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1.  Transverse Process and Needles of Medial Branch Block to Facet Joint as Landmarks for Ultrasound-Guided Selective Nerve Root Block 
Clinics in Orthopedic Surgery  2013;5(1):44-48.
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.
PMCID: PMC3582870  PMID: 23467334
Lumbar spine; Spinal injections; Ultrasound
2.  Endoscopically Guided Foraminal and Dorsal Rhizotomy for Chronic Axial Back Pain Based on Cadaver and Endoscopically Visualized Anatomic Study 
Conventional fluoroscopically guided continuous radiofrequency (CRF) and pulsed Radiofrequency (PRF) lesioning of the medial branch, dorsal ramus, a standard technique to treat facet pain, is compared to an endoscopic visually guided technique. The endoscopic technique (Figure 1) is designed to ablate a larger area of the transverse process where the medial branch crosses to innervate the facet. Endoscopically guided visualization provides confirmation of nerve ablation or transection in the most common location of the branches of the dorsal ramus innervating the facet joint.
Surgical setup for ablation of the medial, intermediate and lateral branches of the dorsal ramus.
Materials and Method
A retrospective non randomized study of 50 initial patients assessed the efficacy of endoscopic rhizotomy. Patients with lumbar spondylosis and facet arthrosis who had at least 50% pain relief by medial branch blocks met the inclusion criteria for the visualized, surgically directed endoscopic technique. A specially designed cannula and endoscope (Richard Wolf, GmBh) (Figure 2) was developed specifically for this purpose. After completion of the initial 50 patient pilot study in 2005, utilizing a low-temperature, ultra-high frequency (1.7-4.0 MHz) bipolar energy radiofrequency source (Elliquence Int, Hewlett, NY) that demonstrated efficacy, 400 subsequent patients were added to this retrospective study by May 2013. The surgical technique refinement was guided by cadaveric variations observed from additional cadaver dissections (Figure 3) and endoscopic visualization of foraminal nerves that revealed variable locations of the dorsal ramus, including the medial branch. The anatomic variations supported a need for visualized rhizotomy. The inclusion criteria also involved increasing the percentage of back pain relief from medial branch blocks to a base of 75% estimated improvement in order to overcome the variable subjectiveness of a 50% improvement threshold that served to disappoint a small percentage of patients who overestimated the reported 50% improvement in hopes that they would qualify for the endoscopic guided procedure.
Richard Wolf YESS Rhizotomy Set. The cannulas, endoscope, bitip and surgical bipolar RF probes by Elliquence are configured ergonomically to provide excellent focal length imaging to keep image in focus with the endoscope scope resting on cannula. The bitip probe cuts tissue, and the RF probe thermally ablates tissue efficiently.
Cadaver dissection of the dorsal ramus and its branches out- lining the areas where branches of the dorsal ramus may be visualized and ablated before it reaches the facet joint.
At one year follow-up in the initial study design, VAS improved 6.2-2.5, and ODI 48-28. All patients had VAS improvement equal or greater than injection. The results remained constant with additional surgical cases that continued to improve when technique and visualized rhizotomy allowed for greater surgical exploration and ablation of the targeted zone where more than just the medial branch could be ablated. Approximately 10 percent of the patients returned at one and two year follow-up with mild recurrence of their axial back pain, but none to the original level of pain. Additional rhizotomy of the upper lumbar facets provided additional relief in selected patients.
Conclusions / level of evidence 3
The cadaver studies demonstrated considerable variability in the location of the medial and lateral branches of the dorsal ramus. Variability was most common cephalad to L3-4. The dorsal ramus and its nerve branches can also be visualized in the foramen ventral to the intertransverse ligament. Neuromas and entrapment of the dorsal ramus has been identified endoscopically, and confirmed by H and E slides (Figure 4). In the upper lumbar spine, we were not able to find the medial branch to the facets consistently at same location. The nerve to the facet joint did not always cross the transverse process. Some branches enter the facet joint before crossing the transverse process adjacent to the tip of the SAP (Figure 5). The nerve can be mistaken for a furcal nerve or foraminal ligament. Nerve Ablation at above L3-4 levels may require lesioning of the dorsal ramus or targeting the nerve innervation on the facet wall, pedicle or capsule.
This H and E slide of the biopsied specimen is consistent with a peripheral nerve fiber.
This foraminal view of a branch of the dorsal ramus is in the foramen at the level of the SAP. The nerve runs along the ventral lateral aspect of the superior facet to the tip, and can also run in the vicinity of the foraminal ligament. Endoscopic rasps, trephines, kerrisons, and burrs can be used for foraminoplasty. The nerve should be preserved, if possible, but transection of a branch of the dorsal ramus contributes to axial back pain relief. Branches of the dorsal ramus originates in the foramen before exiting to traverse the transverse process. These nerves are difficult to differentiate from furcal nerves arising from the spinal nerves. Palpating the nerve using local anesthesia can sometimes demonstrate a pain response, but not always, depending on the level of sedation and anesthetic use.
Clinical Relevance
Endoscopically guided facet rhizotomy provides more consistent ablation of the medial and lateral branches of the lumbar dorsal ramus compared to radiographically guided pulsed radiofrequency. The variations in the location of facet innervation can explain the variability of clinical results in fluoroscopically guided RF lesioning. This observation dictates a need for visually guided MIS procedure for best results.
PMCID: PMC4325504
Endoscopic; rhizotomy; visualization
3.  Comparison of Ultrasonography- and Fluoroscopy-Guided Facet Joint Block in the Lumbar Spine 
Asian Spine Journal  2010;4(1):15-22.
Study Design
Retrospective study.
Facet joint block is performed for diagnostic or therapeutic purposes and generally carried out under computerd tomography (CT) or radiologic fluoroscopy guidance. Ultrasonography-guided facet block has recently been attempted. So, we compared the results of ultrasonography-guided facet joint block with the results of fluoroscopy-guided facet joint block.
Overview of Literature
Because fluoroscopic or CT guided facet joint block has been reported side effects, we performed spinal facet block using a fluoroscopy-guided method.
We selected 133 patients who had lumbar pain or referred pain. They were diagnosed as having spinal stenosis and hospitalized from January 2008 to June 2008. As the subjects, we selected 105 patients who had been follow-up for more than 6 months and carried out a prospective study.
Twenty six subjects were male and 25 were female in the fluoroscopy group (group 1) and their mean age was 56.1 years (range, 45 to 79 years). Twenty one were male and 33 were female in the ultrasonography-guided group (group 2). Their mean age was 58.3 years (range, 47 to 83 years). We studied the average time of the procedures, complications, the difference of the therapeutic cost between the two groups. We also evaluated the visual analogue scale (VAS) score and the Oswestry disability index.
The procedure in group 2 averaged 4 minutes and 25 seconds, and in group 1, 4 minutes and 7 seconds. The coast was an average of 38,000 won in group 2 and 25,000 won in group 1. The VAS score was improved from an average of 7.5 (range, 5 to 9) to 2.8 (range, 2 to 6) in group 2 and from 7.8 (range, 4 to 10) to 2.7 (range, 2 to 5) in group 1. The Oswestry disability index was improved from an average of 32.3 (range, 28 to 41) to 23.5 (range, 17 to 26) in group 2 and from 34.2 (range, 29 to 43) to 24.8 (range, 18 to 28) in group 1. As for complications, worsening of lumbar pain, paresthesia, headache and allergic reaction were detected in 5 cases of group 2 and in 3 of group 1. Those symptoms were improved within several hours. One case of superficial infection that developed in group 2 was improved within several days.
We should consider that ultrasonography-guided facet joint block is a minimal invasive procedure that is easily carried out without radiation exposure.
PMCID: PMC2900164  PMID: 20622950
Lumbar pain; Ultrasonography; Facet joint block
4.  Image-guided lumbar facet joint infiltration in nonradicular low back pain 
To assess the efficacy of facet joint infiltrations for pain relief in 44 selected patients with chronic nonradicular low back pain (LBP).
Materials and Methods:
Forty-four patients with chronic LBP of more than 3 months' duration were selected for facet joint infiltration. The majority (n = 24) had facetal pain with no evidence of significant facetal arthropathy on imaging. Fifteen patients had radiological evidence of facetal arthropathy, one had a facet joint synovial cyst, three were post–lumbar surgery patients, and two patients had spondylolysis. Facet joint injections were carried out under fluoroscopic guidance in 39 patients and under CT guidance in 5 cases. Pain relief was assessed using the visual analog scale at 1 h post-procedure and, thereafter, at 1, 4, 12, and 24 weeks.
A total of 141 facet joints were infiltrated in 44 patients over a 2-year period. There was significant pain relief in 81.8% patients 1 h after the procedure, in 86.3% after 1 week, in 93.3% after 4 weeks, in 85.7% after 12 weeks, and in 62.5% after 24 weeks. No major complications were encountered.
Facet nerve block was found to be a simple, minimally invasive, and safe procedure. With meticulous patient selection, we achieved long-term success rates of over 60%. We conclude that this method represents an important alternative treatment for nonradicular back pain.
PMCID: PMC2747413  PMID: 19774136
Facetal arthropathy; facetal infiltrations; low back pain
5.  A novel radiographic targeting guide for percutaneous placement of transfacet screws in the cervical spine with limited fluoroscopy: A cadaveric feasibility study 
We describe a technique for percutaneous transfacet screw placement in the cervical spine without the need for lateral-view fluoroscopy.
Previously established articular pillar morphometry was used to define the ideal trajectory for transfacet screw placement in the subaxial cervical spine. A unique targeting guide was developed to allow placement of Kirschner wires across the facet joint at 90° without the guidance of lateral-view fluoroscopy. Kirschner wires and cannulated screws were placed percutaneously in 7 cadaveric specimens. Placement of instrumentation was performed entirely under modified anteroposterior-view fluoroscopy. All specimens were assessed for acceptable screw placement by 2 fellowship-trained orthopaedic spine surgeons using computed tomography. Open dissection was used to confirm radiographic interpretation. Acceptable placement was defined as a screw crossing the facet joint, achieving purchase in the inferior and superior articular processes, and not violating critical structures. Malposition was defined as a violation of the transverse foramen, spinal canal, or nerve root or inadequate fixation.
A total of 48 screws were placed. Placement of 45 screws was acceptable. The 3 instances of screw malposition included a facet fracture, a facet distraction, and a C6-7 screw contacting the C7 nerve root in a specimen with a small C7 superior articular process.
Our data show that with the appropriate radiographic technique and a targeting guide, percutaneous transfacet screws can be safely placed at C3-7 without the need for lateral-view fluoroscopy during the targeting phase. Because of the variable morphometry of the C7 lateral mass, however, care must be taken when placing a transfacet screw at C6-7.
Clinical Relevance
This study describes a technique that has the potential to provide a less invasive strategy for posterior instrumentation of the cervical spine. Further investigation is needed before this technique can be applied clinically.
PMCID: PMC4300881
Transfacet screws; Cervical spine; Radiographic targeting guide; Minimally invasive surgery of the spine
6.  Ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in oral and maxillofacial surgery 
Dentomaxillofacial Radiology  2013;42(2):29945724.
We examined the application of an ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in patients undergoing oral and maxillofacial surgery.
A total of 19 patients receiving ultrasound-guided combined intermediate and deep cervical plexus anaesthesia followed by neck surgery were examined prospectively. The sternocleidomastoid and the levator of the scapula muscles as well as the cervical transverse processes were used as easily depicted ultrasound landmarks for the injection of local anaesthetics. Under ultrasound guidance, a needle was advanced in the fascial band between the sternocleidomastoid and the levator of the scapula muscles and 15 ml of ropivacaine 0.75% was injected. Afterwards, the needle was advanced between the levator of the scapula and the hyperechoic contour of the cervical transverse processes and a further 15 ml of ropivacaine 0.75% was injected. The sensory block of the cervical nerve plexus, the analgesic efficacy of the block within 24 h after injection and potential block-related complications were assessed.
All patients showed a complete cervical plexus nerve block. No patient required analgesics within the first 24 h after anaesthesia. Two cases of blood aspiration were recorded. No further cervical plexus block-related complications were observed.
Ultrasound-guided combined intermediate and deep cervical plexus block is a feasible, effective and safe method for oral and maxillofacial surgical procedures.
PMCID: PMC3699012  PMID: 22933534
cervical plexus; interventional ultrasonography; nerve block
7.  Evaluation of Pulsed Radiofrequency Denervation in the Treatment of Chronic Facetjoint Pain: An Observational Study 
Anesthesiology and Pain Medicine  2012;1(3):168-173.
Low back disorder is the most common problem in the entire spinal axis. About two-thirds of adults suffer from low back pain (LBP) at some time. Pain generators in the lumbar spine include the annulus of the disc, the posterior longitudinal ligament, a portion of the dural membrane, the facet joints, the spinal nerve roots and ganglia, and the associated paravertebral muscle fascia. There is no doubt that the facet joint is a potential source of chronic LBP. Facet joints are true synovial joints that have a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. If conservative measures fail in the treatment of facet joint pain, pulsed radiofrequency (PRF) of the medial branches can be administered.
The aim of this observational study was to evaluate the efficacy of PRF in the treatment of lumbar chronic facet joint pain.
Patients and Methods:
In this prospective observational study, we selected 300 patients who suffered from lumbar facet joint pain, were referred to the Pain Therapy Department, and underwent PRF treatment of the lumbar medial branches. We analyzed patients with facet joint pain that was unresponsive to conventional treatment, with a positive response to diagnostic medial branch block, who underwent PRF of the lumbar area for 18 months at San Giovanni Hospital of Rome.
Three hundred patients were eligible for the study. After 1 month, 62% of patients (186 patients) reported good pain relief [95% confidence interval (CI) 0.53, 0.7]; 8.6% (26 patients) reported excellent pain relief (95% CI 0.07-0.09); 20. 4% (61 patients) reported poor pain relief (95% CI 0.18-0.22), and 9% (27 patients) reported no pain relief (95% CI 0.08-0.099). The average pain numeric rating scale (NRS) score before the procedure was 6 (range 4-9), decreasing to 2 after the procedure (range 0-4). SF-36 physical and mental parameters improved significantly after the treatment [≥ 1 standard deviation (SD)]. Results after 6 months were similar to those obtained after 1 month.
This study suggests that PRF treatment of the lumbar medial branches provides good pain relief for at least 6 months in 70% of patients who suffer from lumbar facet joint pain.
PMCID: PMC4018694  PMID: 24904787
Low Back Pain; Osteoarthritis; Pulsed Radiofrequency Treatment
8.  Ultrasound-guided rectus sheath block in children with umbilical hernia: Case series 
Saudi Journal of Anaesthesia  2013;7(4):432-435.
Umbilical hernia repair, a common day-case surgery procedure in children, is associated with a significant postoperative pain. The most popular peripheral nerve blocks used in umbilical hernia repair are rectus sheath infiltration and caudal block. The rectus sheath block may offer improved pain relief following umbilical hernia repair with no undesired effects such as lower limb motor weakness or urinary retention seen with caudal block which might delay discharge from the hospital. Ultrasound guidance of peripheral nerve blocks has reduced the number of complications and improved the quality of blocks. The aim of this case series is to assess the post rectus sheath block pain relief in pediatric patients coming for umbilical surgery.
Twenty two (22) children (age range: 1.5-8 years) scheduled for umbilical hernia repair were included in the study. Following the induction of general anesthesia, the ultrasonographic anatomy of the umbilical region was studied with a 5-16 MHz 50 mm linear probe. An ultrasound-guided posterior rectus sheath block of both rectus abdominis muscles (RMs) was performed (total of 44 punctures). An in-plain technique using Stimuplex A insulated facet tip needle 22G 50mm. Surgical conditions, intraoperative hemodynamic parameters, and postoperative analgesia by means of the modified CHEOPS scale were evaluated.
ultrasonograghic visualization of the posterior sheath was possible in all patients. The ultrasound guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia except for one patient who postoperatively required morphine 0.1 mg/kg intravenously. There were no complications.
Ultrasound guidance enables performances of an effective rectus sheath block for umbilical hernia. Use of the Stimuplex A insulated facet tip needle 22G 50mm provides easy, less traumatic skin and rectus muscle penetration and satisfactory needle visualiza.
PMCID: PMC3858695  PMID: 24348296
Anesthesia; analgesia; anesthetic techniques; peripheral nerve block; postoperative; regional; rectus sheath block; surgery; umbilical hernia; ultrasonography; umbilical
9.  Magnetic resonance-guided focused ultrasound treatment of facet joint pain: summary of preclinical phase 
Study design
A phantom experiment, two thermocouple experiments, three in vivo pig experiments, and a simulated treatment on a healthy human volunteer were conducted to test the feasibility, safety, and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) for treating facet joint pain.
The goal of the current study was to develop a novel method for accurate and safe noninvasive facet joint ablation using MRgFUS.
Summary of background data
Facet joints are a common source of chronic back pain. Direct facet joint interventions include medial branch nerve ablation and intra-articular injections, which are widely used, but limited in the short and long term. MRgFUS is a breakthrough technology that enables accurate delivery of high-intensity focused ultrasound energy to create a localized temperature rise for tissue ablation, using MR guidance for treatment planning and real-time feedback.
We validated the feasibility, safety, and efficacy of MRgFUS for facet joint ablation using the ExAblate 2000® System (InSightec Ltd., Tirat Carmel, Israel) and confirmed the system's ability to ablate the edge of the facet joint and all terminal nerves innervating the joint. A phantom experiment, two thermocouple experiments, three in vivo pig experiments, and a simulated treatment on a healthy human volunteer were conducted.
The experiments showed that targeting the facet joint with energies of 150–450 J provides controlled and accurate heating at the facet joint edge without penetration to the vertebral body, spinal canal, or root foramina. Treating with reduced diameter of the acoustic beam is recommended since a narrower beam improves access to the targeted areas.
MRgFUS can safely and effectively target and ablate the facet joint. These results are highly significant, given that this is the first study to demonstrate the potential of MRgFUS to treat facet joint pain.
PMCID: PMC4036610  PMID: 24921048
Chronic back pain; Facet joints; MRgFUS; Pain palliation
10.  Reduction of radiation dose during facet joint injection using the new image guidance system SabreSource™: a prospective study in 60 patients 
European Spine Journal  2008;18(4):546-553.
Interventional procedures are associated with high radiation doses for both patients and surgeons. To reduce the risk from ionizing radiation, it is essential to minimize radiation dose. This prospective study was performed to evaluate the effectiveness in reducing radiation dose during facet joint injection in the lumbar spine and to evaluate the feasibility and possibilities of the new real time image guidance system SabreSource™. A total of 60 patients, treated with a standardized injection therapy of the facet joints L4–L5 or L5–S1, were included in this study. A total of 30 patients were treated by fluoroscopy guidance alone, the following 30 patients were treated using the new SabreSource™ system. Thus a total of 120 injections to the facet joints were performed. Pain, according to the visual analogue scale (VAS), was documented before and 6 h after the intervention. Radiation dose, time of radiation and the number of exposures needed to place the needle were recorded. No significant differences concerning age (mean age 60.5 years, range 51–69), body mass index (mean BMI 26.2, range 22.2–29.9) and preoperative pain (VAS 7.9, range 6–10) were found between the two groups. There was no difference in pain reduction between the two groups (60 vs. 61.5%; P = 0.001) but the radiation dose was significantly smaller with the new SabreSource™ system (reduction of radiation dose 32.7%, P = 0.01; reduction of mean entrance surface dose 32.3%, P = 0.01). The SabreSource™ System significantly reduced the radiation dose received during the injection therapy of the lumbar facet joints. With minimal effort for the setup at the beginning of a session, the system is easy to handle and can be helpful for other injection therapies (e.g. nerve root block therapies).
PMCID: PMC2899461  PMID: 19082641
Facet joint injection; Radiation dose; Navigation; Fluoroscopy-guided; Low back pain
11.  Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report 
Korean Journal of Family Medicine  2013;34(2):152-155.
Thoracolumbar junction syndrome is characterized by referred pain which may originate at the thoracolumbar junction, which extends from 12th thoracic vertebra to 2nd lumbar vertebra, due to functional abnormalities. Clinical manifestations include back pain, pseudo-visceral pain and pseudo-pain on the posterior iliac crest, as well as irritable bowel symptoms. During clinical examination, pain can be demonstrated by applying pressure on the facet joints or to the sides of the spinous processes. Radiological studies show only mild and insignificant degenerative changes in most cases. We report a 42-year-old female patient with osteogenesis imperfecta who suffered from chronic low back pain. Under the diagnosis of thoracolumbar junction syndrome, she was treated with an epidural block and a sympathetic nerve block, which improved her symptoms.
PMCID: PMC3611104  PMID: 23560215
Vertebrae; Thoracic; Lumbar; Back Pain; Iliac
12.  Ultrasound-Guided Greater Occipital Nerve Blocks and Pulsed Radiofrequency Ablation for Diagnosis and Treatment of Occipital Neuralgia 
Anesthesiology and Pain Medicine  2013;3(2):256-259.
Occipital neuralgia is a condition manifested by chronic occipital headaches and is thought to be caused by irritation or trauma to the greater occipital nerve (GON). Treatment for occipital neuralgia includes medications, nerve blocks, and pulsed radiofrequency ablation (PRFA). Landmark-guided GON blocks are the mainstay in both the diagnosis and treatment of occipital neuralgia. Ultrasound is being utilized more and more in the chronic pain clinic to guide needle advancement when performing procedures; however, there are no reports of ultrasound used to guide a diagnostic block or PRFA of the GON. We report two cases in which ultrasound was used to guide diagnostic greater occipital nerve blocks and greater occipital nerve pulsed radiofrequency ablation for treatment of occipital neuralgia. Two patients with occipital headaches are presented. In Case 1, ultrasound was used to guide diagnostic blocks of the greater occipital nerves. In Case 2, ultrasound was utilized to guide placement of radiofrequency probes for pulsed radiofrequency ablation of the greater occipital nerves. Both patients reported immediate, significant pain relief, with continued pain relief for several months. Further study is needed to examine any difference in outcomes or morbidity between the traditional landmark method versus ultrasound-guided blocks and pulsed radiofrequency ablation of the greater occipital nerves.
PMCID: PMC3833045  PMID: 24282778
Pulsed Radiofrequency Treatment; Headache Disorders; Pain; Ultrasonography; Nerve Block
13.  The Efficacy of Repeated Radiofrequency Medial Branch Neurotomy for Lumbar Facet Syndrome 
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.
PMCID: PMC2966726  PMID: 21082052
Facet syndrome; Zygapophyseal joint denervation; Radiofrequency neurotomy; Repeat operation; Outcome
14.  Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? 
International Orthopaedics  2013;37(5):865-870.
The purpose of this study was to assess the value of SPECT/CT imaging in patients with chronic spinal pain.
This was a retrospective consecutive study. Patients with chronic neck or back pain from outpatient spinal clinics with clinical features raising the possibility of a facetogenic pain generator and non-conclusive MRI/CT findings were included. Imaging was performed on a dual-headed, hybrid SPECT/CT γ-camera with a low-dose CT transmission scan acquired after the SPECT study. SPECT/CT studies were viewed in the coronal, axial, and sagittal planes and in 3-dimensional mode. Descriptive statistical analysis was performed.
Seventy-two patients were included (37 females, 35 males, mean age of 53.9 years). There were 25 cervical spine scans and 49 lumbar spine scans. In the cervical spine group, 13 (52 %) patients had scintigraphically active cervical facet joint arthropathy and ten (36 %) had other pathology identified. Two thirds of patients diagnosed with facet joint arthropathy received steroid guided injections following their scans. In the lumbar spine group 34 (69.4 %) patients had scintigraphically active lumbar facet joint arthropathy and eight had other pathology identified. Twenty patients (58.8 %) diagnosed with facet joint arthropathy subsequently received steroid guided injections.
Hybrid SPECT/CT imaging identified potential pain generators in 92 % of cervical spine scans and 86 % of lumbar spine scans. The scan precisely localised SPECT positive facet joint targets in 65 % of the referral population and a clinical decision to inject was made in 60 % of these cases.
PMCID: PMC3631481  PMID: 23412368
15.  Minimal access direct spondylolysis repair using a pedicle screw-rod system: a case series 
Symptomatic spondylolysis is always challenging to treat because the pars defect causing the instability needs to be stabilized while segmental fusion needs to be avoided. Direct repair of the pars defect is ideal in cases of spondylolysis in which posterior decompression is not necessary. We report clinical results using segmental pedicle-screw-rod fixation with bone grafting in patients with symptomatic spondylolysis, a modification of a technique first reported by Tokuhashi and Matsuzaki in 1996. We also describe the surgical technique, assess the fusion and analyze the outcomes of patients.
Case presentation
At Cairo University Hospital, eight out of twelve Egyptian patients’ acute pars fractures healed after conservative management. Of those, two young male patients underwent an operative procedure for chronic low back pain secondary to pars defect. Case one was a 25-year-old Egyptian man who presented with a one-year history of axial low back pain, not radiating to the lower limbs, after falling from height. Case two was a 29-year-old Egyptian man who presented with a one-year history of axial low back pain and a one-year history of mild claudication and infrequent radiation to the leg, never below the knee. Utilizing a standardized mini-access fluoroscopically-guided surgical protocol, fixation was established with two titanium pedicle screws place into both pedicles, at the same level as the pars defect, without violating the facet joint. The cleaned pars defect was grafted; a curved titanium rod was then passed under the base of the spinous process of the affected vertebra, bridging the loose fragment, and attached to the pedicle screw heads, to uplift the spinal process, followed by compression of the defect. The patients were discharged three days after the procedure, with successful fusion at one-year follow-up. No rod breakage or implant-related complications were reported.
Where there is no evidence of frank spondylolisthesis or displacement and pain does not radiate below the knee, we recommend direct repair of the pars interarticularis fracture, especially in young active adults. We describe a modified form of the Buck screw procedure with a minimally invasive, image-guided method of pars interarticularis fixation. The use of image guidance simplifies the otherwise difficult visualization required for pars interarticularis screw placement and allows minimal skin and muscle dissection, which may translate into a more rapid postoperative recovery.
PMCID: PMC3514323  PMID: 23176068
16.  Double insurance transfacetal screws for lumbar spinal stabilization 
The authors report experience with 14 cases where two screws or “double insurance” screws were used for transfacetal fixation of each joint for stabilization of the lumbar spinal segment. The anatomical subtleties of the technique of insertion of screws are elaborated.
Materials and Methods:
During the period March 2011 to June 2014, 14 patients having lumbar spinal segmental instability related to lumbar canal stenosis were treated by insertion of two screws into each articular assembly by transfacetal technique. After a wide surgical exposure, the articular cartilage was denuded and bone chips were impacted into the joint cavity. For screw insertion in an appropriate angulation, the spinous process was sectioned at its base. The screws (2.8 mm in diameter and 18 mm in length) were inserted into the substance of the medial or inferior articular facet of the rostral vertebra via the lateral limit of the lamina approximately 6–8 mm away from the edge of the articular cavity. The screws were inserted 3 mm below the superior edge and 5 mm above the inferior edge of the medial (inferior) facets and directed laterally and traversed through the articular cavity into the lateral (superior) articular facet of the caudal vertebra toward and into the region of junction of base of transverse process and of the pedicle. During the period of follow-up all treated spinal levels showed firm bone fusion. There was no complication related to insertion of the screws. There was no incidence of screw misplacement, displacementor implant rejection.
Screw insertion into the firm and largely cortical bones of facets of lumbar spine can provide robust fixation and firm stabilization of the spinal segment. The large size of the facets provides an opportunity to insert two screws at each spinal segment. The firm and cortical bone material and absence on any neural or vascular structure in the course of the screw traverse provides strength and safety to the process.
PMCID: PMC4158636  PMID: 25210338
Facets; lumbar canal stenosis; lumbar instability; transfacetal screws
17.  The Effects of Lumbar Facet Dowels on Joint Stiffness: A Biomechanical Study 
The Ochsner Journal  2014;14(1):44-50.
Facet joint arthrosis may play a significant role in low back pain generation. The placement of facet dowels is a percutaneous treatment that aims to fuse the facets and increase joint stiffness. In this cadaveric study, we evaluated spine stiffness after facet dowel insertion in combination with several surgical procedures and determined which motions promote dowel migration.
Six fresh frozen lumbar spines were tested in flexion-extension, lateral bending, and axial rotation. Spine stiffness was determined for the intact specimens, after L4 laminectomy, and after bilateral L4-L5 facet dowel placement, respectively. One specimen underwent a unilateral transforaminal lumbar interbody fusion (TLIF) construct and another underwent extreme lateral interbody fusion (XLIF) graft (22 mm) placement, followed by placement of facet dowels. Afterwards, the specimens were subjected to 10,000 cycles of fatigue testing in flexion-extension or axial rotation.
The overall decrease in stiffness after laminectomy was 4.6%. Facet dowel placement increased overall stiffness by 7.2%. The greatest increase was seen with axial rotation (13%), compared to flexion, extension, and lateral bending (9.5%, 2.3%, and 5.6%, respectively). The TLIF and XLIF plus dowel construct increased specimen stiffness to 266% and 163% of baseline, respectively. After fatigue testing, dowel migration was detected by computed tomography in the 2 uninstrumented specimens undergoing axial rotation cycling.
Facet dowels increase the stiffness of the motion segment to which they are applied and can be used in conjunction with laminectomy procedures to increase the stiffness of the joint. However, dowel migration can occur after axial rotation movements. Hybrid TLIF or XLIF plus facet dowel constructs have significantly higher stiffness than noninstrumented ones and may prevent dowel migration.
PMCID: PMC3963051  PMID: 24688332
Biomechanics; foreign-body migration; instrumentation; laminectomy; low back pain; lumbar vertebrae; surgical procedures–minimally invasive
18.  Ultrasound and electrical nerve stimulation-guided S1 nerve root block 
Journal of Anesthesia  2013;27(5):775-777.
A selective lumbosacral nerve root block is generally is performed under X-ray fluoroscopy, which has the disadvantage of radiation exposure and the need for fluoroscopy equipment. In this study, we assessed the effectiveness of ultrasound and nerve stimulation-guided S1 nerve root block on 37 patients with S1 radicular syndrome. With the patient in a prone position, an ultrasound scan was performed by placing the probe parallel to the body axis. The needle was pointed slightly medial from the lateral side of the probe and advanced toward a hyperechoic area in the sacral foramina with ultrasound guidance. Contrast medium was then injected and its dispersion confirmed by fluoroscopy. The acquired contrast images were classified into intraneural, perineural, and paraneural patterns. The significance of differences in the effect of the block among the contrast image patterns was analyzed. After nerve block, decreased sensation at the S1 innervated region and pain relief was achieved in all patients. No significant difference was noted in the effect of the block between perineural and paraneural patterns. In conclusion, this technique provided reliable S1 nerve root block in patients with S1 radicular syndrome and minimized radiation exposure.
PMCID: PMC3825138  PMID: 23494676
Ultrasound; Nerve stimulation; Nerve root block
19.  Feasibility of Nerve Stimulator as a Supplemental Aid for Lumbar Transforaminal Epidural Block 
Clinics in Orthopedic Surgery  2014;6(3):324-328.
The purpose of this study was to evaluate the clinical feasibility of an electric nerve stimulator in a lumbar transforaminal epidural block.
Using an electric nerve stimulator, transforaminal epidural blocks were performed in 105 segments of 49 patients who presented with lower back pain with radiating pain to lower extremities. The contrast medium was injected to delineate the nerve root after positioning an insulated needle at the intervertebral foramen under fluoroscopic guidance. Then, the nerve root was electrically stimulated with the insulated needle to confirm whether or not the same radiating pain was evoked.
Of the 105 foraminal segments, the same radiating pain was evoked at 0.5 mAh in 47 segments (44.8%), at 1.0 mAh in 22 (21.0%), at 1.5 mAh in 3 (2.9%), at 2.0 mAh in 15 (14.3%), at 2.5 mAh in 4 (3.8%), and at 3.0 mAh in 5 (4.8%). No response was observed in 9 segments (8.6%). The fluoroscopy revealed successful positioning of the needle in the patients with an evoked radiating pain over 2.0 mAh. The visual analogue scale (VAS) obtained for pain improved from a mean of 7.5 to 2.7 after the block (p = 0.001). In the 9 cases without response to electrical stimulation, the patients showed an improvement on VAS from 7.8 to 3.4 (p= 0.008) also.
A nerve stimulator can help to predict the accuracy of needle positioning as a supplemental aid for a successful lumbar transforaminal epidural block. It is sufficient to initiate a proper stimulation amplitude of the nerve at 2 mAh.
PMCID: PMC4143521  PMID: 25177459
Lumbar; Transforaminal epidural block; Electric nerve stimulator
20.  Evaluation of Lumbar Facet Joint Nerve Blocks in Managing Chronic Low Back Pain: A Randomized, Double-Blind, Controlled Trial with a 2-Year Follow-Up 
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.
PMCID: PMC2880841  PMID: 20567613
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
21.  Ultrasound-Guided (Needle In-Plane) Perineural Catheter Insertion: The Effect of Catheter Insertion Distance on Postoperative Analgesia 
When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle-in plane and nerve in short-axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to-nerve contact during the subsequent perineural infusion, leading to inferior analgesia. While a potential solution may appear obvious—advancing the catheter tip only to the tip of the needle, leaving the catheter tip at the target nerve—this technique has not been prospectively evaluated. We therefore hypothesized that during needle in-plane ultrasound-guided perineural catheter placement, inserting the catheter a minimum distance (0-1 cm) past the needle tip is associated with improved postoperative analgesia compared with inserting the catheter a more-traditional 5-6 cm past the needle tip.
Preoperatively, subjects received a popliteal-sciatic perineural catheter for foot or ankle surgery using ultrasound guidance exclusively. Subjects were randomly assigned to have a single-orifice, flexible catheter inserted either 0-1 (n=50) or 5-6 cm (n=50) past the needle tip. All subjects received a single-injection mepivacaine (40 mL of 1.5% with epinephrine) nerve block via the needle, followed by catheter insertion and a ropivacaine 0.2% infusion (basal 6 mL/h, bolus 4 mL, 30 min lockout), through at least the day following surgery. The primary end point was average surgical pain as measured with a 0-10 numeric rating scale the day following surgery. Secondary end points included time for catheter insertion, incidence of catheter dislodgement, maximum (“worst”) pain scores, opioid requirements, fluid leakage at the catheter site, and the subjective degree of an insensate extremity.
Average pain scores the day following surgery for subjects of the 0-1 cm group was a median (interquartile) of 2.5 (0.0-5.0), compared with 2.0 (0.0-4.0) for subjects of the 5-6 cm group (p=0.42). Similarly, among the secondary end points, no statistically significant differences were found between the two treatment groups. There was a trend of more catheter dislodgements in the minimum-insertion group (5 vs. 1; p=0.20).
This study did not find evidence to support the hypothesis that for popliteal-sciatic perineural catheters placed using ultrasound guidance and a needle in-plane technique, inserting the catheter a minimum distance (0-1 cm) past the needle tip improves (or worsens) postoperative analgesia compared with inserting the catheter a more-traditional distance (5-6 cm). Caution is warranted if extrapolating these results to other catheter designs, ultrasound approaches, or anatomic insertion sites.
PMCID: PMC3085850  PMID: 21519311
22.  In Vivo Measurement of Lumbar Facet Joint Area in Asymptomatic and Chronic Low Back Pain Subjects 
Spine  2010;35(8):924-928.
Study Design
In vivo measurement of lumbar facet joint surface area.
To investigate lumbar facet joint surface area in relation to age and the presence of chronic low back pain.
Summary of Background Data
Facet joint surface area is an important parameter for understanding facet joint function and pathology, but information on the lumbar facet joint is limited especially in relation with age and low back pain symptoms.
In vivo measurements of the lumbar facet joints (L3/L4-L5/S1) were performed on 90 volunteers (57 asymptomatic subjects, 33 chronic low back pain subjects) using subject-based three-dimensional facet joint surface CT models.
The facet joint surface area increased significantly at each successive inferior level. In the low back pain subjects over 40 years old, both superior and inferior facet surface areas increased except superior facets at L5/S1 compared to younger subjects. In the asymptomatic subjects over 40 years old, only the superior facets showed an increase in the L3/4 facet surface area compared to younger subjects.
The lumbar facet areas measured in vivo in the current study were similar to previous cadaveric studies. The lumbar facet area was significantly greater at the inferior lumbar levels and also increased with age. This age related increase in the facet joint surface was observed more in the low back pain subjects compared to asymptomatic subjects. The increase in the area of the facet joint surface is probably secondary to increased load-bearing in the lower lumbar segments and facet joint osteoarthritis.
PMCID: PMC2855783  PMID: 20354471
23.  The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration 
Surgical Neurology International  2012;3(Suppl 3):S157-S166.
The surgical management of lumbar synovial cysts that have extruded into the spinal canal remains controversial (e.g. decompression with/without fusion).
The neurological presentation, anatomy, pathophysiology, and surgical challenges posed by synovial cysts in the lumbar spine are well known. Neurological complaints typically include unilateral or, more rarely, bilateral radicular complaints, and/or cauda equina syndromes. Anatomically, synovial cysts constitute cystic dilatations of synovial sheaths that directly extrude from facet joints into the spinal canal. Pathophysiologically, these cysts reflect disruption of the facet joints often with accompanying instability, and potentially compromise both the cephalad and caudad nerve roots.
Aspiration of lumbar synovial cysts, which are typically gelatinous and non-aspirable, and typically performed by “pain specialists” (e.g. pain management, rehabilitation, radiologists, others) utilizing fluoroscopy or CT-guided aspiration, is associated with 50–100% failure rates. Surgical decompression with/without fusion (as the issue regarding fusion remains unsettled) results in the resolution of back and radicular pain in 91.6–92.5% and 91.1–91.9% of cases, respectively.
After a thorough review of the literature, it appears that the treatment with the best outcome for patients with synovial cysts is cyst removal utilizing surgical decompression; the need for attendant fusion remains unsettled. The use of an alternative treatment, percutaneous aspiration of cysts, appears to have a much higher recurrence and failure rate, but may be followed by surgery if warranted.
PMCID: PMC3422091  PMID: 22905322
Decompression; extruded lumbar synovial cysts; failed aspiration; failed techniques; fusion
24.  Paraspinal Abscess Communicated with Epidural Abscess after Extra-Articular Facet Joint Injection 
Yonsei Medical Journal  2007;48(4):711-714.
Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 × 109 per liter, an erythrocyte sedimentation rate of 52mm/hour, and 10.88mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.
PMCID: PMC2628056  PMID: 17722247
Complication; infection; injection; facet joint
25.  A New Anterior Approach for Fluoroscopy-guided Suprascapular Nerve Block - A Preliminary Report - 
The Korean Journal of Pain  2012;25(3):168-172.
The aim of the study was to investigate the feasibility of fluoroscopy-guided anterior approach for suprascapular nerve block (SSNB).
Twenty patients with chronic shoulder pain were included in the study. All of the nerve blocks were performed with patients in a supine position. Fluoroscopy was tilted medially to obtain the best view of the scapular notch (medial angle) and caudally to put the base of coracoid process and scapular spine on same line (caudal angle). SSNB was performed by introducing a 100-mm, 21-gauge needle to the scapular notch with tunnel view technique. Following negative aspiration, 1.0 ml of contrast was injected to confirm the scapular notch, and 1 % mepivacaine 2 ml was slowly injected. The success of SSNB was assessed by numerical rating scale (NRS) before and after the block.
The average NRS was decreased from 4.8 ± 0.6 to 0.6 ± 0.5 after the procedure (P < 0.05). The best view of the scapular notch was obtained in a medial angle of 15.1 ± 2.2 (11-19°) and a caudal angle of 15.4 ± 1.7° (12-18°). The average distance from the skin to the scapular notch was 5.8 ± 0.6 cm. None of the complications such as pneumothorax, intravascular injection, and hematoma formation was found except one case of partial brachial plexus block.
SSNB by fluoroscopy-guided anterior approach is a feasible technique. The advantage of using a fluoroscopy resulted in an effective block with a small dose of local anesthetics by an accurate placement of a tip of needle in the scapular notch while avoiding pneumothorax.
PMCID: PMC3389321  PMID: 22787547
contrast media; fluoroscopy; nerve block; shoulder pain

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