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Sancar KS, Şeref Ç, Hamit G, Yavuz AE, Şaziye Ş. Does the severity of facet joint osteoarthritis affect facet medial branch radiofrequency thermocoagulation results? NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2025; 30:144-149. [PMID: 40199535 PMCID: PMC11977580 DOI: 10.17712/nsj.2025.30.4.20240037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 01/21/2025] [Indexed: 04/10/2025]
Abstract
OBJECTIVES To assess how facet medial branch radiofrequency thermocoagulation (FMB-RFT) outcomes are affected by severe facet joint osteoarthritis (FJO). METHODS This retrospective study involved 91 individuals with lumbar facet joint disease-related chronic lower back pain (CLBP), all of whom underwent FMB-RFT. The patients were assigned to 3 groups using the Weishaupt facet grading system (WFGS). Pain scores were assessed prior to treatment, as well as at the 1-, 6-, and 12-month marks. RESULTS Based on the WFGS, 38 of the 91 patients were assigned a grade 1 FJO, 28 a grade 2 FJO, and 25 a grade 3 FJO. The percentage of patients in each group who saw a 50% or greater improvement in their pain scores at 1, 6, and 12 months did not differ significantly. CONCLUSION For patients with CLBP, FMB-RFT has been shown to be safe and effective in both the short and long terms. The results from FMB-RFT do not seem to be affected by the severity of FJO.
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Affiliation(s)
- Kaya S. Sancar
- From the Deparment of Pain Medicine (Sancar), Adiyaman University Training and Research Hospital, Adıyaman, from the Deparment of Pain Medicine (Şeref, Yavuz, Şaziye), University of Health Sciences Ankara City Hospital, and from the Deparment of Pain Medicine (Hamit), Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey.
| | - Çelik Şeref
- From the Deparment of Pain Medicine (Sancar), Adiyaman University Training and Research Hospital, Adıyaman, from the Deparment of Pain Medicine (Şeref, Yavuz, Şaziye), University of Health Sciences Ankara City Hospital, and from the Deparment of Pain Medicine (Hamit), Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey.
| | - Göksu Hamit
- From the Deparment of Pain Medicine (Sancar), Adiyaman University Training and Research Hospital, Adıyaman, from the Deparment of Pain Medicine (Şeref, Yavuz, Şaziye), University of Health Sciences Ankara City Hospital, and from the Deparment of Pain Medicine (Hamit), Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey.
| | - Akçaboy E. Yavuz
- From the Deparment of Pain Medicine (Sancar), Adiyaman University Training and Research Hospital, Adıyaman, from the Deparment of Pain Medicine (Şeref, Yavuz, Şaziye), University of Health Sciences Ankara City Hospital, and from the Deparment of Pain Medicine (Hamit), Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey.
| | - Şahin Şaziye
- From the Deparment of Pain Medicine (Sancar), Adiyaman University Training and Research Hospital, Adıyaman, from the Deparment of Pain Medicine (Şeref, Yavuz, Şaziye), University of Health Sciences Ankara City Hospital, and from the Deparment of Pain Medicine (Hamit), Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey.
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Manchikanti L, Abd-Elsayed A, Kaye AD, Sanapati MR, Pampati V, Shekoohi S, Hirsch JA. A Systematic Review of Regenerative Medicine Therapies for Axial Spine Pain of Facet Joint Origin. Curr Pain Headache Rep 2025; 29:61. [PMID: 40085275 DOI: 10.1007/s11916-025-01376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2025] [Indexed: 03/16/2025]
Abstract
PURPOSE OF REVIEW This review aims to assess the effectiveness of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) injections in treating axial spinal pain originating from the facet joints. A systematic evaluation of available evidence on these biological therapies was conducted to determine their clinical utility. RECENT FINDINGS Recent studies emphasize the therapeutic promise of intraarticular biologics, including MSCs, PRP, and alpha-2-macroglobulin, in managing facet joint-related axial spinal pain. Emerging evidence suggests improvements in pain relief, physical function, and quality of life following these treatments. Based on our search criteria, 20 publications were identified and considered for inclusion. Of these, 4 randomized controlled trials (RCTs) and 6 observational studies met the inclusion criteria. Among the RCTs, 3 trials involved lumbar facet joints, and one trial involved cervical facet joints using PRP. Among the observational studies, 4 studies used PRP, with 3 focusing on the lumbar spine and one study, with 2 publications, on the cervical spine, and only 2 studies evaluated stem cell treatments. The summary of evidence utilizing various criteria, including Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) evidence synthesis, the evidence for PRP injections in facet joints is Level II, or moderate, and Level IV, or limited, overall, with low certainty. For PRP, the recommendation is moderate, and for MSCs, the recommendation is weak.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY, USA
- University of Louisville School of Medicine, Louisville, KY, USA
- Departments of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin, Madison, WI, USA
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Mahendra R Sanapati
- Pain Management Centers of America, Evansville, IN, USA
- University of Louisville School of Medicine, Louisville, KY, USA
- Indiana University School of Medicine, Evansville, IN, USA
| | | | - Sahar Shekoohi
- Departments of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA.
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Cauchon AM, Mares C, Fan XY, Bois MC, Hagemeister N, Noiseux N, Roy A. Comparing the efficacy of intra-articular injection of Platelet Rich Plasma (PRP) with corticosteroids (CS) in patients with chronic zygapophyseal joint low back pain confirmed by double intra-articular diagnostic blocks: A triple-blinded randomized multicentric controlled trial with a 6-month follow-up. INTERVENTIONAL PAIN MEDICINE 2024; 3:100525. [PMID: 39717452 PMCID: PMC11665351 DOI: 10.1016/j.inpm.2024.100525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 11/19/2024] [Accepted: 11/20/2024] [Indexed: 12/25/2024]
Abstract
Objective To compare the safety and effectiveness in improving function and reducing pain of autologous PRP to corticosteroid (CS) zygapophyseal (Z-joint) intra-articular (IA) injections at six months for patients with chronic osteoarthritis Z-joint mediated low back pain (LBP). Design Prospective triple-blinded multicentric randomized controlled trial. Methods Fifty participants with radiological signs of Z-joint OA and chronic Z-joint mediated LBP confirmed by a ≥80 % pain improvement after two IA local anesthetic injections were randomized into PRP and CS groups, using a 1:1 ratio. Participants completed questionnaires at baseline, and at 1-, 3- and 6-month post-treatment, with adverse effect data collected at 1 month. Function (Oswestry disability index (ODI)), pain (Numeric Rating Scale (NRS)), treatment satisfaction (modified MacNab criteria), and quality of life (Short Form survey 36 (SF-36)) were assessed at each follow-up. The primary outcome was the percentage of participants improving their function (ODI score) above the minimal clinically important difference (MCID) of 17 points. The secondary outcomes were the percentage of participants with a >50 % NRS improvement, satisfaction to treatment and mean score improvement. Proportions were compared between groups using a chi-square test. Mean scores were compared using a two-way ANOVA or the nonparametric Brunner & Langer test. Results Both groups were similar at baseline, no major adverse effects occurred, and no participants were lost at follow-up. The proportion of participants improving their ODI scores above the MCID, the proportion of participants with a >50 % NRS improvement, and mean ODI scores were significantly different between groups in favor of PRP at 6 months. Modified MacNab satisfaction scale, NRS and SF36 mean scores were not statistically different between groups, but all followed the same pattern: the CS groups had a greater improvement a one month, both groups were equivalent at three months and the PRP group had a greater improvement at six months. Conclusion This first triple-blinded multicentric RCT demonstrates the safety of PRP IA Z-joint injections and its superiority in improving pain and function at six months post-treatment compared to CS for patients with chronic OA Z-joint mediated LBP. To perform a blinded control study, two intra-articular treatments were compared. However, knowing that radiofrequency neurotomy (RFN) of the medial branch diagnosed by branch blocks has been standard of care for pain originating from Z-joints, further studies comparing PRP to RFN are still needed. Clinicaltrials gov registry number NCT05188820.
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Affiliation(s)
- Anne-Marie Cauchon
- Department of Physical Medicine and Rehabilitation, Université Laval, Québec, Québec, Qc, Canada
| | - Christopher Mares
- Physiatry Department, Université de Montréal, Montréal, Québec, Qc, Canada
| | - Xin Yi Fan
- School of Medicine, Université de Montréal, Montréal, Québec, Qc, Canada
| | - Marie-Claude Bois
- Physiatry Department, Université de Montréal, Montréal, Québec, Qc, Canada
| | - Nicola Hagemeister
- Laboratoire D’Innovation ouverte en Technologies de la santé, École de Technologie supérieure, Montréal, Québec, Qc, Canada
| | - Nicolas Noiseux
- Centre de Recherche Du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Qc, Canada
| | - André Roy
- CPMSR and CRCHUM, Montréal, Québec, Qc, Canada
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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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Klessinger S, Casser HR, Gillner S, Koepp H, Kopf A, Legat M, Meiler K, Norda H, Schneider M, Scholz M, Slotty PJ, Tronnier V, Vazan M, Wiechert K. Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline. Global Spine J 2024; 14:2124-2154. [PMID: 38321700 PMCID: PMC11418679 DOI: 10.1177/21925682241230922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
STUDY DESIGN Systematic review of the literature and subsequent meta-analysis for the development of a new guideline. OBJECTIVES This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure. METHODS A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS 20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications. CONCLUSION Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.
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Affiliation(s)
- Stephan Klessinger
- Neurochirurgie Biberach, Biberach, Germany
- Universitätsklinikum Ulm, Ulm, Germany
| | | | | | - Holger Koepp
- Wirbelsäulenzentrum, St Josefs-Hospital, Wiesbaden, Germany
| | - Andreas Kopf
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | - Matti Scholz
- ATOS Orthopädische Klinik Braunfels GmbH & Co KG, Braunfels, Germany
| | | | | | - Martin Vazan
- Wirbelsäulen- und Rückenzentrum Dresden, Praxis für Neurochirurgie, Dresden, Germany
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Bogduk N, MacVicar J. Osteoarthritis of zygapophysial joints as a cause of back pain and neck pain: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:541-552. [PMID: 38702827 PMCID: PMC11369356 DOI: 10.1093/pm/pnae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/19/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Zygapophysial joints (Z joints) can be a source of back pain and of neck pain, but the cause of pain is not known. Some authors attribute the pain to osteoarthritis but without citing evidence. OBJECTIVES The present review was undertaken to determine if there was sufficient evidence of association between spinal pain and osteoarthritis of Z joints to justify osteoarthritis being held to be the cause of pain. The null hypothesis was that osteoarthritis of Z joints does not cause back pain or neck pain. ELIGIBILITY CRITERIA Relevant studies were ones that provided primary data on the association between pain and osteoarthritis of Z joints. These could be population studies, diagnostic studies, or case-control studies. SOURCES OF EVIDENCE The database of PubMed was searched using the terms: Lumbar or cervical, zygapophysial or facet, pain, and osteoarthritis or degeneration or degenerative. CHARTING METHODS Data pertinent to the research question were extracted from original articles and tabulated for reporting. Odds ratios for associations were calculated, as were the prevalence rates of osteoarthritis in subjects with pain, and conversely the prevalence rates of pain in subjects with osteoarthritis. RESULTS The searches retrieved 11 population studies, 4 diagnostic studies, and 3 cases control studies. No study showed any positive association between osteoarthritis of Z joints and pain. All studies found pain to be independent of the presence or severity of osteoarthritis. Osteoarthritis was as common in subjects with no pain as in subjects with pain. The null hypothesis was not refuted. CONCLUSION The published evidence does not support the belief that osteoarthritis causes Z joint pain. All the evidence contradicts this belief.
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Affiliation(s)
- Nikolai Bogduk
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Tran J, Lawson A, Agur A, Loh E. Parasagittal needle placement approach for lumbar medial branch denervation: a brief technical report. Reg Anesth Pain Med 2024; 49:609-614. [PMID: 38176741 DOI: 10.1136/rapm-2023-105152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024]
Abstract
Radiofrequency denervation of lumbar medial branches is a viable treatment option to manage chronic facetogenic low back pain. Traditionally, lumbar medial branch denervation involves placement of the electrode's active tip at a 20-degree angulation away from the parasagittal plane. However, more recent anatomical studies have provided evidence supporting the feasibility of an alternative parasagittal approach targeting the posterior half of the lateral neck of the superior articular process to capture the lumbar medial branches. Currently, there is a lack of clinical data on the effectiveness of the alternative parasagittal needle placement technique. Therefore, in this brief technical report, the parasagittal needle placement technique and the pain relief outcomes in four consecutive patients following treatment with the parasagittal approach are described.
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Affiliation(s)
- John Tran
- Surgery (Division of Anatomy), University of Toronto, Toronto, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, Ontario, Canada
| | - Arden Lawson
- Lawson Health Research Institute, London, Ontario, Canada
| | - Anne Agur
- Surgery (Division of Anatomy), University of Toronto, Toronto, Ontario, Canada
| | - Eldon Loh
- Department of Physical Medicine and Rehabilitation, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
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Scholten P, Sheikh M, Atchison J, Eldrige JS, Garcia D, Sandhu S, Qu W, Nottmeier E, Fox WC, Buchanan I, Pirris S, Chen S, Quinones-Hinojosa A, Abode-Iyamah K. Correlating SPECT-CT activity in lumbar facet joints with response to lumbar medial branch and L5 dorsal ramus blocks. INTERVENTIONAL PAIN MEDICINE 2024; 3:100387. [PMID: 39239486 PMCID: PMC11372969 DOI: 10.1016/j.inpm.2024.100387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/30/2023] [Accepted: 01/15/2024] [Indexed: 09/07/2024]
Abstract
Introduction Lumbar facet arthritis is a significant source of back pain and impaired function that is amenable to treatment with medial branch radiofrequency neurotomy (RFN). Identifying appropriate patients for this treatment requires integration of information from the history, physical exam, and diagnostic imaging, but the current diagnostic standard for facet-mediated pain is positive comparative medial branch blocks (MBBs). Lumbar SPECT-CT has recently been evaluated as a potential predictor of positive MBBs with mixed results. The purpose of this retrospective analysis was to determine if the level of concordance between SPECT-CT uptake and facet joints targeted with MBB was associated with a positive block. Methods A retrospective review was performed to identify all patients undergoing lumbar MBB within 12 months after having a lumbar SPECT-CT. Each procedure was classified into one of four categories based on the level of concordance between facet joints demonstrating increased 99mTc uptake on SPECT-CT and those being blocked: 1) Complete Concordance (all joints demonstrating increased uptake were blocked and no additional joints blocked); 2) Partial Concordance (all joints demonstrating increased uptake were blocked, with at least one joint not demonstrating increased uptake blocked); 3) Partial Discordance (at least one but not all joints demonstrating increased uptake were blocked); 4) Complete Discordance (all blocks performed at joints not demonstrating increased uptake). Statistical analysis was performed to determine if the level of concordance between increased uptake on SPECT-CT and joints undergoing MBB was associated with a positive block using cutoffs of 50 % and 80 % pain relief. Results A total of 180 procedures were analyzed (23 % Complete Concordance, 22 % Partial Concordance, 31 % Partial Discordance, 24 % Complete Discordance) and all groups demonstrated improvement in pain Numeric Rating Scale (NRS) scores. There was no significant association between level of concordance and having a positive block using thresholds of 50 % pain relief, χ 2(3, N = 180) = 4.880, p = .181; or 80 % pain relief, χ 2(3, N = 180) = 1.272, p = .736. Conclusion SPECT-CT findings do not accurately predict positive lumbar MBB but may provide valuable information that can be considered with other factors when deciding which joints to treat.
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Affiliation(s)
- Paul Scholten
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Mateen Sheikh
- University of North Florida, 1 UNF Dr., Jacksonville, FL, 32224, USA
| | - James Atchison
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Jason S Eldrige
- Department of Pain Medicine, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Diogo Garcia
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sukhwinder Sandhu
- Department of Neuroradiology, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Wenchun Qu
- Department of Pain Medicine, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Eric Nottmeier
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - W Christopher Fox
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Ian Buchanan
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Stephen Pirris
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Selby Chen
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Alfredo Quinones-Hinojosa
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kingsley Abode-Iyamah
- Departement of Neurologic Surgery, Mayo Clinic Florida, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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Landers MH, Newton F, Alvarado M, Bogduk N. Comparing the effectiveness of lumbar medial branch radiofrequency coagulation using 18-gauge and 16-gauge cannulae. INTERVENTIONAL PAIN MEDICINE 2023; 2:100279. [PMID: 39239217 PMCID: PMC11373004 DOI: 10.1016/j.inpm.2023.100279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/07/2024]
Affiliation(s)
- Milton H Landers
- Department of Anesthesiology, University of Kansas School of Medicine, Wichita, KS, USA
- Pain Management Associates, Wichita, KS, USA
| | - Felecia Newton
- Department of Anesthesiology, University of Kansas School of Medicine, Wichita, KS, USA
| | - Michael Alvarado
- Department of Anesthesiology, University of Kansas School of Medicine, Wichita, KS, USA
| | - Nikolai Bogduk
- College of Health, Medicine, and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia
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Wong MJ, Rajarathinam M. Ultrasound-guided axial facet joint interventions for chronic spinal pain: A narrative review. Can J Pain 2023; 7:2193617. [PMID: 37214187 PMCID: PMC10193888 DOI: 10.1080/24740527.2023.2193617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 05/24/2023]
Abstract
Background Axial facet joint interventions (e.g., medial branch block and radiofrequency ablation, facet joint intra-articular injection) are commonly performed for managing chronic spinal pain. Although traditionally performed with fluoroscopy or computed tomography (CT) guidance, ultrasound-guided techniques have also been developed for these interventions. Aims The aim of this study is to present contemporary ultrasound-guided techniques for facet joint interventions and synthesize data addressing their accuracy, safety, and efficacy. Methods The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of ultrasound-guided facet joint interventions with human subjects from November 1, 1992, to November 1, 2022. Additional sources were drawn from reference lists and citations of relevant studies. Results We found 48 studies assessing ultrasound-guided facet joint interventions. Ultrasound guidance for injection of the cervical facet joints and their innervating nerves had favorable accuracy (78%-100%), with lower procedural time compared to fluoroscopy or CT guidance and comparable pain relief. Accuracy with ultrasound-guided lumbar facet joint intra-articular injection (86%-100%) was more reliable than medial branch block (72%-97%); analgesia was comparable to fluoroscopy and CT guidance. In general, these procedures were more challenging for patients with obesity, and deeper structures were more difficult to accurately target (e.g., lower cervical levels, L5 dorsal ramus). Conclusions Ultrasound-guided facet joint interventions continue to evolve. Some technically challenging interventions may be impractical for widespread usage or require further technical refinement. The utility of ultrasound guidance with obesity and abnormal anatomy may be reduced.
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Affiliation(s)
- Michael J. Wong
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Manikandan Rajarathinam
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Farooque M. Specific and Nonspecific Low Back Pain-Mind the Gap and its Impact in Clinical Practice: Opinion of a Recovering Interventional Spine Physiatrist. Spine J 2023:S1529-9430(23)00170-5. [PMID: 37116719 DOI: 10.1016/j.spinee.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Mustafa Farooque
- Department of Medicine at the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA; Back & Spine Program at Aurora St. Luke's Medical Center, Milwaukee, WI, 2901 W Kinnickinnic River Pkwy, Suite 310, Milwaukee, WI.
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12
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Rodriguez-Merchan EC, Delgado-Martinez AD, De Andres-Ares J. Radiofrequency Ablation for the Management of Pain of Spinal Origin in Orthopedics. THE ARCHIVES OF BONE AND JOINT SURGERY 2023; 11:666-671. [PMID: 38058968 PMCID: PMC10697193 DOI: 10.22038/abjs.2023.71327.3333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/28/2023] [Indexed: 12/08/2023]
Abstract
Radiofrequency (RF) is a minimally invasive procedure for interrupting or modifying nociceptive pathways to manage musculoskeletal neuropathic and nociplastic pain. RF has been used to manage cervical and lumbar facet joint syndromes. The benefits of RF are the following: it is safer than surgery; it doesn´t need general anesthesia, by that means diminishing the complications; it causes pain alleviation for a minimum of 3-4 months; it can be repeated if needed; it improves joint function; and it minimizes the necessity for oral pain treatment. RF must not be used in pregnant women; unstable joints, uncontrolled diabetes mellitus; and presence of an implanted defibrillator. Even though complications from RF are rare, possible adverse events are infection, hemorrhage, numbness or dysesthesia, greater pain in the procedure area, and differentiation impact. Even though there is a peril of injuring non-targeted neural tissue and other tissues, this can be lessened by carrying out the procedure with the help of fluoroscopy, ultrasonography or computed tomography. RF seems to be a helpful procedure for relieving chronic pain syndromes; despite this, definite proof of the procedure's effectiveness is still needed. RF is an encouraging procedure for treating chronic spinal pain, especially when other procedures are pointless or not feasible.
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Affiliation(s)
| | - Alberto D. Delgado-Martinez
- Department of Orthopedic Surgery, Hospital Universitario de Jaén, Jaén, Spain
- Department of Surgery, University of Jaén, Jaén, Spain
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13
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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14
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El-Hassan R, Michalik A, Snyder J, Laplante BL, Everett C, Patel R. First-Time Lumbar Medial Branch Radiofrequency Ablation: Patient-Reported Outcomes Measurement Information System as a Metric of Outcome. Arch Phys Med Rehabil 2022; 103:2311-2315. [PMID: 35429466 DOI: 10.1016/j.apmr.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate the ability of Patient-Reported Outcomes Measurement Information System (PROMIS) to capture the therapeutic effect of first-time medial branch radiofrequency ablation (RFA). DESIGN Before-after trial. SETTING Single academic spine center. PARTICIPANTS Patients who underwent first-time medial branch RFA for lumbar facet joint pain identified by dual comparative medial branch block with ≥80% pain relief between January 1, 2015 and September 1, 2019 were identified using procedural billing codes. Charts were reviewed manually to confirm accuracy and strict adherence to the 80% pain relief threshold for each medial branch block. Thirty-nine patients met the criteria and were included in this study (N=39). INTERVENTIONS Medial branch RFA. MAIN OUTCOME MEASURES PROMIS score domains of Depression, Pain Interference, and Physical Function collected pre- and post RFA were compared. Pretreatment scores were within 6 weeks prior to the first medial branch block. Posttreatment scores were between 5 weeks and 6 months after RFA. Paired-sample t test analyses were used to calculate responsiveness to treatment, with significance assigned as P<.05 prior to acquiring data. Effect size was calculated using Cohen's d. RESULTS PROMIS domains of Pain Interference and Physical Function demonstrated a statistically significant improvement (P=.004 and P=.017, respectively). The PROMIS domain of Depression did not demonstrate a statistically significant change (P=.12). The effect size was medium (d=-0.43) for Pain Interference, small/medium (d=0.31) for Physical Function, and small (d=-0.12) for Depression. CONCLUSIONS Medial branch RFA as a treatment for lumbar facet syndrome is associated with a statistical improvement in PROMIS domains of Physical Function and Pain Interference.
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Affiliation(s)
- Ramzi El-Hassan
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY.
| | - Adam Michalik
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - James Snyder
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Ben L Laplante
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Clifford Everett
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Rajeev Patel
- Department of Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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15
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Radiofrequency denervation and cryoablation of the lumbar zygapophysial joints in the treatment of positive lumbar facet joint syndrome – a report of three cases. Radiol Case Rep 2022; 17:4515-4520. [PMID: 36189159 PMCID: PMC9519502 DOI: 10.1016/j.radcr.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/22/2022] Open
Abstract
Radiofrequency denervation of the zygapophysial (facet) joints is a frequently performed procedure for chronic low back pain. However, cryoablation represents a novel therapeutic approach for this condition. We observed and analyzed 3 cases with confirmed positive lumbar facet joint syndrome. Our results show a significant improvement in the clinical state of the patients in the first and third months after the procedure. The 6-month follow-up examination demonstrates a recurrence of pain and a gradual deterioration in the quality of life with a lasting partial pain-relief effect. Thermal radiofrequency denervation and cryoablation of the lumbar zygapophysial joints represent an effective, albeit temporary treatment option for lumbar facet joint syndrome patients, resulting from the pathophysiology of sensory nerve regeneration after destructive procedures. This type of treatment can be used repeatedly in the case of a positive response.
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16
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Li H, An J, Zhang J, Kong W, Yun Z, Yu T, Nie X, Liu Q. Comparative efficacy of radiofrequency denervation in chronic low back pain: A systematic review and network meta-analysis. Front Surg 2022; 9:899538. [PMID: 35990102 PMCID: PMC9388860 DOI: 10.3389/fsurg.2022.899538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Facet joint pain is a common cause of chronic low back pain (CLBP). Radiofrequency (RF) denervation is an effective treatment option. Purpose A systematic review and network meta-analysis (NMA) was performed to evaluate and compare the efficacy and effectiveness of different RF denervation treatments in managing facet joint-derived CLBP. Methods The Cochrane Library, Embase, PubMed, and China Biology Medicine were searched to identify eligible randomized controlled trials (RCTs) from January 1966 through December 2021. Interventions included conventional radiofrequency denervation (CRF), pulsed radiofrequency denervation (PRF), pulsed radiofrequency treatment of the dorsal root ganglia (PRF-DRG), radiofrequency facet capsule denervation (RF-FC), and radiofrequency ablation under endoscopic guidance (ERFA). The outcome was the mean change in visual analog scale (VAS) score from baseline. A random-effects NMA was used to compare the pain relief effects of the interventions over the short term (≤6 months) and long term (12 months). The rank of effect estimation for each intervention was computed using the surface under the cumulative ranking curve. Results A total of 10 RCTs with 715 patients met the inclusion criteria. Moderate evidence indicated that CRF denervation had a greater effect on pain relief than sham control in the short term (standardized mean difference (SMD) −1.58, 95% confidence intervals (CI) −2.98 to −0.18) and the long term (SMD −4.90, 95% CI, −5.86 to −3.94). Fair evidence indicated that PRF denervation was more effective than sham control for pain over the long term (SMD −1.30, 95% CI, −2.17 to −0.43). Fair evidence showed that ERFA denervation was more effective for pain relief than sham control in the short term (SMD −3.07, 95% CI, −5.81 to −0.32) and the long term (SMD −4.00, 95% CI, −4.95 to −3.05). Fair evidence showed that RF-FC denervation was more effective for pain relief than sham control in the long term (SMD −1.11, 95% CI, −2.07 to −0.15). A fair level of evidence indicated that PRF-DRG denervation was more effective for pain relief than sham control in the short term (SMD −5.34, 95% CI, −8.30 to −2.39). Conclusion RF is an effective option for patients diagnosed with facet joint-derived CLBP. Systematic Review Registration: Identifier: CRD42022298238.
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Affiliation(s)
- Han Li
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Junyan An
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Jun Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Weijian Kong
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhihe Yun
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Tong Yu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Xinyu Nie
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Qinyi Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Correspondence: Qinyi Liu
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17
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Bara GA, Salemdawod A, Vychopen M, Rana S, Vatter H, Maciaczyk J, Scorzin J, Banat M. Bipolar Lumbar Radiofrequency Medial Branch Neurotomy in a Patient with Deep Brain Stimulation Implant. J Neurol Surg A Cent Eur Neurosurg 2022; 84:300-303. [PMID: 35439825 DOI: 10.1055/s-0042-1743514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic axial lower back pain is one of the most common conditions that patients seek medical attention for in pain practices. About 15 to 40% of axial lower back pain is due to facet-mediated pain. Diagnostic blocks of the medial branch reliably identify the facet joint as the pain generator and offer a prognostic factor for response to radiofrequency neurotomy of the identified facet joints resulting in profound pain relief. However, deep brain stimulation implants have been considered a contraindication for neurotomy. We present an illustrative case of a patient with deep brain stimulation system treated with bipolar medial branch neurotomy using a two-needle technique.
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Affiliation(s)
- Gregor A Bara
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | | | - Martin Vychopen
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Shaleen Rana
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | | | - Jasmin Scorzin
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Mohammed Banat
- Department of Neurosurgery, University of Bonn, Bonn, Germany
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18
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Yuan HJ, Wang CY, Wang YF. Endoscopic joint capsule and articular process excision to treat lumbar facet joint syndrome: A case report. World J Clin Cases 2021; 9:8545-8551. [PMID: 34754866 PMCID: PMC8554426 DOI: 10.12998/wjcc.v9.i28.8545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/27/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lumbar facet joint syndrome (LFJS) is a pain condition arising from lumbar facet joint diseases. Treatments of LFJS includes patient education, oral medication, bed rest, physical therapy, and procedural interventions. For some refractory cases that fail conservative therapies, dorsal ramus medial brunch radiofrequency ablation is warranted. However, as nerve fibers can regenerate, their efficacy is impermanent, and the recurrence rate is relatively high. Considering synovial impingement is a paramount pathogenesis of LFJS, in this case, we removed the culprit hyperplastic articular capsule and the articular process partially through a spinal endoscope. As the culprit hyperplastic joint capsule was excised, it is supposed to generate more prolonged efficacy and a lower recurrence rate than radiofrequency treatment. CASE SUMMARY A 40-year-old female patient was diagnosed with LFJS. She complained of low back pain and right buttock pain for half a year. The patient was placed in the prone position. After disinfection and draping, a 25-cm 18-gauge needle was inserted into the dorsal surface of the right L5 articular process. Subsequently, a guidewire, dilating tubes, and a working cannula was inserted successively. The spinal endoscope was positioned in the working cannula. Under the endoscope, the microvascular tissue, muscle tissue attached on the L5 inferior articular process and S1 superior articular process, as well as the capsule and minor portion of the inferior articular process were removed. After the joint space was clear and no bleeding points existed, the endoscope and working cannula were shifted, and the incision was sutured. After treatment, the symptoms were completely relieved. The patient was pain-free during the follow-up period of 6 mo. CONCLUSION The endoscopic partial joint capsule and articular process excision is an effective procedure for LFJS, especially for cases caused by synovial impingement.
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Affiliation(s)
- Hong-Jie Yuan
- Department of Pain Medicine, Nantong Hospital of Traditional Chinese Medicine, Nantong 226001, Jiangsu Province, China
| | - Chun-Yan Wang
- Department of Cardiovascular, Shanghai Public Health Clinical Center, Shanghai 201508, China
| | - Yu-Feng Wang
- Department of Radiology, Jinshan Branch, Shanghai Sixth People’s Hospital, Shanghai 201599, China
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19
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Wong O, Zhang G, Matthews H, Skalski M, Asadi H, Lalloo S, Kurda D. Image-guided spinal injection for pain management. J Med Imaging Radiat Oncol 2021; 66:79-91. [PMID: 34369081 DOI: 10.1111/1754-9485.13308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/11/2021] [Accepted: 07/15/2021] [Indexed: 01/12/2023]
Abstract
Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.
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Affiliation(s)
- Osanna Wong
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - George Zhang
- Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Hayden Matthews
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Mathew Skalski
- Palmer College of Chiropractic - West Campus, San Jose, California, USA
| | - Hamed Asadi
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia.,Department of Radiology, Monash Health, Melbourne, Victoria, Australia.,Deakin University, Geelong, Victoria, Australia
| | - Shivendra Lalloo
- Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Dylan Kurda
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
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20
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Hambraeus J, Ehsanian R, Cheng DS, McKenna MJ, McCormick ZL. Inadequate Selection and Treatment Results in Poor Outcomes and Lack of Cost-Effectiveness. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1234-1235. [PMID: 34372989 DOI: 10.1016/j.jval.2020.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 06/13/2023]
Affiliation(s)
- Johan Hambraeus
- Department of Epidemiology and Global Health, Umeå University, Sweden, and Smartkliniken Eques Indolor, Vallentuna, Sweden
| | - Reza Ehsanian
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedics and Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - David S Cheng
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA.
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21
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Conger A, Burnham T, Salazar F, Tate Q, Golish M, Petersen R, Cunningham S, Teramoto M, Kendall R, McCormick ZL. The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks. PAIN MEDICINE 2021; 21:902-909. [PMID: 31609391 DOI: 10.1093/pm/pnz248] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Although the effectiveness of lumbar medial branch radiofrequency ablation (RFA) for the treatment of zygapophyseal joint (z-joint)-mediated low back pain has been characterized, few studies have described outcomes in patients selected using a guideline-concordant paradigm of ≥80% pain relief with dual comparative medial branch blocks (MBBs). We investigated long-term treatment outcomes of patients selected according to this paradigm. DESIGN Cross-sectional cohort study. METHODS The medical records of 111 consecutive patients were reviewed; 85 met inclusion criteria. A standardized telephone survey was used to capture current numerical rating scale (NRS) and Patient Global Impression of Change (PGIC) scores. The primary outcome was the proportion of patients reporting ≥50% reduction of index pain. Binary logistic regression analysis was performed to explore associations between the primary outcome and covariates, including age, duration of pain, presence of scoliosis, degenerative spondylolisthesis, and >75% disc height loss. RESULTS At six to 12, 12-24, and >24 months, 63.2% (95% confidence interval [CI] = 41-85%), 65.6% (95% CI = 49-82%), and 44.1% (95% CI = 27-61%) of patients reported a ≥50% pain reduction (P = 0.170), respectively. At a minimum of six months, 70.6% of patients reported a pain reduction of two or more points (minimally clinically important change), and 54.1% reported a PGIC score consistent with "much improved" or better. Older age and a smaller Cobb angle were associated with a ≥50% pain reduction (P < 0.05). CONCLUSION Lumbar medial branch RFA is an effective, durable treatment for a significant proportion of patients with recalcitrant lumbar z-joint pain when candidacy is determined by the guideline-concordant paradigm of ≥80% pain relief with dual comparative MBBs.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Taylor Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Fabio Salazar
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Quinn Tate
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Mathew Golish
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Russell Petersen
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Shellie Cunningham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Richard Kendall
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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22
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MacVicar J, MacVicar AM, Bogduk N. The Prevalence of "Pure" Lumbar Zygapophysial Joint Pain in Patients with Chronic Low Back Pain. PAIN MEDICINE 2021; 22:41-48. [PMID: 33543264 DOI: 10.1093/pm/pnaa383] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Estimates of the prevalence of lumbar zygapophysial joint (Z joint) pain differ in the literature, as do case definitions for this condition. No studies have determined the prevalence of "pure" lumbar Z joint pain, defined as complete relief of pain following placebo-controlled diagnostic blocks. OBJECTIVE The objective of this study was to estimate the prevalence of "pure" lumbar Z joint pain. METHODS In a private practice setting, 206 patients with possible lumbar Z joint pain underwent controlled diagnostic blocks using one of two protocols: placebo-controlled comparative blocks and fully randomized, placebo-controlled, triple blocks. RESULTS In the combined sample, the prevalence of "pure" lumbar Z joint pain was 15% (10-20%). CONCLUSIONS The prevalence of "pure" lumbar Z joint pain is substantially and significantly less than most of the prevalence estimates of lumbar Z joint pain reported in the literature.
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Affiliation(s)
- John MacVicar
- Southern Rehabilitation Institute, Christchurch, New Zealand
| | | | - Nikolai Bogduk
- Faculty of Medicine and Health Sciences, University of Newcastle, Newcastle, Australia
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23
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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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Tay M, Sian SCSH, Eow CZ, Ho KLK, Ong JH, Sirisena D. Ultrasound-Guided Lumbar Spine Injection for Axial and Radicular Pain: A Single Institution Early Experience. Asian Spine J 2021; 15:216-223. [PMID: 32872762 PMCID: PMC8055452 DOI: 10.31616/asj.2019.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/07/2020] [Accepted: 03/15/2020] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Clinical audit via retrospective review of a database. PURPOSE To report an early experience using ultrasound-guided lumbar spinal injection for axial and radicular pain in an Asian multiethnic cohort. OVERVIEW OF LITERATURE Ultrasound-guided spine injection therapy is a comparatively new technique in the management of axial and radicular pain from degenerative lumbar spinal conditions, which may be a reasonable alternative to conventional fluoroscopic or computed tomography-guided injection. METHODS A retrospective review was conducted, involving all patients who underwent ultrasound-guided lumbar spine injection therapy at a single institution over 1 year. Patients were evaluated by two interventionists, who then performed standardized ultrasound-guided lumbar facet joint and pararadicular spinal injections. RESULTS There were 42 patients treated at our Sports Medicine Centre; with 27 patients (64.3%) receiving facet joint injections and 18 patients (42.9%) receiving nerve root injections. The majority (90.5%) of patients experienced an improvement of >30% in pain intensity at 3 months post-injection, using the Numerical Rating Scale pain score (p<0.001); with 40 patients (95.2%) reporting a reduction in Oswestry Disability Index score (p<0.001). No complications were reported. CONCLUSIONS Our initial experience confirms the safety, feasibility, and effectiveness of ultrasound-guided lumbar spinal injection for the treatment of axial and radicular pain in an Asian multiethnic cohort.
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Affiliation(s)
- Matthew Tay
- Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore
| | | | - Chen Zhi Eow
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Kelvin Lor Kah Ho
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - Joo Haw Ong
- Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
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25
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Sources of lumbar back pain during aging and potential therapeutic targets. VITAMINS AND HORMONES 2021; 115:571-583. [PMID: 33706962 DOI: 10.1016/bs.vh.2020.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Lumbar back pain during aging is a major clinical problem, the origins and underlying mechanisms of which are challenging to study. Degenerative changes occur in various parts of the functional spinal unit, such the vertebral endplate and intervertebral disc. The homeostasis of these structural components is regulated by signaling molecules, such as transforming growth factor-β and parathyroid hormone. Previous efforts to understand sources of lumbar back pain focused on sensory innervation in the degenerative intervertebral disc, but intervertebral disc degeneration is frequently asymptomatic. An in vivo mouse model of lumbar spine aging and degeneration, combined with genetic technology, has identified endplate innervation as a major source of lumbar back pain and a potential therapeutic target. In this review, we consider how each structural component of the functional spinal unit contributes to lumbar back pain, how the homeostasis of each component is regulated, and how these findings can be used to develop potential therapies.
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Abd-Elsayed A, Hughes M, Narel E, Loebertman MD. The Efficacy of Radiofrequency Ablation for Pain Management in Patients with Pre-Existing Hardware at the Site of Ablation. Pain Ther 2020; 9:709-716. [PMID: 33034012 PMCID: PMC7648770 DOI: 10.1007/s40122-020-00201-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/23/2020] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Radiofrequency ablation (RFA) is an interventional procedure that provides pain relief by using thermal energy to disrupt peripheral nerves carrying nociceptive signals back to the central nervous system. In the past, having implantable hardware at the planned site of RFA was considered to confer increased risk of adverse outcomes given the theoretical risk of heating of the hardware components. The present study examines patient outcomes to determine whether the efficacy of RFA was affected by the presence of implanted hardware directly at the site. METHODS This was a retrospective case-control study that included 52 patients who received RFA procedures in the presence of hardware at the site of RFA and a control group of 170 patients who received RFA procedures in the absence of hardware. Data were collected from electronic medical records entered into an Excel sheet and then analyzed using SPSS version 22. Outcomes tested included post procedure pain scores, percent, and duration of improvement, if any. RESULTS We found no statistically significant difference in measured outcomes between either group. CONCLUSIONS This study provides some evidence in support of the theory that RFA procedures performed on patients with pre-existing hardware have similar efficacy when compared to their hardware-free counterparts.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, USA.
| | - Meghan Hughes
- School of Medicine and Public Health, University of Wisconsin, Madison, USA
| | - Emily Narel
- School of Medicine and Public Health, University of Wisconsin, Madison, USA
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27
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Perfitt JS, Plunkett N, Jones S. Placebo effect in the management of chronic pain. BJA Educ 2020; 20:382-387. [PMID: 33456922 DOI: 10.1016/j.bjae.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- J S Perfitt
- Sheffield Teaching Hospitals, Northern General Hospital, Sheffield, UK
| | - N Plunkett
- Sheffield Teaching Hospitals, Northern General Hospital, Sheffield, UK
| | - S Jones
- Sheffield Children's Hospital, Sheffield, UK
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Sansone P, Giaccari LG, Lippiello A, Aurilio C, Paladini A, Passavanti MB, Pota V, Pace MC. Pulsed Radiofrequency for Lumbar Facet Joint Pain: A Viable Therapeutic Option? A Retrospective Observational Study. Pain Ther 2020; 9:573-582. [PMID: 32770486 PMCID: PMC7648804 DOI: 10.1007/s40122-020-00187-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Low back pain (LBP) is a common problem, and facet joint pain is responsible for 15–45% of cases. Treatment is multidisciplinary, and when conservative measures are not sufficient, radiofrequency (RF) is often used. It allows the interruption of nociceptive input, producing a heat lesion in a continuous or pulsed mode. Methods Medical records of 60 patients who underwent pulsed RF denervation were examined. The standard procedure provided follow-up of pain intensity. Numerical rating scale (NRS) and Douleur Neuropathique en 4 Questions (DN4) were recorded before treatment, and 15 and 40 days, and 6 months after treatment. Oswestry Disability Index (ODI) and patient satisfaction were also recorded. Successful treatment was defined as more than a 50% reduction in the NRS scores at 6 months compared with pretreatment scores. Results Scores on the NRS and DN4 were statistically different over time (p < 0.05). Scores at 6 months were significantly decreased when compared with pretreatment scores (p < 0.05). ODI scores decreased during the follow-up period. No adverse effect was recorded and 57 patients (97%) reported successful pain relief. Conclusions Continuous RF is the gold standard in the management of lumbar facet joint pain. Pulsed RF is a promising technique: patients with chronic LBP who had not responded to conservative care tended to improve after pulsed RF. The procedure was well tolerated in the absence of contraindications, and reliable if the nerve endings regrew.
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Affiliation(s)
- Pasquale Sansone
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Luca G Giaccari
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonietta Lippiello
- Department of Neurosurgery, "Santa Maria delle Grazie Hospital", Pozzuoli, Italy
| | - Caterina Aurilio
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Maria Beatrice Passavanti
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vincenzo Pota
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Children and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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Cohen SP, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten WM, Hurley RW, Kennedy DJ, McLean BC, Moon JY, Narouze S, Pangarkar S, Provenzano DA, Rauck R, Sitzman BT, Smuck M, van Zundert J, Vorenkamp K, Wallace MS, Zhao Z. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med 2020; 45:424-467. [PMID: 32245841 PMCID: PMC7362874 DOI: 10.1136/rapm-2019-101243] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. METHODS After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached. RESULTS 17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary). CONCLUSIONS Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
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Affiliation(s)
- Steven P Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network-Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Tim Deer
- Spine & Nerve Centers, Charleston, West Virginia, USA
| | - Shuchita Garg
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David J Kennedy
- Physical Medicine & Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Brian C McLean
- Anesthesiology, Tripler Army Medical Center, Tripler Army Medical Center, Hawaii, USA
| | - Jee Youn Moon
- Dept of Anesthesiology, Seoul National University College of Medicine, Seoul, The Republic of Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Sanjog Pangarkar
- Dept of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Richard Rauck
- Carolinas Pain Institute, Winston Salem, North Carolina, USA
| | | | - Matthew Smuck
- Dept.of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford Medicine, Stanford, California, USA
| | - Jan van Zundert
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Lanaken, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Mark S Wallace
- Anesthesiology, UCSD Medical Center-Thornton Hospital, San Diego, California, USA
| | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
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30
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Breloff SP, Carey RE, Dutta A, Sinsel EW, Warren CM, Dai F, Wu JZ. Kneeling trunk kinematics during simulated sloped roof shingle installation. INTERNATIONAL JOURNAL OF INDUSTRIAL ERGONOMICS 2020; 77:10.1016/j.ergon.2020.102945. [PMID: 33897076 PMCID: PMC8064732 DOI: 10.1016/j.ergon.2020.102945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Trunk musculoskeletal disorders are common among residential roofers. Addressing this problem requires a better understanding of the movements required to complete working tasks, such as affixing shingles on a sloped residential roof. We analyzed the extent to which the trunk kinematics during a shingling process are altered due to different angles of roof slope. Eight male subjects completed a kneeling shingle installation process on three differently sloped roof surfaces. The magnitude of the trunk kinematics was significantly influenced by both slope and task phase of the shingling process, depending on the metric. The results unequivocally point to roof slope and task phase as significant factors altering trunk kinematics. However, extension of the results to roofing workers should be done carefully, depending on the degree to which the study protocol represents the natural setting. Future studies on shingle installation in residential roofing should absolutely consider capturing a wider array of shingling procedures in order to encapsulate all the possible methods that are used due to the lack of a standardized procedure.
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Affiliation(s)
- Scott P. Breloff
- National Institute for Occupational Safety & Health, Centers for Disease Control and Prevention, Health Effects Laboratory Division, 1095 Willowdale Rd, Morgantown, WV, 26505, USA
| | - Robert E. Carey
- National Institute for Occupational Safety & Health, Centers for Disease Control and Prevention, Health Effects Laboratory Division, 1095 Willowdale Rd, Morgantown, WV, 26505, USA
| | - Amrita Dutta
- West Virginia University, Department of Civil & Environmental Engineering, Morgantown, WV, 26506, USA
| | - Erik W. Sinsel
- National Institute for Occupational Safety & Health, Centers for Disease Control and Prevention, Health Effects Laboratory Division, 1095 Willowdale Rd, Morgantown, WV, 26505, USA
| | - Christopher M. Warren
- National Institute for Occupational Safety & Health, Centers for Disease Control and Prevention, Health Effects Laboratory Division, 1095 Willowdale Rd, Morgantown, WV, 26505, USA
| | - Fei Dai
- West Virginia University, Department of Civil & Environmental Engineering, Morgantown, WV, 26506, USA
| | - John Z. Wu
- National Institute for Occupational Safety & Health, Centers for Disease Control and Prevention, Health Effects Laboratory Division, 1095 Willowdale Rd, Morgantown, WV, 26505, USA
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Shih CL, Shen PC, Lu CC, Liu ZM, Tien YC, Huang PJ, Chou SH. A comparison of efficacy among different radiofrequency ablation techniques for the treatment of lumbar facet joint and sacroiliac joint pain: A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 195:105854. [PMID: 32353665 DOI: 10.1016/j.clineuro.2020.105854] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the efficacy of different radiofrequency techniques (thermal, pulsed, and cooled radiofrequency) for treating lumbar facet joint (LFJ) or sacroiliac joint (SIJ) pain. PATIENTS AND METHODS The inclusion criteria were as follows: (1) age > 18 years; (2) patients suffering from LFJ or SIJ pain; and (3) patients receiving radiofrequency treatments. Four electronic databases, including Pubmed, Embase, Cochrane Library, and ISI Web of Knowledge were systematically searched from inception until December 2019 for relevant articles. The search was conducted on 2 January 2020. When the outcomes among articles showed heterogeneity, then a random-effects model was adopted to calculate the effect size; otherwise, a fixed-effects model was adopted. RESULTS All the three techniques showed significant improvements in LFJ or SIJ pain for up to 12 months compared with the baseline level. However, no significant differences among the three techniques were observed at any follow-up visits except for possibly a trend for variance in efficacy. For treating LFJ pain, cooled radiofrequency was the most effective, followed by thermal radiofrequency and then pulsed radiofrequency as the least respectively for the follow-up visit at 6 months. No serious complications were reported after receiving treatment using the three techniques. CONCLUSION Sequentially, cooled radiofrequency followed by thermal radiofrequency and then pulsed radiofrequency for treating LFJ pain were identified as most to least effective at the 6-month follow-up.
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Affiliation(s)
- Chia-Lung Shih
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Chih Shen
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Chang Lu
- Department of Orthopedics, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Zi-Miao Liu
- College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yin-Chun Tien
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Ju Huang
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Hsiang Chou
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Kennedy DJ, Fraiser R, Zheng P, Huynh L, Levin J, Smuck M, Schneider BJ. Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. PAIN MEDICINE 2020; 20:246-251. [PMID: 30541041 DOI: 10.1093/pm/pny225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine if intra-articular (IA) injection of corticosteroids is effective in reducing the need for radiofrequency ablation (RFA) in those with dual comparative medial branch block (MBB)-confirmed lumbar z-joint pain. DESIGN This was a randomized, double blind, placebo-controlled study. SETTING Two academic medical centers. SUBJECTS Fifty-six consecutive subjects who had ≥80% pain relief during an initial screening MBB were recruited. METHODS Patients received a second confirmatory MBB and concurrent IA injection of either corticosteroid or saline per randomization. Twenty-nine of 56 received intra-articular corticosteroid (triamcinolone 20 mg), of whom 24 also had a positive confirmatory MBB per Spine Interventional Society guidelines, with ≥80% pain relief from both MBBs. Twenty-seven of 56 received IA saline into the z-joint during the confirmatory MBB, of whom 22 also had a positive confirmatory MBB. The primary outcome measure was the categorical need for RFA due to insufficient pain relief with intra-articular injection, and the secondary outcome was time to RFA. RESULTS There was no statistically significant difference in the need for an RFA between the groups (16/24 steroid, 67%, 95% confidence interval [CI] = 47-82%) vs 15/22 saline (68%, 95% CI = 47-84%, P = 1.00). The average time to RFA was also not different, at 6.00 weeks for steroids vs 6.55 weeks for saline (P = 0.82). CONCLUSIONS Intra-articular corticosteroids were not effective in reducing the need for or the time to a radiofrequency ablation of the medial branches in those with dual MBB-confirmed lumbar z-joint pain.
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Affiliation(s)
- David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Ryan Fraiser
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Patricia Zheng
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lisa Huynh
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Joshua Levin
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Matthew Smuck
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
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Schneider BJ, Doan L, Maes MK, Martinez KR, Gonzalez Cota A, Bogduk N. Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique. PAIN MEDICINE 2020; 21:1122-1141. [DOI: 10.1093/pm/pnz349] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques.
Design
Comprehensive systematic review.
Methods
A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.
Outcome Measures
The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes.
Results
Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months.
Conclusions
This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.
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Affiliation(s)
- Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Lisa Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, New York, USA
| | - Marc K Maes
- Department of Anesthesia, Pain Clinic, A.Z. Jan Portaels, Vilvoorde, Belgium, Rugpoli Brabant/Kliniek, Tilburg, the Netherlands
| | | | | | - Nikolai Bogduk
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
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Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul) 2020; 15:8-18. [PMID: 33329784 PMCID: PMC7713865 DOI: 10.17085/apm.2020.15.1.8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/17/2022] Open
Abstract
Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.
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Affiliation(s)
- Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
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El Abd OH, Amadera JE. Low Back Strain or Sprain. ESSENTIALS OF PHYSICAL MEDICINE AND REHABILITATION 2020:264-268. [DOI: 10.1016/b978-0-323-54947-9.00048-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Joshi A, Amrhein TJ, Holmes MA, Talsma J, Shonyo M, Taylor AB. The Source and the Course of the Articular Branches to the T4-T8 Zygapophysial Joints. PAIN MEDICINE 2019; 20:2371-2376. [PMID: 31120121 DOI: 10.1093/pm/pnz116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To define the source and the course of the articular branches to the midthoracic zygapophysial ("z") joints. DESIGN Cadaveric dissection. SETTING The Gross Anatomy Laboratory of the Duke University School of Medicine. SUBJECTS Ten human cadaveric thoraces. METHODS Gross and stereoscopic dissection of dorsal rami T4-T8 was performed bilaterally on 10 adult embalmed cadavers. The medial and lateral branches were traced to their origins from the dorsal rami, and the course of the articular nerves was documented through digital photography. Radio-opaque wire (20 gauge) was applied to the nerves. Fluoroscopic images were obtained to delineate their radiographic course with respect to osseous landmarks. RESULTS Forty-eight inferior articular branches were identified. Three (6.3%) originated from the medial branch and 44 (91.7%) from the dorsal ramus. One was indeterminate. Fifty-one superior articular branches were identified. Eight (15.7%) originated from the medial branch and 43 (84.3%) from the dorsal ramus. In 12% of cases (6/50), there was side-to-side asymmetry in the origins of the articular branches. Nerves were commonly suspended in the intertransverse space. The articular branches contacted an osseous structure in only 39% of cases. As previously reported, a "descending branch" was not identified in any specimen. CONCLUSIONS Articular branches to the T4-T8 z-joints have substantial inter- and intraspecimen variability of origin. They typically arise from the dorsal ramus rather than the medial branch and frequently do not contact any osseous structure to allow percutaneous needle placement.
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Affiliation(s)
- Anand Joshi
- Department of Orthopaedic Surgery, School of Medicine
| | | | - Megan A Holmes
- Department of Community & Family Medicine, Duke University, Durham, North Carolina
| | - Joel Talsma
- Department of Basic Science, College of Osteopathic Medicine, Touro University, Vallejo, California
| | | | - Andrea B Taylor
- Department of Basic Science, College of Osteopathic Medicine, Touro University, Vallejo, California
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The Effectiveness and Safety of Percutaneous Platelet-Rich Plasma and Bone Marrow Aspirate Concentrate for the Treatment of Suspected Discogenic Low Back Pain: a Comprehensive Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00243-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Yolcu YU, Lehman VT, Bhatti AUR, Goyal A, Alvi MA, Bydon M. Use of Hybrid Imaging Techniques in Diagnosis of Facet Joint Arthropathy: A Narrative Review of Three Modalities. World Neurosurg 2019; 134:201-210. [PMID: 31655232 DOI: 10.1016/j.wneu.2019.10.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 11/18/2022]
Abstract
Facet joint osteoarthritis/arthropathy of the spine is a common cause of back and neck pain that frequently overlaps clinically with other diseases of the spine. Because of the possible overlap, it is crucial to have an accurate diagnostic strategy, especially when determining the management approach. Various strategies have been suggested and adopted, with several these still being used in clinics. Over the years, because of the disadvantages of single-modality imaging methods (computed tomography, magnetic resonance imaging, single-photon emission computed tomography), the interest in radiologic examination started to move toward hybrid imaging techniques. Although the data are mixed, many initial studies have shown promise. However, there are relatively few data with comparative medial branch blocks, and further investigation is needed. Given the advantages and disadvantages of these new techniques, the imaging results have to be interpreted within clinical context and with consideration of the current state of knowledge in the decision-making process.
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Affiliation(s)
- Yagiz Ugur Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Atiq Ur Rehman Bhatti
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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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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Unilateral Osteotomy of Lumbar Facet Joint Induces a Mouse Model of Lumbar Facet Joint Osteoarthritis. Spine (Phila Pa 1976) 2019; 44:E930-E938. [PMID: 30896583 DOI: 10.1097/brs.0000000000003023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The lumbar facet joint (LFJ) osteoarthritis (OA) model that highly mimics the clinical conditions was established and evaluated. OBJECTIVE Here, we innovatively constructed and evaluated the aberrant mechanical loading-related LFJ OA model. SUMMARY OF BACKGROUND DATA LFJ is the only true synovial joint in a functional spinal unit in mammals. The LFJ osteoarthritis is considered to contribute 15% to 45% of low back pain. The establish of animal models highly mimicking the clinical conditions is a useful tool for the investigation of LFJ OA. However, the previously established animal models damaged the LFJ structure directly, which did not demonstrate the effect of aberrant mechanical loading on the development of LFJ osteoarthritis. METHODS In the present study, an animal model for LFJ degeneration was established by the unilateral osteotomy of LFJ (OLFJ) in L4/5 unit to induce the spine instability. Then, the change of contralateral LFJ was evaluated by morphological and molecular biological techniques. RESULTS We showed that the OLFJ induced instability accelerated the cartilage degeneration of the contralateral LFJ. Importantly, the SRμCT elucidated that the three-dimensional structure of the subchondral bone changed in contralateral LFJ, indicated as the abnormity of bone volume/total volume ratio (BV/TV), trabecular pattern factor (Tb. Pf), and the trabecular thickness (Tb. Th). Immunostaining further demonstrated the uncoupled osteoclastic bone resorption, and bone formation in the subchondral bone of contralateral LFJ, indicated as increased activity of osteoclast, osteoblast, and Type H vessels. CONCLUSION We develop a novel LFJ OA model demonstrating the effect of abnormal mechanical instability on the degeneration of LFJ. This LFJ degeneration model that highly mimics the clinical conditions is a valuable tool to investigate the LFJ osteoarthritis. LEVEL OF EVIDENCE N/A.
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McCormick ZL, Vorobeychik Y, Gill JS, Kao MCJ, Duszynski B, Smuck M, Stojanovic MP. Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials. PAIN MEDICINE 2019; 19:2127-2137. [PMID: 29579232 DOI: 10.1093/pm/pny046] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine. Design Narrative review. Method We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers. Results Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data. Conclusions Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Yakov Vorobeychik
- Department of Anesthesiology, Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jatinder S Gill
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ming-Chih J Kao
- Department of Anesthesiology, Stanford University, Palo Alto, California
| | | | - Matthew Smuck
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
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Conger A, Burnham T, Speckman RA, Randall D, Reisinger R, Tate Q, Spiker R, Schneider B, Cushman DM, McCormick ZL. The Accuracy of SPECT/CT for Diagnosing Lumbar Zygapophyseal Joint Pain: a Systematic Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00237-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Magnitude, response, and psychological determinants of placebo effects in chronic low-back pain: a randomised, double-blinded, controlled trial. Pain Rep 2019; 4:e744. [PMID: 31583358 PMCID: PMC6749916 DOI: 10.1097/pr9.0000000000000744] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/17/2019] [Accepted: 03/12/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction: Denervation of the lumbar zygapophyseal joints by medial branch radiofrequency neurotomy has shown some benefit in treating chronic low-back pain. Before denervation, a diagnosis is made by one or more blinded injections on separate occasions to ascertain whether the relevant joints are contributing to the pain. Placebo injections have been advocated in a diagnostic regime that also includes local anaesthesia, with a decision to proceed to neurotomy based on response to local anaesthesia and not to placebo. Objectives: We investigated the magnitude of and response rate to placebo injections, and the roles of expectation, desire for pain relief, and anxiety as determinants of response to placebo. Methods: One hundred twenty patients were randomised to receive placebo and local anaesthetic injections on alternate occasions in a double-blind manner. A smaller control group with 2 local anaesthetic injections was also used. Responses to placebo were characterised, including magnitude and frequency. Results: This study demonstrated very large response to placebo injections, both response rate (78%) and magnitude (effect size d = 1.85). Expectation and anxiety were important modulators of response to placebo in this setting, with support given to expectation as a dynamic modulator of placebo responses. Large response to placebo (both in rate and magnitude) was observed when participants reported the belief that they were in the placebo arm. Conclusion: This study demonstrated large placebo responses in the context of injections for low-back pain and further characterised the importance of expectation and anxiety as important psychological mediators.
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Starr JB, Gold L, McCormick Z, Suri P, Friedly J. Trends in lumbar radiofrequency ablation utilization from 2007 to 2016. Spine J 2019; 19:1019-1028. [PMID: 30639589 PMCID: PMC6534485 DOI: 10.1016/j.spinee.2019.01.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/06/2018] [Accepted: 01/06/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar radiofrequency ablation (RFA) is an intervention used to treat facet-mediated chronic low back pain. In some studies with methods consistent with clinical practice guidelines, RFA results in improvements in pain and functional limitations. However, in other studies, RFA demonstrates limited benefit. Despite unanswered questions regarding efficacy of RFA, its use is widespread. PURPOSE To describe trends in the utilization and cost of lumbar RFA and lumbar facet injections. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE The sample was derived from the IBM/Watson MarketScan Commercial Claims and Encounters Databases from 2007 to 2016. OUTCOME MEASURES Longitudinal trends in the distribution and quantity of lumbar facet injections before lumbar RFA, corticosteroid administration during lumbar facet injections, progression to lumbar RFA after lumbar facet injections, lumbar RFA utilization, and costs of these interventions. METHODS Two primary cohorts were identified from patients who received lumbar RFA or lumbar facet injection procedures. Utilization rates per 100,000 enrollees were determined for both cohorts. The mean, median, and interquartile ranges of the number of facets targeted and costs per procedure were calculated by year and laterality, as well as overall. Costs in 2018 dollars were estimated by summing gross payment totals from patients and insurance plans. This study was supported by funds from the NIH, and has no conflict of interest associated biases. RESULTS From 2007 to 2016, lumbar RFA sessions performed per 100,000 enrollees per year increased from 49 to 113, a 130.6% overall increase (9.7% annually). Lumbar facet injection use increased from 201 to 251 sessions per 100,000 enrollees, a 24.9% overall increase (2.5% annually). In the year after a lumbar facet injection, 26.7% of patients received lumbar RFA; 28.6% received another injection but not RFA; and 44.7% received neither. The number of patients receiving two lumbar facet injection procedures prior to lumbar RFA grew from 51.1% in 2010 to 58.8% in 2016. For lumbar RFA, the cost per 100,000 enrollees went from $94,570 in 2007 to $266,680 in 2016, a 12.2% annual increase. For lumbar facet injections, the cost per 100,000 enrollees went from $257,280 in 2007 to $396,580 in 2016, a 4.9% annual increase. CONCLUSIONS This analysis showed consistent growth in both the frequency and procedure cost of lumbar RFA and facet injections among a large, national, commercially insured population from 2007 to 2016.
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Affiliation(s)
- Jordan B Starr
- Department of Anesthesiology and Pain Medicine, University of Washington, Box 356540, Seattle, WA 98195, USA.
| | - Laurie Gold
- CLEAR Center, University of Washington, Box 359455, Seattle, WA 98195, USA
| | - Zachary McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Pradeep Suri
- Department of Rehabilitation Medicine, University of Washington, Box 359612, Seattle, WA 98104, USA; Rehabilitation Care Services, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, Box 359612, Seattle, WA 98104, USA
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Predictors of Response to a Medial Branch Block: MRI Analysis of the Lumbar Spine. J Clin Med 2019; 8:jcm8040538. [PMID: 31010137 PMCID: PMC6518052 DOI: 10.3390/jcm8040538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as ≥30% or a 2-point reduction in the numeric rating scale (NRS) compared with the baseline at the 1-month follow-up. The facet angle, facet angle difference, facet joint degeneration, disc height and spondylolisthesis grade were analyzed from an MRI at the L3 to S1 levels. Univariate and multivariate logistic regression analyses were used to evaluate independent factors associated with a successful response of MBB. In the univariate analysis, the disc height at L5-S1 and facet angle difference at L3-4 were lower in the positive responders (p = 0.022 and p = 0.087, respectively). In the multivariate analysis, the facet angle difference at L3-4 and disc height at L5-S1 were independent factors associated with a successful response (odds ratio = 0.948; p = 0.038 and odds ratio = 0.864; p = 0.038, respectively). In patients with a degenerative disc at L5-S1, MBB can lead to a good response for at least one month. In patients with facet tropism at L3-4 level, the response to MBB after one month is likely to be poor.
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de Andrés Ares J, Gilsanz F. Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:213-221. [PMID: 30683428 DOI: 10.1016/j.redar.2018.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 06/09/2023]
Abstract
Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit.
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Affiliation(s)
- J de Andrés Ares
- Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, España.
| | - F Gilsanz
- Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, España
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Chen AS, Miccio VF, Smith CC, Christolias GC, Blanchard AR. Procedural Pain During Lumbar Medial Branch Blocks With and Without Skin Wheal Anesthesia: A Prospective Comparative Observational Study. PAIN MEDICINE 2019; 20:779-783. [DOI: 10.1093/pm/pny322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Allen S Chen
- Department of Orthopedic Surgery, University of California Los Angeles, UCLA Spine Center
| | - Vincent F Miccio
- Department of Rehabilitation Medicine, Weill Cornell Medical Center, New York, New York
| | - Clark C Smith
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center
| | - George C Christolias
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center
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Abstract
This paper offers a mechanistic account of back pain which attempts to incorporate all of the most important recent advances in spinal research. Anatomical and pain-provocation studies show that severe and chronic back pain most often originates in the lumbar intervertebral discs, the apophyseal joints, and the sacroiliac joints. Psychosocial factors influence many aspects of back pain behaviour but they are not important determinants of who will experience back pain in the first place. Back pain is closely (but not invariably) associated with structural pathology such as intervertebral disc prolapse and endplate fractures, although age-related biochemical changes such as those revealed by a ‘dark disc’ on MRI have little clinical relevance. All features of structural pathology (including disc prolapse) can be re-created in cadaveric specimens by severe or repetitive mechanical loading, with a combination of bending and compression being particularly harmful to the spine. Structural disruption alters the mechanical environment of disc cells in a manner that leads to cell-mediated degenerative changes, and animal experiments confirm that surgical disruption of a disc is followed by widespread disc degeneration. Some people are more vulnerable to spinal degeneration than others, largely because of their genetic inheritance. Age-related biochemical changes and loading history can also affect tissue vulnerability. Finally the concept of ‘functional pathology’ is introduced, according to which, back pain can arise because postural habits generate painful stress concentrations within innervated tissues, even though the stresses are not high enough to cause physical disruption.
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Chakraverty R, Dias R. Audit of Conservative Management of Chronic Low Back Pain in a Secondary Care Setting – Part I: Facet Joint and Sacroiliac Joint Interventions. Acupunct Med 2018; 22:207-13. [PMID: 15628778 DOI: 10.1136/aim.22.4.207] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The work of a chronic back pain service in secondary care in the West Midlands is reported. The service offers acupuncture, spinal injection procedures, osteopathy and a range of other interventions for patients whose back pain has not responded to conservative management. This section of the report focuses on injection procedures for lumbar facet joint and sacroiliac joint pain, which have been shown to be the cause of chronic low back pain in 16–40% and 13–19% of patients respectively. Diagnosis relies on the use of intra-articular or sensory nerve block injections with local anaesthetic. Possible treatments following diagnosis include intra-articular corticosteroid, radiofrequency denervation (for facet joint pain) or ligament prolotherapy injections (for sacroiliac joint pain). The results of several hospital audits are reported. At six month follow up, 50% of 38 patients undergoing radiofrequency denervation following diagnostic blocks for facet joint pain had improved by more than 50%, compared to 29% of 34 patients treated with intra-articular corticosteroid injection. Sixty three per cent of 19 patients undergoing prolotherapy following diagnostic block injection for sacroiliac joint pain had improved at six months, compared to 33% of 33 who had intra-articular corticosteroid. Both radiofrequency denervation and sacroiliac prolotherapy showed good long-term outcomes at one year.
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