Study Design: A randomized, double-blind, controlled trial.
Objective: To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin.
Summary of Background Data: Lumbar facet joints have been shown as the source of chronic pain in 21% to 41% of low back patients with an average prevalence of 31% utilizing controlled comparative local anesthetic blocks. Intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin.
Methods: The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids. The inclusion criteria was based upon a positive response to diagnostic controlled, comparative local anesthetic lumbar facet joint blocks.
Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months.
Results: Significant improvement with significant pain relief of ≥ 50% and functional improvement of ≥ 40% were observed in 85% in Group 1, and 90% in Group II, at 2-year follow-up.
The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks, requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment.
Conclusions: Therapeutic lumbar facet joint nerve blocks, with or without steroids, may provide a management option for chronic function-limiting low back pain of facet joint origin.
Chronic low back pain; lumbar facet or zygapophysial joint pain; facet joint nerve or medial branch blocks; comparative controlled local anesthetic blocks; therapeutic lumbar facet joint nerve blocks
While chronic neck pain is a common problem in the adult population, with a typical 12-month prevalence of 30%–50%, there is a lack of consensus regarding its causes and treatment. Despite limited evidence, cervical epidural injections are one of the commonly performed nonsurgical interventions in the management of chronic neck pain.
A randomized, double-blind, active, controlled trial was conducted to evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of chronic neck pain with or without upper extremity pain in patients without disc herniation, radiculitis, or facet joint pain.
One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain by means of controlled diagnostic medial branch blocks were randomly assigned to one of two treatment groups, ie, injection of local anesthetic only (group 1) or local anesthetic mixed with nonparticulate betamethasone (group 2). The primary outcome of significant pain relief and improvement in functional status (≥50%) was demonstrated in 72% of group 1 and 68% of group 2. The overall average number of procedures per year was 3.6 in both groups with an average total relief per year of 37–39 weeks in the successful group over a period of 52 weeks.
Cervical interlaminar epidural injections of local anesthetic with or without steroids may be effective in patients with chronic function-limiting discogenic or axial pain.
chronic neck pain; cervical disc herniation; cervical discogenic pain; cervical epidural injections; epidural steroids; local anesthetics
Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.
Facet joint; Zygapophyseal joint; Low back pain; Pain; Radiculopathy; Sciatica; Catheter ablation; Steroids; Lumbar vertebrae; Humans; Male; Female; Nerve block; Diagnostic errors
Among the multiple causes of chronic low back pain, axial and discogenic pain are common. Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections. However, there is a paucity of evidence regarding the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. In an interventional pain management practice in the US, a randomized, double-blind, active control trial was conducted. The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin. However, disc herniation, radiculitis, facet joint pain, or sacroiliac joint pain were excluded. Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the, Oswestry Disability Index, Secondary outcome measurements included employment status, and opioid intake. Significant improvement or success was defined as at least a 50% decrease in pain and disability. Significant improvement was seen in 77% of the patients in Group I and 67% of the patients in Group II. In the successful groups (those with at least 3 weeks of relief with the first two procedures), the improvement was 84% in Group I and 71% in Group II. For those with chronic function-limiting low back pain refractory to conservative management, it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain. This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source.
lumbar disc herniation; axial or discogenic pain; lumbar interlaminar epidural injections; local anesthetic; steroids; controlled comparative local anesthetic blocks; NCT00681447
Radiofrequency (RF) medial branch neurotomy is an effective management of lumbar facet syndrome. However, pain may recur after period of time. When pain recurs, it can be repeated, but the successful outcome and duration of relief from repeated procedures are not clearly known. The objective of this study was to determine the success rate and duration of pain relief from repeated radiofrequency medial branch neurotomy for lumbar facet syndrome.
A retrospective review of medical records was done on 60 consecutive patients, from March of 2006 to February of 2009, who had an initial successful RF neurotomy but subsequently underwent repeated procedures due to recurrence of pain. All procedures were done in carefully selected patients after at least two responsive medial branch nerve blocks. C-arm fluoroscopic guide, impedance, sensory and motor threshold monitoring tools were used for the precise placement of electrodes. Responses of repeated procedures were compared with initial radiofrequency neurotomy for success rates and duration of pain relief.
There were 48 females and 12 males. Mean age was 52.4 years (range, 26-83). RF medial branch neurotomy was done on one side in 38 and both sides in 22 patients, each covering at least three segments. Average visual analog scale at last procedure was 6.8. Twelve patients had previous lumbar operations, including 4 patients with instrumentations. Fifty-five patients had two procedures and five patients had three procedures. Mean duration of successful pain relief (> 50% of previous pain for at least 3 months period) after initial radiofrequency neurotomy was 10.9 months (range, 3-28) in 51 (85%) patients. From repeated procedures, successful pain relief was seen in 50 (91%) patients with average duration of 10.2 months (range, 3-24). Five patients had third procedure, which was successful in 4 (80%) patients with mean duration of 9.8 months (range, 5-16). This was not statistically different from initial results. There were no permanent neurological complications from the procedures.
Results of this study indicate that the frequency of success and durations of relief from repeated RF medial branch neurotomy for lumbar facet syndrome are similar to initial results that provided relatively prolonged period of pain relief without major side effects. Each procedure seems to provide successful pain relief for about 10 months in more than 85% of carefully selected patients when properly done.
Facet syndrome; Zygapophyseal joint denervation; Radiofrequency neurotomy; Repeat operation; Outcome
Chronic neck and arm pain or cervicobrachialgia commonly occurs with the degeneration of cervical spine. Authors investigated the usefulness of radiofrequency (RF) neurotomies of cervical medial branches in patients with cervicobrachialgia and analyzed the factors which can influence the treatment outcome. Demographic data, types of pain distribution, responses of double controlled blocks, electrical stimulation parameters, numbers and levels of neurotomies, and surgical outcomes were evaluated after mean follow-up of 12 months. Pain distribution pattern was not significantly correlated with the results of diagnostic blocks. Average stimulation intensity was 0.45 V, ranging from 0.3 to 0.69, to elicit pain response in cervical medial branches. The most common involvement of nerve branches was C4 (89%), followed by C5 (82%), C6 (75%), and C7 (43%). Among total of 28 patients, nineteen (68%) reported successful outcome according to outcome criteria after 6 months of follow-up (p=0.001), and eight (42%) of 19 patients reported complete relief (100%) of pain. Four patients showed recurrence of pain between 6 and 12 months. It was therefore concluded that cervical medial branch neurotomy is considered useful therapeutic modality for the management of cervicobrachialgia in selected patients, particularly in degenerative zygapophyseal disorders.
Neck pain; Cervicobrachialgia; Neurotomy; Radiofrequency; Catheter Ablation; Cervical Vertebrae
Chronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections.
A randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment.
Significant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months.
Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.
chronic axial low back pain; discogenic pain; disc herniation; caudal epidural injections
Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice.
Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting.
The prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49% – 61%), with thoracic spine pain was 42% (95% CI, 30% – 53%), and in with lumbar spine pain was 31% (95% CI, 27% – 36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54% – 72%) in the cervical spine, 55% (95% CI, 39% – 78%) in the thoracic spine, and 27% (95% CI, 22% – 32%) in the lumbar spine.
This study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.
A prospective study.
To determine the success rate and duration of relief of radiofrequency neurotomy for lumbar facet joint pain.
Overview of Literature
There is a lack of effective treatment for chronic low back pain. Radiofrequency denervation appears to be an emerging technology, with substantial variations in use.
Fifty-eight patients underwent radiofrequent neurotomy on the posterior primary ramus for chronic low back pain. All patients with low back pain of more than 3 months duration, with or without non-radicular radiation to the buttock and hip, were included in the study. From October 2005 to December 2006, eligible patients underwent a standardized diagnostic work-up, which included the use of a visual analog scale (VAS), physical examination, review of imaging studies, and diagnostic blockades. Pain relief was assessed on the third day, and at 3 months and 6 months post-treatment, using the visual analog scale.
There were 44 women and 14 men included in the study. The mean age was 57.7 years (range, 20~80 years). Radiofrequency neurotomy denervated three segments and a bilateral lesion in all patients. The visual analogue scale (VAS) scores on the third day (mean VAS score: 1.48) and 3 months (mean VAS score: 1.79) after treatment decreased significantly when compared with the pre-treatment scores (mean VAS score: 6.56). However, the final values of the VAS scores after 6 months were slightly increased as compared to the VAS scores measured at the beginning of the study (mean VAS score: 2.91). No cases of infection, new motor deficits, or new sensory deficits were identified.
We suggest that radiofrequency neurotomy offers an effective palliative management of lumbar facet pain. However, there is limited evidence that radiofrequency neurotomy offers short-term relief for chronic low back pain. Further high-quality randomized controlled trials are needed with larger patient numbers and more data on the long-term effects, for which current evidence is inconclusive.
Lumbar facet joint; Chronic low back pain; Radiofrequency neurotomy
To evaluate the outcomes of medial branch block in facet joint pain for osteoporotic compression fracture and utilize multiple regression, the relationship between their impact on treatment outcome and other factor, such as the radiologic finding, clinical parameters was analyze.
Fifty-three patients with axial back pain from osteoporotic compression fracture were enrolled. The clinical outcomes were measured by Verbal Numeric Rating Scale (VNS) and Oswestry Disability Index (ODI) before treatment, 2 weeks, 3 months, and 12 months after the medial branch block. Radiographic analysis included measurement of overall sagittal alignment, collapsed vertebral height, and vertebral kyphotic angle. After 12 months, patients' satisfaction was classified to five categories: excellent, good, fair, poor or fail. Statistical analysis of both radiographic and clinical parameters along with treatment outcome was performed to determine any significant correlations between the two.
VNS and ODI was improved 2 weeks after the injection and continued to improve until 12 months. Significant improvement with significant pain relief (>40%), functional improvement (>20%), and the patients rated their satisfaction level as "excellent" or "good" at 12 months after the first injection were observed in 78.9%. The radiographic and clinical parameters were not significantly correlated with treatment outcome.
Our retrospective study demonstrated that the medial branch block provided significant pain relief and functional recovery to the patients with osteoporotic spinal compression fractures complaining of continuous facet joint pain after vertebroplasty or conservative treatment. A placebo-controlled prospective randomized double-blind study should be conducted in the future to evaluate the treatment effects.
Compression fractures; Osteoporotic fractures; Spinal injections
Facet joint pain is an important aspect of degenerative lumbar spine disease, and radiofrequency medial branch neurotomy remains an established therapy, while cryodenervation has still been poorly examined. This study was undertaken to examine the effects of medial branch cryodenervation in the treatment of lumbar facet joint pain. This was a prospective clinical case series. Patient selection was based on the history, physical examination and positive medial branch blocks. Percutaneous medial branch cryodenervation was performed using a Lloyd Neurostat 2000. Target parameters were low back pain (VAS), limitation of activity (McNab) and overall satisfaction. Fifty patients were recruited, and 46 completed the study. The follow-up time was 1 year. At 6 weeks, 33 patients (72%) were pain free or had major improvement of low back pain; 13 (28%) had no or little improvement. Including failures, mean low back pain decreased significantly from 7.7 preoperatively to 3.2 at 6 weeks, 3.3 at 3 months, 3.0 at 6 months and 4.2 at 12 months (P<0.0001). Limitation of the activities of daily living improved parallel to reduced pain. Our results suggest that medial branch cryodenervation is a safe and effective treatment for lumbar facet joint pain.
Cervicogenic headache (CGH) is known to be mainly related with upper cervical problems. In this study, the effect of radiofrequency neurotomy (RFN) for lower cervical (C4-7) medial branches on CGH was evaluated.
Eleven patients with neck pain and headache, who were treated with lower cervical RFN due to supposed lower cervical zygapophysial joint pain without symptomatic intervertebral disc problem or stenosis, were enrolled in this study. CGH was diagnosed according to the diagnostic criteria of the cervicogenic headache international study group. Visual analogue scale (VAS) score and degree of VAS improvement (VASi) (%) were checked for evaluation of the effect of lower cervical RFN on CGH.
The VAS score at 6 months after RFN was 2.7±1.3, which were significantly decreased comparing to the VAS score before RFN, 8.1±1.1 (p<0.001). The VASi at 6 months after RFN was 63.8±17.1%. There was no serious complication.
Our data suggest that lower cervical disorders can play a role in the genesis of headache in addition to the upper cervical disorders or independently.
Cervicogenic headache; Radiofrequency; Neurotomy; Medial branch
Pain originating from the lumbar facet joints is estimated to represent about 15% of all low back pain complaints. The diagnostic block is considered to be a valuable tool for confirming facetogenic pain. It was demonstrated that a block of the ramus medialis of the ramus dorsalis is preferred over an intra-articular injection. The outcome of the consequent radiofrequency treatment is not different in patients reporting over 80% pain relief after the diagnostic block than in those who have between 50% and 79% pain relief. There is one well-conducted comparative trial assessing the value of one or two controlled diagnostic blocks to none. The results of the seven randomized trials on the use of radiofrequency treatment of facet joint pain demonstrate that good patient selection is imperative for good clinical outcome. Therefore, we suggest one block of the ramus medialis of the ramus dorsalis before radiofrequency treatment.
Facet joints; Zygapophyseal joints; Low back pain; Diagnostic block; Medial branch block; Radiofrequency treatment; Evidence rating; Pain management
Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.
A randomized, placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-5 primary dorsal rami and S1-3 lateral branch radiofrequency denervation using cooling-probe technology following a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who failed to respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology.
One, 3 and 6-months post-procedure, 11 (79%), 9 (64%) and 8 (57%) of radiofrequency treated patients experienced ≥ 50% pain relief and significant functional improvement. In contrast, only 2 (14%) patients in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3-months post-procedure. In the crossover group (n=11), 7 (64%), 6 (55%) and 4 (36%) patients experienced improvement 1, 3 and 6-months post-procedure. One year after treatment, only 2 (14%) patients in the treatment group continued to demonstrate persistent pain relief.
These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm our results, and determine the optimal candidates and treatment parameters for this poorly understood disorder.
Facet joint disease plays a major role in axial low-back pain. Few diagnostic tests and imaging methods for identifying this condition exist. Single photon emission computed tomography (SPECT) is reported that it has a high sensitivity and specificity in diagnosing facet disease. We prospectively evaluated the use of bone scintigraphy with SPECT for the identification of patients with low back pain who would benefit from medial branch block.
SPECT was performed on 33 patients clinically suspected of facet joint disease. After SPECT, an ultrasound guided medial branch block was performed on all patients. On 28 SPECT-positive patients, medial branch block was performed based on the SPECT findings. On 5 negative patients, medial branch block was performed based on clinical findings. For one month, we evaluated the patients using the visual analogue scale (VAS) and Oswestry disability index. SigmaStat and paired t-tests were used to analyze patient data and compare results.
Of the 33 patients, the ones who showed more than 50% reduction in VAS score were assigned 'responders'. SPECT positive patients showed a better response to medial branch blocks than negative patients, but no changes in the Oswestry disability index were seen.
SPECT is a sensitive tool for the identification of facet joint disease and predicting the response to medial branch block.
facet; medial branch block; SPECT
Comorbid psychopathology is an important predictor of poor outcome for many types of treatments for back or neck pain. But it is unknown if this applies to the results of medial branch blocks (MBBs) for chronic low back or neck pain, which involves injecting the medial branch of the dorsal ramus nerves that innervate the facet joints. The objective of this study was to determine whether high levels of psychopathology are predictive of pain relief after MBB injections in the lumbar or cervical spine.
This was a prospective cohort study. Consecutive patients in a pain medicine practice undergoing MBBs of the lumbar or cervical facets with corticosteroids were recruited to participate. Subjects were selected for a MBB based on operationalized selection criteria and the procedure was performed in a standardized manner. Subjects completed the Brief Pain Inventory (BPI) and the Hospital Anxiety and Depression Scale (HADS) just prior to the procedure and at one-month follow up. Scores on the HADS classified the subjects into three groups based on psychiatric symptoms, which formed the primary predictor variable: Low, Moderate, or High levels of psychopathology. The primary outcome measure was the percent improvement in average daily pain rating one-month following an injection. Analysis of variance and chi-square were used to analyze the analgesia and functional rating differences between groups, and to perform a responder analysis.
Eighty six (86) subjects completed the study. The Low psychopathology group (n = 37) reported a mean of 23% improvement in pain at one-month while the High psychopathology group (n = 29) reported a mean worsening of -5.8% in pain (p < .001). Forty five percent (45%) of the Low group had at least 30% improvement in pain versus 10% in the High group (p < .001). Using an analysis of covariance, no baseline demographic, social, or medical variables were significant predictors of pain improvement, nor did they mitigate the effect of psychopathology on the outcome.
Psychiatric comorbidity is associated with diminished pain relief after a MBB injection performed with steroid at one-month follow-up. These findings illustrate the importance of assessing comorbid psychopathology as part of a spine care evaluation.
The diagnosis “lumbar facet syndrome” is common and often indicates severe lumbar spine surgery procedures. It is doubtful whether a painful facet joint (FJ) can be identified by a single FJ block. The aim of this study was to clarify the validity of a single and placebo controlled bilateral FJ blocks using local anesthetics. A prospective single blinded triple cross-over study was performed. 60 patients (31 f, 29 m, mean age 53.2 yrs (22–73)) with chronic low back pain (mean pain persistance 31 months, 6 months of conservative treatment without success) admitted to a local orthopaedic department for surgical or conservative therapy of chronic LBP, were included in the study. Effect on pain reduction (10 point rating scale) was measured. The 60 subjects were divided into six groups with three defined sequences of fluoroscopically guided bilateral monosegmental lumbar FJ test injections in “oblique needle” technique: verum-(local anaesthetic-), placebo-(sodium chloride-) and sham-injection. Carry-over and periodic effects were evaluated and a descriptive and statistical analysis regarding the effectiveness, difference and equality of the FJ injections and the different responses was performed. The results show a high rate of non-response, which documents the lack of reliable and valid predictors for a positive response towards FJ blocks. There was a high rate of placebo reactions noted, including subjects who previously or later reacted positively to verum injections. Equivalence was shown among verum vs. placebo and partly vs. sham also. With regard to test validity criteria, a single intraarticular FJ block with local anesthetics is not useful to detect the pain-responsible FJ and therefore is no valid and reliable diagostic tool to specify indication of lumbar spine surgery. Comparative FJ blocks with local anesthetics and placebo-controls have to be interpretated carefully also, because they solely give no proper diagnosis on FJ being main pain generator.
Study Design: A randomized, double-blind, active controlled trial.
Objective: To evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in the management of chronic neck pain and upper extremity pain in patients with disc herniation and radiculitis.
Summary of Background Data: Epidural injections in managing chronic neck and upper extremity pain are commonly employed interventions. However, their long-term effectiveness, indications, and medical necessity, of their use and their role in various pathologies responsible for persistent neck and upper extremity pain continue to be debated, even though, neck and upper extremity pain secondary to disc herniation and radiculitis, is described as the common indication. There is also paucity of high quality literature.
Methods: One-hundred twenty patients were randomly assigned to one of 2 groups: Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL); Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL of nonparticulate betamethasone.
Primary outcome measure was ≥ 50 improvement in pain and function. Outcome assessments included Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), opioid intake, employment, and changes in weight.
Results: Significant pain relief and functional status improvement (≥ 50%) was demonstrated in 72% of patients who received local anesthetic only and 68% who received local anesthetic and steroids. In the successful group of participants, significant improvement was illustrated in 77% in local anesthetic group and 82% in local anesthetic with steroid group.
Conclusions: Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for patients with cervical disc herniation and radiculitis.
Chronic neck pain; cervical disc herniation; upper extremity pain; cervical epidural injections; epidural steroids; local anesthetics
The purpose of the present study was to assess the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following the treatment. The results of this study showed that RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. In conclusion, RF cervical zygapophyseal joint neurotomy has shown to provide substantial pain relief in patients with chronic cervicogenic headache
when carefully selected.
Cervicogenic Headache; Zygapophyseal Joint; Radiofrequency Neurotomy
Chronic low back pain is a disabling phenomenon that can cause a severe reduction in quality of life, especially in elderly patients. Surgical treatment is sometimes a big challenge for these elderly patients. Radiofrequency (RF) ablation is an increasingly popular method for treating low back pain caused by facet syndrome. The purpose of this study was to evaluate whether RF neurotomy is effective in terms of pain reduction and functional outcome in elderly patients.
Patients and methods
Fifty-eight patients aged 80 years and older who had chronic mechanical low back pain were examined after they underwent RF heat lesion of the medial branch. Follow-up occurred 1, 3, 6, and 12 months after treatment. Pain was measured on the visual analog scale and functional outcome was measured using the Oswestry Disability Index.
After 1 month, 43 patients (74%) were satisfied with the results. After 3 months, 38 patients (66%) had clinically significant pain relief. After 6 months, 33 patients (57%) had pain relief, and at the 1-year follow-up, 30 patients (52%) showed good results while 28 patients (48%) showed no effect. The Oswestry Disability Index score was substantially improved even after 1 year. Minor complications occurred in eleven patients (19%), who had transient discomfort and burning pain.
RF is a safe and partially effective procedure for treating elderly patients with mechanical back pain due to facet syndrome.
radiofrequency; mechanical back pain; facet syndrome; elderly; octogenarians
Chronic spine pain poses a peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features and nonspecific radiological findings. Facet joint injection is an interventional pain management tool for facet-related spinal pain that can be effectively administered by a radiologist. This technique is the gold standard for identifying facet joints as the source of spinal pain. The major indications for facet injections include strong clinical suspicion of the facet syndrome, focal tenderness over the facet joints, low back pain with normal radiological findings, post-laminectomy syndrome with no evidence of arachnoiditis or recurrent disc disease, and persistent low back pain after spinal fusion. The contraindications are more ancillary, with none being absolute. Like any synovial joint degeneration, inflammation and injury can lead to pain on motion, initiating a vicious cycle of physical deconditioning, irritation of facet innervations and muscle spasm. Image-guided injection of local anesthetic and steroid into or around the facet joint aims to break this vicious cycle and thereby provide pain relief. This outpatient procedure has high diagnostic accuracy, safety and reproducibility but the therapeutic outcome is variable.
Facet syndrome; intra-articular facet injection; imaging-guided injections; interventional spinal procedures; low back pain; spinal pain
Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-007-0391-1) contains supplementary material, which is available to authorized users.
Systematic review; Low back pain; Diagnosis
Selective lumbar nerve root block (SNRB) is generally accepted as an effective treatment method for back pain with sciatica. However, it requires devices producing radioactive materials such as C-arm fluoroscopy. This study evaluated the usefulness of the longitudinal view of transverse process and needles for medial branch block as landmarks under ultrasonography.
We performed selective nerve root block for 96 nerve roots in 61 patients under the guidance of ultrasound. A curved probe was used to identify the facet joints and transverse processes. Identifying the lumbar nerve roots under the skin surface and ultrasound landmarks, the cephalad and caudal medial branch blocks were undertaken under the transverse view of sonogram first. A needle for nerve root block was inserted between the two transverse processes under longitudinal view, while estimating the depth with the needle for medial branch block. We then injected 1.0 mL of contrast medium and checked the distribution of the nerve root with C-arm fluoroscopy to evaluate the accuracy. The visual analog scale (VAS) was used to access the clinical results.
Seven SNRBs were performed for the L2 nerve root, 15 for L3, 49 for L4, and 25 for L5, respectively. Eighty-six SNRBs (89.5%) showed successful positioning of the needles. We failed in the following cases: 1 case for the L2 nerve root; 2 for L3; 3 for L4; and 4 for L5. The failed needles were positioned at wrong leveled segments in 4 cases and inappropriate place in 6 cases. VAS was improved from 7.6 ± 0.6 to 3.5 ± 1.3 after the procedure.
For SNRB in lumbar spine, the transverse processes under longitudinal view as the ultrasound landmark and the needles of medial branch block to the facet joint can be a promising guidance.
Lumbar spine; Spinal injections; Ultrasound
Study Design: A randomized, active control, double-blind trial. Objective: To evaluate the effectiveness of fluoroscopically directed caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to post lumbar surgery syndrome. Summary of Background Data: There is a paucity of evidence concerning caudal epidural injections for managing chronic persistent low back pain with or without lower extremity pain caused by post lumbar surgery syndrome.
Methods: This active control randomized study included 140 patients with 70 patients in each group. Group I received 0.5% lidocaine, 10 mL; Group II received 9 mL of 0.5% lidocaine mixed with 1 mL of 6 mg of nonparticulate betamethasone. The multiple outcome measures included the numeric rating scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as at least 50% improvement in pain and Oswestry Disability Index scores. Patients with a positive response to the first 2 procedures with at least 3 weeks of relief were considered to be successful. All others were considered as failures.
Results: Overall in Group I, 53% and 47% of the patients and in Group II, 59% and 58% of the patients, showed significant improvement with reduction in pain scores and disability index at 12 months and 24 months. In contrast, in the successful groups, significant pain relief and improvement in function were observed in 70% and 62% of Group I at one and 2 years; in 75% and 69% of Group II at one and 2 years. The results in the successful group showed that at the end of the first year patients experienced approximately 38 weeks of relief and at the end of 2 years Group I had 62 weeks and Group II had 68 weeks of relief. Overall total relief for 2 years was 48 weeks in Group I and 54 weeks in Group II. The average procedures in the successful groups were at 4 in one year and 6 at the end of 2 years.
Conclusion: Caudal epidural injections of local anesthetic with or without steroid might be effective in patients with chronic persistent low back and/or lower extremity pain in patients with post lumbar surgery syndrome.
Chronic low back pain; post lumbar surgery syndrome; recurrent disc herniation; epidural fibrosis; spinal stenosis; caudal epidural steroid injections.
This is a prospective study.
To develop a methodological approach for conducting ultrasound-guided lumbar facet nerve block by defining essential ultrasound-guided landmarks in order to assess the feasibility of this method.
Overview of Literature
The current role of ultrasound guidance for musculoskeletal intervention treatments has been reported upon in previous literature.
Ultrasound-guided facet nerve block was done in 95 segments for 50 patients with chronic back pain by facet arthropathy. After the surface landmarks of the spinous process and iliac crest line were confirmed, longitudinal facet views were obtained by a curved array transducer to identify the different spinal segments. The spinous process and facet joint with transverse process were delineated by transverse sonograms at each level and the target point for the block was defined as lying on the upper edge of the transverse process. The needle was inserted toward the target point. After a contrast injection, the placement of the needle and contrast was checked by fluoroscopy.
Eighty-seven segments (91.6%) could be guided successfully to the right facet nerve block by using ultrasound. After fluoroscopic control, 8 needles had to be corrected because of problems with other segments (3 cases) and lamina placements (5 cases). For the 42 patients who underwent successful block by ultrasound, however, the mean visual analogue score for back pain was improved from 6.2 ± 0.9 before the block to 4.0 ± 1.0 after the block (p = 0.001).
Ultrasound-guided longitudinal facet view and the surface landmarks of the spinous process and iliac crest line seems to be a promising guidance technique for the lumbar facet nerve block technique.
Lumbosacral region; Nerve block; Ultrasonography