Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks

Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us

BACKGROUND CONTEXT

The prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.

PURPOSE

This article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.

STUDY DESIGN

Review article.

METHODS

Extensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.

RESULTS

Fluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective. Intraarticular sacroiliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.

CONCLUSIONS

The prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.

Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates

STUDY DESIGN

A case-control study of older adults with and without chronic low back pain (CLBP).

OBJECTIVE

Compare and describe the radiographic severity of degenerative disc and facet disease in the lumbosacral spine of community-dwelling older adults with and without CLBP and to examine the relationship between spinal pathology and pain.

SUMMARY OF BACKGROUND DATA

Degenerative spinal pathology is often implicated as the primary reason for CLBP in older adults. Despite evidence that spinal pathology may be ubiquitous in older adults regardless of pain status, radiography continues to be heavily used in the diagnostic process.

METHODS

Participants in this case-control study included 162 older adults (> or =65) with CLBP and an age and gender matched pain-free group of 158 people. CLBP was characterized as pain of at least moderate intensity occurring daily or almost everyday for at least 3 months. Radiographic severity of disc and facet disease was graded using a reliable and valid system.

RESULTS

Results demonstrated that the presence of degenerative disc and facet pathology in older adults is ubiquitous, regardless of clinical status, with greater than 90% demonstrating some level of degeneration. Higher radiographic severity scores were associated with the presence of CLBP. In fact, presence of severe disc pathology was associated with 2-fold greater odds of having CLBP. But, radiographic severity of disc and facet disease was not associated with pain severity among those with CLBP.

CONCLUSION

From a research perspective, radiographic evaluation of spinal pathology provides additional information about older adults with CLBP compared to pain-free individuals, but its clinical utility for diagnostic purposes is still in question.

Thoracic costotransverse joint pain patterns: a study in normal volunteers

Background

Pain referral patterns of asymptomatic costotransverse joints have not been established. The objective of this study was to determine the pain referral patterns of asymptomatic costotransverse joints via provocative intra-articular injection.

Methods

Eight asymptomatic male volunteers received a combined total of 21 intra-articular costotransverse joint injections. Fluoroscopic imaging was used to identify and isolate each costotransverse joint and guide placement of a 25 gauge, 2.5 inch spinal needle into the costotransverse joint. Following contrast medium injection, the quality, intensity, and distribution of the resultant pain produced were recorded.

Results

Of the 21 costotransverse joint injections, 16 (76%) were classified as being intra-articular via arthrograms taken at the time of injection, and 14 of these injections produced a pain sensation distinctly different from that of needle placement. Average pain produced was 3.3/10 on a 0–10 verbal pain scale. Pain was described generally as a deep, dull ache, and pressure sensation. Pain patterns were located superficial to the injected joint, with only the right T2 injections showing referred pain 2 segments cranially and caudally. No chest wall, upper extremity or pseudovisceral pains were reported.

Conclusion

This study provides preliminary data of the pain referral patterns of costotransverse joints. Further research is needed to compare these findings with those elicited from symptomatic subjects.

Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up

STUDY DESIGN

A double-blind, randomized, controlled trial.

OBJECTIVE

To determine the clinical effectiveness of therapeutic local anesthetic cervical medial branch blocks with or without steroid in managing chronic neck pain of facet joint origin.

SUMMARY OF BACKGROUND DATA

The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Intra-articular injections, medial branch nerve blocks, and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin.

METHODS

A total of 120 patients were included, with 60 patients in each of the local anesthetic and steroid groups. All the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, and the inclusion criteria. Group I consisted of medial branch blocks with bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Numerical pain scores, Neck Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months, and 12 months.

RESULTS

Significant pain relief (>or=50%) and functional status improvement was observed at 3 months, 6 months, and 12 months in over 83% of patients. The average number of treatments for 1 year was 3.5 +/- 1.0 in the nonsteroid group and 3.4 +/- 0.9 in the steroid group. Duration of average pain relief with each procedure was 14 +/- 6.9 weeks in the nonsteroid group, and it was 16 +/- 7.9 weeks in the steroid group. Significant relief and functional improvement was reported for 46 to 48 weeks in a year.

CONCLUSION

Therapeutic cervical medial branch nerve blocks, with or without steroids, may provide effective management for chronic neck pain of facet joint origin.

The prevalence of facet-joint-related chronic neck pain in postsurgical and nonpostsurgical patients: a comparative evaluation

BACKGROUND

Facet (zygapophysial) joints may be clinically important sources of chronic cervical spinal pain. Previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, and reported an overall prevalence of 36% to 67% facet joint involvement in cervical spinal pain. The reports of lumbar facet joint-involvement in postsurgery syndrome have been shown to be highly variable with prevalence ranging from 8% to 32%. To date, however, the prevalence of postsurgical facet joint-related pain in the cervical spine has not been evaluated. In light of this, the present retrospective study was conducted to assess and compare the prevalence of chronic postsurgical facet joint cervical spinal pain to nonsurgical, chronic cervical facet joint pain.

METHODS

Patients presenting with chronic neck pain were studied. The procedures were performed by a single physician in an interventional pain management ambulatory surgery center. The prevalence of cervical facet joint pain in postsurgical patients was assessed and compared to nonsurgical patients.

RESULTS

A total of 251 patients (45 postsurgery vs. 206 nonsurgical patients) with chronic persistent neck pain were evaluated using controlled, comparative local anesthetic blocks in accordance with IASP criteria. The prevalence of the cervical facet joint pain and false-positive rate of single blocks in postsurgical patients were 36% and 50% compared with 39% and 43% in nonsurgical patients.

CONCLUSIONS

Cervical facet joints are clinically important pain generators in a significant proportion of patients with chronic persistent neck pain after surgical intervention(s). The prevalence of cervical facet joint pain was similar in both postsurgical and nonsurgical patients.