syndrome between January 2018 and December 2018 were included in our study. The patients underwent denervation with radiofrequency under fluoroscopy in a sterile operating room condition. The pre-procedure and 6th month follow-up VAS (visual analogue scale) and ODI (Oswestry disability index) scores of the patients were recorded. When the demographic data of the patients were analysed, the mean age of the patients was found to be 52. Of the patients, 61.7% were female. In the evaluation of VAS and ODI scores, which we used to measure the efficiency of the procedure, the 6th month values were found to be statistically lower than the pre-procedure values (p<0.05). The first treatment for facet joint syndrome is bed rest and medical treatment. Resistant cases also benefit from physical therapy and intra-articular steroid injection. In patients unresponsive to these treatments, denervation with radiofrequency appears to be an effective method. At least two levels must be performed for the procedure to be successful. Studies have shown that pain decreases in the long term (6-12 months) and quality of life increases. We also obtained similar results in our studies. In conclusion, we think that RF (radiofrequency) can be used as an effective method in cases where other treatments fail.
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Affiliation(s)
- Zafer Gündoğdu
- Department of Anaesthesiology and Reanimation, Elazığ Medical Park Hospital, Elazığ, Turkey
| | - Mesut Öterkuş
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Malatya Turgut Özal University, Malatya, Turkey.
| | - Ümit Karatepe
- Department of Anaesthesiology and Reanimation, Elazığ Fethi Sekin City Hospital, Elazığ, Turkey
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Hegmann KT, Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Eskay-Auerbach M, Galper J, Goertz M, Haldeman S, Hooper PD, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Invasive Treatments for Low Back Disorders. J Occup Environ Med 2021; 63:e215-e241. [PMID: 33769405 DOI: 10.1097/jom.0000000000001983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION Quality evidence should guide invasive treatment for all phases of managing low back disorders.
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Affiliation(s)
- Kurt T Hegmann
- American College of Occupational and Environmental Medicine, Elk Grove Village, Illinois
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Abstract
OBJECTIVE In this narrative review, the current literature on therapeutic interventions for low back pain of facet joint etiology is assessed from an economic value perspective. SUMMARY OF BACKGROUND DATA The efficacy and economics of facet joint interventions in the treatment of lumbar back pain is a controversial topic. Trends show that facet joint interventions are becoming increasingly used, perhaps as physicians become more averse to treating chronic low back pain with opioids. With the emphasis on value-based spine care and changing reimbursement models, the perspective of rigorously evaluating the outcomes these interventions provide and the costs they incur is particularly relevant. DISCUSSION Although the evidence is noted to be limited, most systematic reviews fail to demonstrate the therapeutic utility of intra-articular facet joint injections in low back pain because of high study heterogeneity. A few good quality studies and systematic reviews describe moderate evidence for the utilization of therapeutic medial branch blocks and radiofrequency neurotomies in alleviating facet joint pain. CONCLUSION Consequently, there is a need for high-quality cost-effectiveness studies for facet joint interventions so that evidence-based and economically viable solutions can be used to optimize patient care at a societally affordable price.
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Soriano E, Bellinger E. Adult degenerative lumbar spondylolisthesis: Nonoperative treatment. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.semss.2020.100805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Onafowokan OO, Fine NF, Brooks F, Stokes OM, Briggs TWR, Hutton M. Multiple injections for low back pain: What’s the future? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:564-578. [DOI: 10.1007/s00586-019-06258-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/04/2019] [Accepted: 12/16/2019] [Indexed: 12/28/2022]
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Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. Am J Phys Med Rehabil 2019; 97:741-746. [PMID: 29734232 DOI: 10.1097/phm.0000000000000960] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks. OBJECTIVE The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy. METHODS This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection. RESULTS No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%-99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%-100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy. CONCLUSIONS Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.
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Balázsfi M, Kis D, Tóth T, Zsoldos T, Barzó P. Radiofrequency facet joint denervation efficiency based on the severity of spondylarthrosis and in osteoporotic vertebral compression fractures. A retrospective study. Clin Neurol Neurosurg 2019; 186:105497. [PMID: 31563692 DOI: 10.1016/j.clineuro.2019.105497] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Radiofrequency denervation of the facet joints is performed via a well-established method. Its primary, direct indication is a positive response to a nerve block injection (MBB). Our study aimed to find other, effective but indirect indication signs through the retrospective analysis of our patients treated earlier. PATIENTS AND METHODS In our institute between 1 January, 2008 and 31 December, 2017 facet joint denervation has been performed in more than 2000 cases, and we included 529 patients in our retrospective study. We had separate groups for vertebral compression fractures and for spondylarthrosis of different severity (Grade 1; 2-3; 4), thus we assessed the postoperative condition of these patients using Visual Analoge Scale (VAS). The efficacy of the intervention was examined in every groups separately according to symptoms and previous spine surgeries. RESULTS In view of our results, chronic lumbago and dorsalgia that are attributable to osteoporotic vertebral compression fracture are obvious indications if they do not respond to conservative therapy, as 76.8% of such patients remained asymptomatic for minimum 6 months (p = 0,000). Another indication is Grade 2 or 3 chronic spondylarthrosis without radicular involvement, since these groups reported a 51.4% success rate (asymptomatic for minimum 6 months) (p = 0,015). Long term pain relief is obviously impaired by the presence of radicular compression, as we were not able to decrease the pain of 97% of such patients. Our findings also suggest that the vast majority of those who have previously undergone spine surgery cannot benefit from the intervention. CONCLUSION Based on this study, facet joint denervation can serve as an effective therapy supplement in a properly selected group of patients who do not respond to oral NSAIDs, exercise and physiotherapy. By this procedure we found we can reach long term benefit in the groups of osteoporotic vertebral fracture patients and patients with moderate spondylarthrosis. According to our results and the literature datas the properly patient selection for the indication of the RF ablation can be as effective as the controversial diagnostic nerve block injections.
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Affiliation(s)
- Márton Balázsfi
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Csongrad County, Hungary.
| | - Dávid Kis
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Csongrad County, Hungary
| | - Tamás Tóth
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Csongrad County, Hungary
| | - Tamás Zsoldos
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Csongrad County, Hungary
| | - Pál Barzó
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Csongrad County, Hungary
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Rodrigues JC, Poetscher AW, Lenza M, Gotfryd AO, Martins Filho DE, Rodrigues LMR, Garcia RG, Rosemberg LA, Barros DDCS, Kihara Filho EN, Ferretti M, Bang GSS. Prognostic factors in low back pain individuals undergoing steroid and anaesthetic intra-articular facet joint infiltration: a protocol for a prospective, longitudinal, cohort study. BMJ Open 2019; 9:e026903. [PMID: 31292177 PMCID: PMC6624116 DOI: 10.1136/bmjopen-2018-026903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 04/15/2019] [Accepted: 05/30/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Lumbar pain of facet origin is a common problem worldwide. For those patients not responding to traditional treatment, one approach may be intra-articular infiltration of corticoid and anaesthetic. However, despite the increasing demand for this procedure, no consensus exists regarding its therapeutic value. The selection of eligible participants may be a determining factor since only those with an inflammatory process will benefit from the use of corticosteroids. This study aims to identify differences in disability, pain and quality of life scores in individuals with and without facet joint inflammation who were diagnosed using MRI. METHOD AND ANALYSIS This prospective cohort will include individuals older than 18 years with a clinical diagnosis of facet syndrome who underwent intra-articular infiltration. Changes in scores of pain, disability and quality of life questionnaires at 1, 3, 6 and 12 months of follow-up compared with baseline will be analysed. An MRI examination performed before infiltration will help to distinguish between exposed (with inflammation) and non-exposed (non-inflammation) groups with facet syndrome. The primary outcome will be the disability questionnaire (Roland Morris), and the secondary outcomes will be the score questionnaires for pain (Visual Analogue Scale), quality of life (EuroQol Quality of Life Questionnaire) and disability (Oswestry). ETHICS AND DISSEMINATION The Internal Review Board approved this study, which started only after the approval number (5291417.0.0000.0071) was received. All recruited participants will receive a verbal explanation about the purpose of the study, and their decision to participate will be free and voluntary. All participants enrolled in the study will provide a signed informed consent form including confidentiality terms. The results obtained in this study will be presented at national and international conferences and published in peer-reviewed scientific journals to disseminate the knowledge. TRIALS REGISTRATION NUMBER NCT03304730; Pre-results.
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Affiliation(s)
- João Carlos Rodrigues
- Departamento de Radiologia, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Departamento de Radiologia, Universidade de São Paulo, Hospital das Clinicas da Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, São Paulo, Brazil
| | | | - Mario Lenza
- Programa Locomotor, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Rodrigo Gobbo Garcia
- Departamento de Radiologia Intervencionista, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laercio Alberto Rosemberg
- Departamento de Radiologia, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Departamento de Radiologia, Universidade de São Paulo, Hospital das Clinicas da Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, São Paulo, Brazil
| | | | | | - Mario Ferretti
- Programa Locomotor, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Kershen LM, Nacey NC, Patrie JT, Fox MG. Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief. AJNR Am J Neuroradiol 2018; 39:2161-2165. [PMID: 30287461 DOI: 10.3174/ajnr.a5805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/30/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain. MATERIALS AND METHODS All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded. RESULTS Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level (P < .001) and patient age (P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) (P = .005). CONCLUSIONS Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection.
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Affiliation(s)
- L M Kershen
- From the Colorado Imaging Associates (L.M.K.), Golden, Colorado
| | - N C Nacey
- Departments of Radiology and Medical Imaging (N.C.N.)
| | - J T Patrie
- Public Health Sciences (J.T.P.), University of Virginia, Charlottesville Virginia
| | - M G Fox
- Department of Radiology (M.G.F.), Mayo Clinic Arizona, Phoenix, Arizona.
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Snidvongs S, Taylor RS, Ahmad A, Thomson S, Sharma M, Farr A, Fitzsimmons D, Poulton S, Mehta V, Langford R. Facet-joint injections for non-specific low back pain: a feasibility RCT. Health Technol Assess 2018; 21:1-130. [PMID: 29231159 DOI: 10.3310/hta21740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pain of lumbar facet-joint origin is a common cause of low back pain in adults and may lead to chronic pain and disability, with associated health and socioeconomic implications. The socioeconomic burden includes an inability to return to work resulting in loss of productivity in addition to direct and indirect health-care utilisation costs. Lumbar facet-joints are paired synovial joints between the superior and inferior articular processes of consecutive lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Facet-joint pain is defined as pain that arises from any structure that is part of the facet-joints, including the fibrous capsule, synovial membrane, hyaline cartilage and bone. This pain may be treated by intra-articular injections with local anaesthetic and steroid, although this treatment is not standardised. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. Because of the lack of high-quality, robust clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines on the management of chronic low back pain [NICE. Low Back Pain in Adults: Early Management. Clinical guideline (CG88). London: NICE; 2009] did not recommend the use of spinal injections despite their perceived potential to reduce pain intensity and improve rehabilitation, with NICE calling for further research to be undertaken. The updated guidelines [NICE. Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE guideline (NG59). London: NICE; 2016] again do not recommend the use of spinal injections. OBJECTIVES To assess the feasibility of carrying out a definitive study to evaluate the clinical effectiveness and cost-effectiveness of lumbar facet-joint injections compared with a sham procedure in patients with non-specific low back pain of > 3 months' duration. DESIGN Blinded parallel two-arm pilot randomised controlled trial. SETTING Initially planned as a multicentre study involving three NHS trusts in the UK, recruitment took place in the pain and spinal orthopaedic clinics at Barts Health NHS Trust only. PARTICIPANTS Adult patients referred by their GP to the specialist clinics with non-specific low back pain of at least 3 months' duration despite NICE-recommended best non-invasive care (education and one of a physical exercise programme, acupuncture or manual therapy). Patients who had already received lumbar facet-joint injections or who had had previous back surgery were excluded. INTERVENTIONS Participants who had a positive result following a diagnostic test (single medial branch nerve blocks) were randomised and blinded to receive either intra-articular lumbar facet-joint injections with steroids (intervention group) or a sham procedure (control group). All participants were invited to attend a group-based combined physical and psychological (CPP) programme. MAIN OUTCOME MEASURES In addition to the primary outcome of feasibility, questionnaires were used to assess a range of pain-related (including the Brief Pain Inventory and Short-Form McGill Pain Questionnaire version 2) and disability-related (including the EuroQol-5 Dimensions five-level version and Oswestry Low Back Pain Questionnaire) issues. Health-care utilisation and cost data were also assessed. The questionnaire visits took place at baseline and at 6 weeks, 3 months and 6 months post randomisation. The outcome assessors were blinded to the allocation groups. RESULTS Of 628 participants screened for eligibility, nine were randomised to receive the study intervention (intervention group, n = 5; sham group, n = 4), six completed the CPP programme and eight completed the study. LIMITATIONS Failure to achieve our expected recruitment targets led to early closure of the study by the funder. CONCLUSIONS Because of the small number of participants recruited to the study, we were unable to draw any conclusions about the clinical effectiveness or cost-effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. Although we did not achieve the target recruitment rate from the pain clinics, we demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely to all nine randomised participants, thus addressing many of the feasibility objectives. FUTURE WORK Stronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory who are suitable for inclusion in a future trial. TRIAL REGISTRATION EudraCT 2014-003187-20 and Current Controlled Trials ISRCTN12191542. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 74. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Saowarat Snidvongs
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alia Ahmad
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Simon Thomson
- Department of Pain Management, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Manohar Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Angela Farr
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Stephanie Poulton
- Locomotor Pain Service, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Vivek Mehta
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Richard Langford
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
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Ellard DR, Underwood M, Achana F, Antrobus JH, Balasubramanian S, Brown S, Cairns M, Griffin J, Griffiths F, Haywood K, Hutchinson C, Lall R, Petrou S, Stallard N, Tysall C, Walsh DA, Sandhu H. Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial. Health Technol Assess 2018. [PMID: 28639551 DOI: 10.3310/hta21300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. OBJECTIVES To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. DESIGN The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. SETTING Five NHS acute trusts in England. PARTICIPANTS Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. INTERVENTIONS All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. MAIN OUTCOME MEASURES Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. RESULTS Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. LIMITATIONS Poor recruitment was a limiting factor. CONCLUSIONS This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. FUTURE WORK Further work is needed to test recruitment from alternative clinical situations. TRIAL REGISTRATION EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Felix Achana
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - James Hl Antrobus
- South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick, UK
| | - Shyam Balasubramanian
- Pain Management Service, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Sally Brown
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Melinda Cairns
- Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - James Griffin
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Frances Griffiths
- Social Science and Systems in Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kirstie Haywood
- Royal College of Nursing Research Institute, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Population Evidence and Technologies Room, Warwick Medical School, University of Warwick, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Colin Tysall
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Maher DP, Cohen SP. Opioid Reduction Following Interventional Procedures for Chronic Pain: A Synthesis of the Evidence. Anesth Analg 2017; 125:1658-1666. [PMID: 28719427 DOI: 10.1213/ane.0000000000002276] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The past decade has witnessed the tremendous growth of procedures to treat chronic pain, which has resulted in increased third-party scrutiny. Although most of these procedures appear to be associated with significant pain relief, at least in the short and intermediate term, their ability to improve secondary outcome measures, including function and work status is less clear-cut. One of these secondary outcome measures that has garnered substantial interest in the pain and general medical communities is whether interventions can reduce opioid intake, which is associated with significant risks that in most cases outweigh the benefits in the long term. In the article, we examine whether procedural interventions for chronic pain can reduce opioid intake. Most studies that have examined analgesic reduction as a secondary outcome measure have not separated opioid and nonopioid analgesics, and, among those studies that have, few have demonstrated between-group differences. Reasons for failure to demonstrate opioid reduction can be broadly classified into procedural, design-related, clinical, psychosocial, biological, and pharmacological categories, all of which are discussed. In the future, clinical trials in which this outcome is examined should be designed to evaluate this, at least on a preliminary basis.
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Affiliation(s)
- Dermot P Maher
- From the *Department of Anesthesiology & Critical Care Medicine and †Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Bethesda, Maryland; and ‡Departments of Anesthesiology and Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Farrokhi S, Mazzone B, Schneider M, Gombatto S, Mayer J, Highsmith MJ, Hendershot BD. Biopsychosocial risk factors associated with chronic low back pain after lower limb amputation. Med Hypotheses 2017; 108:1-9. [DOI: 10.1016/j.mehy.2017.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 11/27/2022]
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Wu J, Zhou J, Liu C, Zhang J, Xiong W, Lv Y, Liu R, Wang R, Du Z, Zhang G, Liu Q. A Prospective Study Comparing Platelet-Rich Plasma and Local Anesthetic (LA)/Corticosteroid in Intra-Articular Injection for the Treatment of Lumbar Facet Joint Syndrome. Pain Pract 2017; 17:914-924. [PMID: 27989008 DOI: 10.1111/papr.12544] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/21/2016] [Accepted: 10/26/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To compare the effectiveness and safety between autologous platelet-rich plasma (PRP) and Local Anesthetic (LA)/corticosteroid in intra-articular injection for the treatment of lumbar facet joint syndrome. METHODS Forty-six eligible patients with lumbar facet joint syndrome were randomized into group A (intra-articular injection with PRP) and group B (intra-articular injection with LA/corticosteroid). The following contents were evaluated: pain visual analog scale (VAS) at rest and during flexion, and the Roland-Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria for pain relief and applications of post-treatment drugs. All outcome assessments were performed immediately after and at 1 week, 1, 2, 3, and 6 months after treatment. RESULTS No significant difference between groups was observed at baseline. Compared with pretreatment, both group A and group B demonstrated statistical improvements in the pain VAS score at rest or during flexion, the RMQ, and the ODI (P < 0.01). And there were significant differences between the 2 groups on the above-mentioned items (P < 0.05). For group B, subjective satisfaction based on the modified MacNab criteria and objective success rate were highest (80% and 85%) after 1 month, but only 50% and 20% after 6 months. However, for group A, they increased over time. In addition, there were no treatment-related complications in either group during follow-up. CONCLUSIONS Both autologous PRP and LA/corticosteroid for intra-articular injection are effective, easy, and safe enough in the treatment of lumbar facet joint syndrome. However, autologous PRP is a superior treatment option for longer duration efficacy.
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Affiliation(s)
- Jiuping Wu
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Jingjing Zhou
- Department of Imaging and Nuclear Medicine, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Chibing Liu
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Jun Zhang
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Wei Xiong
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Yang Lv
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Rui Liu
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Ruiqiang Wang
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Zhenwu Du
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Guizhen Zhang
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
| | - Qinyi Liu
- Department of Orthopaedics, The Second Hospital, Jilin University, Changchun, Jilin, China
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Le Clec'h Y, Peterson CK, Brunner F, Pfirrmann CWA. Cervical Facet Joint Imaging-Guided Injections: A Comparison of Outcomes in Patients Referred Based on Imaging Findings Vs Palpation for Pain. J Manipulative Physiol Ther 2016; 39:480-486. [PMID: 27523428 DOI: 10.1016/j.jmpt.2016.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this study was to compare outcomes of patients referred for cervical facet joint injections by either a medical doctor (MD) primarily basing the selection of facet levels on structural changes found on imaging vs a doctor of chiropractic (DC) selecting the levels for injection based on palpation for pain. METHODS This was a prospective cohort outcome study including 121 consecutive patients receiving cervical facet injections with completed outcomes questionnaires. Medical doctors referred 91 patients and DCs referred 30 patients. Baseline pain numerical rating scale (NRS) data were collected. Outcomes collected at 1 day, 1 week, and 1 month after injection included NRS pain levels and overall "improvement" using the Patient Global Impression of Change scale (primary outcome). The responses "much better" and "better" were considered "improved." The proportion improved was compared between the 2 groups using the χ(2) test. NRS change scores for the 2 groups were compared using the unpaired t test. RESULTS At 1 day, "improvement" was reported in 44.8% of DC-and 29.7% of MD-referred patients (P = .17). At 1 week, 37.9% of DC-and 21.3% of MD-referred patients reported improvement (P = .03). At 1 month, 50.0% of DC-and 31.0% of MD-referred patients reported improvement (P = .1). CONCLUSIONS A greater proportion of DC-referred patients (injection level based on palpation for pain) reported "improvement" at all follow-up time points. This finding reached statistical significance at 1 week. These findings may be because DCs use palpation for pain to determine injection level whereas MDs rely more on imaging findings. The results suggest that the reported moderate results of facet injections partially may be due to the inaccurate selection of the spinal level treated.
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Affiliation(s)
| | - Cynthia K Peterson
- Department of Radiology, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland; Department of Chiropractic Medicine, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland.
| | - Florian Brunner
- Department of Rheumatology, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland
| | - Christian W A Pfirrmann
- Department of Radiology, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland
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Manchikanti L, Hirsch JA, Falco FJE, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop 2016; 7:315-337. [PMID: 27190760 PMCID: PMC4865722 DOI: 10.5312/wjo.v7.i5.315] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/13/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.
METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.
RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.
CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.
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A Narrative Review of Intra-articular Zygapophysial Steroid Injections for Lumbar Zygapophysial-Mediated Pain. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0117-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Proietti L, Schirò GR, Sessa S, Scaramuzzo L. The impact of sagittal balance on low back pain in patients treated with zygoapophysial facet joint injection. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 6:628-33. [PMID: 25212449 DOI: 10.1007/s00586-014-3559-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 09/03/2014] [Accepted: 09/03/2014] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Aim of the study was to evaluate the effectiveness of facet joints injections in lumbar facet syndrome correlating clinical results to the sagittal contour of the spine. METHODS Facet joints degree degeneration was evaluated using MRI according to Fujiwara classification. Sagittal contour of the spine was evaluated according to Roussouly classification. The clinical results were evaluated with visual analog scale (VAS) at regular intervals. RESULTS Twenty-eight (70 %) of the 40 patients had clinical symptoms improvement, 12 (30 %) showed no benefit. There was a statistical significant correlation between postoperative VAS value improvement and Roussouly spine type 1 and 3 (p = 0.003). The benefit was more durable in patients with grade 2 or 3 degeneration. CONCLUSIONS Facet joints injections have a more effective diagnostic than therapeutic value. The procedure could, however, give a temporary pain relief in cases with an overload of the facet joints due to lumbar hyperlordosis.
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Affiliation(s)
- L Proietti
- Division of Spinal Surgery, Department of Orthopaedics and Traumatology, Catholic University Hospital, Largo A. Gemelli 8, 00168, Rome, Italy,
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Watters WC, Resnick DK, Eck JC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Sharan A, Groff MW, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine 2014; 21:79-90. [DOI: 10.3171/2014.4.spine14281] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The medical literature continues to fail to support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. There is limited support for the use of lumbar epidural injections for shortterm relief in selected patients with chronic back pain. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3–6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. There is insufficient evidence to support or refute the use of trigger point injections for chronic lowerback pain without radiculopathy.
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Affiliation(s)
| | - Daniel K. Resnick
- 2Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Jason C. Eck
- 3Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Zoher Ghogawala
- 4Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Praveen V. Mummaneni
- 5Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Tanvir F. Choudhri
- 7Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alok Sharan
- 8Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michael W. Groff
- 9Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sanjay S. Dhall
- 5Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Bogduk N. Time to reconsider steroid injections in the spine? Med J Aust 2013; 199:752. [PMID: 24329643 DOI: 10.5694/mja13.11077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 10/17/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Nikolai Bogduk
- Newcastle Bone and Joint Institute, Newcastle, NSW, Australia.
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Roy C, Chatterjee N, Ganguly S, Sengupta R. Efficacy of combined treatment with medial branch radiofrequency neurotomy and steroid block in lumbar facet joint arthropathy. J Vasc Interv Radiol 2013. [PMID: 23177113 DOI: 10.1016/j.jvir.2012.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the long-term efficacy of combined radiofrequency (RF) neurotomy and steroid nerve block in patients with lumbar facet joint arthropathy. MATERIALS AND METHODS Combined RF neurotomy and steroid nerve block was performed in 34 patients with chronic paravertebral low back pain. The diagnosis was confirmed by comparative double diagnostic block of the medial branch with bupivacaine and lidocaine. Under fluoroscopy, RF thermal ablation of the medial branch was performed (at RF needle tip temperature 85°C for 90 seconds), three times for each target nerve. At the end of the procedure, 20 mg of methylprednisolone acetate (sustained-release preparation) was infiltrated on each ablated nerve. Outcome variable was the degree of improvement in pain using visual analog scale (VAS) and numerical rating scale (NRS). Improvement in the quality of life was assessed using the Roland-Morris (RM) questionnaire. The procedure was repeated in cases of unbearable pain (>5 VAS score). RESULTS Patients had a mean VAS score of 8.6 before the procedure. Thereafter, VAS score was 0.91 immediately after the procedure and 3.0, 2.8, 3.7, and 3.6 at 1 month, 2 months, 6 months, and 1 year. NRS showed pain relief after the procedure of 85%, 65%, 78%, 62%, and 59.5% at the same time points. RM score was 18 before the procedure, 7.6 at 6 months after the procedure, and 8.5 at 1 year after the procedure. No major complication was noted except local pain in all patients and numbness of the back in six patients after the procedure. CONCLUSIONS Combined RF neurotomy and steroid nerve block produced substantial improvement in terms of long-term pain relief and quality of life.
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Affiliation(s)
- Chinmoy Roy
- Departments of Pain Management, Institute of Neurosciences Kolkata, 185/1 AJC Bose Road, Kolkata 700017, West Bengal 700017, India.
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Galhom AE, al-Shatouri MA. Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures. Clin Imaging 2013; 37:649-56. [PMID: 23660156 DOI: 10.1016/j.clinimag.2013.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 01/16/2013] [Accepted: 02/21/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE To evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain. METHODS This prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment. RESULTS One hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures. CONCLUSION Lumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.
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Affiliation(s)
- Ayman E Galhom
- Department of Neurosurgery, Faculty of Medicine, Suez Canal, University Hospital, 41522, Ismailia, Egypt.
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Sokolof JM, Nampiaparampil DE, Chimes GP. Use of medial branch blocks before radiofrequency ablation for lumbar facet joints. PM R 2012; 4:521-6. [PMID: 22814730 DOI: 10.1016/j.pmrj.2012.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Jonas M Sokolof
- Department of Neurology/Rehabilitation Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Imaging-guided lumbar facet injections: is there a difference in outcomes between low back pain patients who remember to return a postal questionnaire and those who do not? Insights Imaging 2012; 3:411-8. [PMID: 22695954 PMCID: PMC3481082 DOI: 10.1007/s13244-012-0178-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/09/2012] [Accepted: 05/16/2012] [Indexed: 12/02/2022] Open
Abstract
Objectives To determine whether data obtained from patients returning postal questionnaires accurately reflect how patients receiving imaging-guided lumbar facet injections respond. Methods Seventy-eight patients receiving lumbar facet joint injections who returned an outcomes questionnaire (responders) were age and gender matched with 78 patients who did not return the postal questionnaire (non-responders) after facet joint injections. Baseline numerical rating scale (NRS) pain data were collected. NRS and Patients’ Global Impression of Change (PGIC) data were collected 1 month after injection by postal questionnaire or telephone interview. Differences in NRS scores were calculated using the unpaired t-test. One level injection patients were compared to patients having ≥2 levels injected using the paired and unpaired t-test. The proportion of patients reporting significant improvement in each group was calculated. Results NRS scores were significantly improved compared to baseline (p = 0.0001). Thirty-eight percent of responders were significantly improved compared to 50 % of non-responders. Patients having ≥2 levels injected reported significantly higher baseline NRS scores, but by 1 month there was no difference in NRS scores between groups. Conclusions Patients returning postal questionnaires report a less favourable outcome. Telephone interview patients having injections at more than one level have better outcomes. Main messages • Patients returning postal questionnaires report worse outcomes after facet injection. • Method of data collection should be considered when reporting treatment outcomes. • Patients receiving facet injections at more than one level report greater levels of pain reduction.
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A prospective randomized double-blinded pilot study to examine the effect of botulinum toxin type A injection versus Lidocaine/Depomedrol injection on residual and phantom limb pain: initial report. Clin J Pain 2012; 28:108-12. [PMID: 21750460 DOI: 10.1097/ajp.0b013e3182264fe9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Botulinum toxin type A (Botox) injection has been used to manage pain. However, it remains to be proved whether Botox injection is effective to relieve residual limb pain (RLP) and phantom limb pain (PLP). DESIGN Randomized, double-blinded pilot study. SETTING Medical College and an outpatient clinic in Department of Physical Medicine and Rehabilitation. PARTICIPANTS Amputees (n=14) with intractable RLP and/or PLP who failed in the conventional treatments. INTERVENTIONS Study amputees were randomized to receive 1 Botox injection versus the combination of Lidocaine and Depomedrol injection. Each patient was evaluated at baseline and every month after the injection for 6 months. MAIN OUTCOME MEASURE The changes of RLP and PLP as recorded by VAS, and the changes of the pressure pain tolerance as determined by a pressure algometer. RESULTS All patients completed the protocol treatment without acute side effects, and monthly assessments of RLP, PLP, and pain tolerance after the treatment. The time trend in the outcomes was modeled as an immediate change owing to the treatment followed by a linear tread afterward. Repeated measures were incorporated using mixed effects modeling. We found that both Botox and Lidocaine/Depomedrol injections resulted in immediate improvements of RLP (Botox: P=0.002; Lidocaine/Depomedrol: P=0.06) and pain tolerance (Botox: P=0.01; Lidocaine/Depomedrol: P=0.07). The treatment effect lasted for 6 months in both groups. The patients who received Botox injection had higher starting pain than those who received Lidocaine/Depomedrol injection (P=0.07). However, there were no statistical differences in RLP and pain tolerance between these 2 groups. In addition, no improvement of PLP was observed after Botox or Lidocaine/Depomedrol injection. CONCLUSIONS Both Botox and Lidocaine/Depomedrol injections resulted in immediate improvement of RLP (not PLP) and pain tolerance, which lasted for 6 months in amputees who failed in conventional treatments.
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Hoelzer BC, Weingarten TN, Hooten WM, Wright RS, Wilson WR, Wilson PR. Paraspinal abscess complicated by endocarditis following a facet joint injection⋆. Eur J Pain 2012; 12:261-5. [PMID: 17606390 DOI: 10.1016/j.ejpain.2007.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 03/29/2007] [Accepted: 05/13/2007] [Indexed: 12/17/2022]
Abstract
Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications.
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Affiliation(s)
- Bryan C Hoelzer
- Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, S.W., Rochester, MN 55905, USA
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Zhou L, Schneck CD, Shao Z. The Anatomy of Dorsal Ramus Nerves and Its Implications in Lower Back Pain. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/nm.2012.32025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wolter T, Deininger M, Hubbe U, Mohadjer M, Knoeller S. Cryoneurolysis for zygapophyseal joint pain: a retrospective analysis of 117 interventions. Acta Neurochir (Wien) 2011; 153:1011-9. [PMID: 21359539 DOI: 10.1007/s00701-011-0966-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 02/03/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE Lumbar facet joint syndrome (LFJS) is the cause of pain in 15-54% of the patients with low-back pain. There are few studies of cryotherapy for LFJS, focusing mainly on pain scores rather than further outcome measures. The aim of the study was to determine the long-term outcome after cryoneurolysis of lumbar facet joints, looking at pain scores, pain-related impairment patient satisfaction, and pain-related anxiety/depression. METHODS The study design was a retrospective observational study. In a 4-year period, 117 cryoneurolyses were performed in 91 patients under CT guidance in the prone position. Data from patient charts and questionnaires pre- and post-treatment were evaluated. RESULTS The mean pain rating sank from 7.70 before treatment to 3.72 post treatment. In the post-interventional 3 months follow-up, this value rose to 4.22. At follow-up (mean 1.7 years, range 6-52 months), the mean visual analogue scale (VAS) was 4.99. The pain disability index revealed statistically significant improvements in the following items: familiar and domestic duties, recreation, social activities, profession and vitally indispensable activities (p < 0.05). Hospital anxiety and depression scale (HADS) scores for depression showed a statistically significant decline after therapy, whereas scores for anxiety did not. A subgroup of patients who did not benefit from cryoneurolysis had elevated depression scores. CONCLUSIONS Cryoneurolysis for LFJS can lead to favourable results with sustained pain relief, amelioration of pain-related disability and reduction of depression scores.
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Affiliation(s)
- Tilman Wolter
- Interdisciplinary Pain Centre, Breisacherstr. 64, 79106, Freiburg, Germany.
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The lumbar facet joint: a review of current knowledge: Part II: diagnosis and management. Skeletal Radiol 2011; 40:149-57. [PMID: 20577735 DOI: 10.1007/s00256-010-0984-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 05/13/2010] [Accepted: 05/14/2010] [Indexed: 02/02/2023]
Abstract
This article is the second article in a two-part review on lumbar facet joint pathology. In this review, we discuss the current concepts and controversies regarding the proper diagnosis and management of patients presenting with presumed facet-mediated lower back pain. All efforts were made to include the most relevant literature from the fields of radiology, orthopaedics, physiatry, and pain management. Our focus in this article is on presenting the evidence supporting or refuting the most commonly employed injection-based therapies for facet-mediated lower back pain.
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Bogduk N. Lumbar Facet Syndrome. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00090-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Kennedy DJ, Shokat M, Visco CJ. Sacroiliac Joint and Lumbar Zygapophysial Joint Corticosteroid Injections. Phys Med Rehabil Clin N Am 2010; 21:835-42. [DOI: 10.1016/j.pmr.2010.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Comparison of ultrasonography- and fluoroscopy-guided facet joint block in the lumbar spine. Asian Spine J 2010; 4:15-22. [PMID: 20622950 PMCID: PMC2900164 DOI: 10.4184/asj.2010.4.1.15] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 08/22/2009] [Accepted: 08/25/2009] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE Facet joint block is performed for diagnostic or therapeutic purposes and generally carried out under computerd tomography (CT) or radiologic fluoroscopy guidance. Ultrasonography-guided facet block has recently been attempted. So, we compared the results of ultrasonography-guided facet joint block with the results of fluoroscopy-guided facet joint block. OVERVIEW OF LITERATURE Because fluoroscopic or CT guided facet joint block has been reported side effects, we performed spinal facet block using a fluoroscopy-guided method. METHODS We selected 133 patients who had lumbar pain or referred pain. They were diagnosed as having spinal stenosis and hospitalized from January 2008 to June 2008. As the subjects, we selected 105 patients who had been follow-up for more than 6 months and carried out a prospective study. Twenty six subjects were male and 25 were female in the fluoroscopy group (group 1) and their mean age was 56.1 years (range, 45 to 79 years). Twenty one were male and 33 were female in the ultrasonography-guided group (group 2). Their mean age was 58.3 years (range, 47 to 83 years). We studied the average time of the procedures, complications, the difference of the therapeutic cost between the two groups. We also evaluated the visual analogue scale (VAS) score and the Oswestry disability index. RESULTS The procedure in group 2 averaged 4 minutes and 25 seconds, and in group 1, 4 minutes and 7 seconds. The coast was an average of 38,000 won in group 2 and 25,000 won in group 1. The VAS score was improved from an average of 7.5 (range, 5 to 9) to 2.8 (range, 2 to 6) in group 2 and from 7.8 (range, 4 to 10) to 2.7 (range, 2 to 5) in group 1. The Oswestry disability index was improved from an average of 32.3 (range, 28 to 41) to 23.5 (range, 17 to 26) in group 2 and from 34.2 (range, 29 to 43) to 24.8 (range, 18 to 28) in group 1. As for complications, worsening of lumbar pain, paresthesia, headache and allergic reaction were detected in 5 cases of group 2 and in 3 of group 1. Those symptoms were improved within several hours. One case of superficial infection that developed in group 2 was improved within several days. CONCLUSIONS We should consider that ultrasonography-guided facet joint block is a minimal invasive procedure that is easily carried out without radiation exposure.
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Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. PAIN MEDICINE 2009; 10:1035-45. [PMID: 19694977 DOI: 10.1111/j.1526-4637.2009.00692.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Confusion persists concerning the nature and efficacy of procedures variously known as facet denervation, lumbar medial branch radiofrequency neurotomy, and radiofrequency neurotomy or denervation for the treatment of back pain. Systematic reviews have not recognized the importance of patient selection and correct surgical technique when appraising the literature. As a result, negative conclusions about procedures have been drawn because lack of efficacy of one procedure has been misattributed to other, cognate, but different procedures. OBJECTIVES To demonstrate how the rationale and efficacy of lumbar medial branch neurotomy depends critically on correct selection of patients and use of surgically correct technique. METHODS A narrative review and description of the available evidence, drawn from the personal libraries of the authors and from the bibliographies of systematic reviews. RESULTS Three studies, commonly accepted as evidence of lack of effectiveness, were not valid tests of lumbar medial branch neurotomy because of errors in selection of patients or errors in surgical technique, or both. Two descriptive studies and three controlled studies that used valid or acceptable techniques consistently showed that lumbar medial branch neurotomy had positive effects on pain and disability. All valid, randomized controlled trials showed medial branch neurotomy to be more effective than sham treatment. DISCUSSION Negative results have been reported only in studies that selected inappropriate patients or used surgically inaccurate techniques. All valid studies showed positive outcomes that cannot be attributed to placebo. Inappropriate conclusions have been drawn by systematic reviews that misrepresent invalid studies as providing evidence against the efficacy of lumbar medial branch neurotomy.
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Affiliation(s)
- Nikolai Bogduk
- University of Newcastle, Newcastle Bone and Joint Institute, Newcastle, Australia.
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Past, Present, and Future of Therapeutic Lumbar Spine Interventional Procedures. Radiol Clin North Am 2009; 47:411-9. [DOI: 10.1016/j.rcl.2008.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34:1078-93. [PMID: 19363456 DOI: 10.1097/brs.0b013e3181a103b1] [Citation(s) in RCA: 236] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. SUMMARY OF BACKGROUND DATA Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. METHODS Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. CONCLUSION Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
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Pain Relief With Intraarticular or Medial Branch Nerve Blocks in Patients With Positive Lumbar Facet Joint SPECT Imaging: A 12-Week Outcome Study. South Med J 2008; 101:931-4. [DOI: 10.1097/smj.0b013e31817e6ffb] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bogduk N. Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy. Spine J 2008; 8:56-64. [PMID: 18164454 DOI: 10.1016/j.spinee.2007.10.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 10/15/2007] [Indexed: 02/03/2023]
Abstract
The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
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Affiliation(s)
- Nikolai Bogduk
- Pain Medicine Department, University of Newcastle, Newcastle, Australia.
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Abstract
Disc degeneration causes back pain because the function of the disc as a load transferring structure is abnormal, producing abnormal patterns of load which cause pain. Fusion has been unpredictable because it only fortuitously addresses loading. A fusion may be in such a position that it takes load from the disc, and this may be reflected in the way the fusion models, demonstrating a weight bearing pattern, but this is unpredictable. Recognition that we are dealing with a problem of load transfer allows us to design any surgical implant to solve this problem, without stopping movement.
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Affiliation(s)
- R C Mulholland
- Spinal Disorders Unit, Nottingham University Hospital, Nottingham, UK.
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Curatolo M, Eichenberger U. Ultrasound-guided blocks for the treatment of chronic pain. ACTA ACUST UNITED AC 2007. [DOI: 10.1053/j.trap.2007.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Although interventional therapy for chronic spinal pain continues to be popular among patients and providers, the scientific evidence supporting these techniques has lagged behind their presence in the market. This article collates both classic and more recent experimental results involved in the interventional assessment and treatment of chronic spinal pain, and presents key findings for physicians. Although much of the body of evidence is either unsupportive or inconclusive, there are some definitive findings involving each technique that can help shape rational practice. As interventional pain medicine seeks to become a more validated specialty, introspection and advancing science will be key to this development.
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Affiliation(s)
- David M Sibell
- Oregon Health and Science University, Department of Anesthesiology and Perioperative Medicine, Comprehensive Pain Center, Portland, OR 97239, USA.
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Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses 2007; 68:74-80. [PMID: 16919887 DOI: 10.1016/j.mehy.2006.06.033] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 06/22/2006] [Indexed: 12/30/2022]
Abstract
Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. This article presents a new, testable pathophysiological model integrating connective tissue plasticity mechanisms with several well-developed areas of research on cLBP (pain psychology, postural control, neuroplasticity). We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise). Non-invasive measures of connective tissue remodeling may eventually become important tools to evaluate and follow patients with cLBP in research and clinical practice. An integrative mechanistic model incorporating behavioral and structural aspects of cLBP will strengthen the rationale for a multidisciplinary treatment approach including direct mechanical tissue stimulation, movement reeducation, psychosocial intervention and pharmacological treatment to address this common and debilitating condition.
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Affiliation(s)
- Helene M Langevin
- Department of Neurology, Given C423, University of Vermont, Burlington, VT 05405, United States.
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Schulte TL, Pietilä TA, Heidenreich J, Brock M, Stendel R. Injection therapy of lumbar facet syndrome: a prospective study. Acta Neurochir (Wien) 2006; 148:1165-72; discussion 1172. [PMID: 17039302 DOI: 10.1007/s00701-006-0897-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Accepted: 08/03/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chronic low back pain remains a major health problem. Facet joint injection therapy is an easy to perform therapeutic option. However, few prospective studies use a standardized protocol to investigate injection therapy. The aim of our study was to evaluate quantity and duration of clinical improvement after this protocol, and to identify the best time for additional repetitive injection therapy. MATERIALS AND METHODS Thirty-nine patients (21 men, 18 women; mean age 55.2 years [range, 29-87 years]) with lumbar facet syndrome were treated with injection using a standardized protocol (prednisolone acetate, lidocaine 1%, phenol 5%) under fluoroscopic control. Follow-up was based on a specially designed questionnaire. Analysis included MacNab criteria, visual analogue scale, and pain disability index. RESULTS Reduction of pain was found up to 6 months after treatment. The outcome was assessed excellent or good by 62% (24 patients) of the patients after 1 month, by 41% (16 patients) after 3 months, and by 36% (14 patients) after 6 months. There was no influence of age, body mass index, or previous lumbar spinal surgery on improvement after treatment. There were no severe side effects. Short-lasting self limiting mild side effects were found in 26% (increased back pain, numbness, heartburn, headache, allergy). CONCLUSION Facet joint injection therapy using a standardized protocol is safe, effective, and easy to perform. The clinical effect is limited, and we recommend repetitive injection according to this protocol after 3 months.
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Affiliation(s)
- T L Schulte
- Department of Orthopaedics, University Hospital Münster, Münster, Germany.
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Huntoon M. Vertebral Compression Fractures in Elderly Osteoporosis Patients Receiving Glucocorticoid Intra-articular Injections. Pain Pract 2006; 6:206-11. [PMID: 17147599 DOI: 10.1111/j.1533-2500.2006.00087.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gallagher RM. The clinical art of pain medicine: balancing evidence, experience, ethics, and policy. PAIN MEDICINE 2005; 6:277-9. [PMID: 16083455 DOI: 10.1111/j.1526-4637.2005.00055.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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