Facet joint syndrome: from diagnosis to interventional management

A new four-area method for evaluating biochemical changes in lumbar facet joint degeneration on T2* mapping

PURPOSE

To investigate the diagnostic efficacy of a new four-area method for evaluating biochemical changes in lumbar facet joint (LFJ) degeneration on T2* mapping.

METHODS

LFJ degeneration was morphologically graded on T2-weighted imaging using the Weishaupt system. T2* value of LFJ was measured on T2* mapping using both all-inclusive and four-area methods. Inter-observer reliability for continuous and categorical variables was evaluated using intraclass correlation coefficient (ICC) and Kappa value, respectively. The correlation between continuous variables and ordered categorical variables was examined using one way ANOVA or Kruskal-Wallis test, as appropriate.

RESULTS

Fifty-eight patients with LBP underwent standard MRI protocols and axial T2* mapping. In all-inclusive method analysis, the median T2* value of grade 0 LFJ (21.32 [18.27, 26.05]) was higher than those of grade I (18.33 [15.47, 22.16], p < 0.001), grade II LFJ (17.99 [15.18, 20.97], p < 0.001), and grade III LFJ (18.29 [15.07, 25.47], p = 0.178). In four-area method analysis, the median T2* value of grade 0 LFJ (21.55 [18.2, 26.72]) was significantly higher than those of grade I (17.94 [15.45, 21.67], p < 0.001), grade II LFJ (17.28 [14.65, 20.38], p < 0.001) and grade III LFJ (18.25 [15.22, 22.41], p = 0.028). A downward trend in T2* value was observed as LFJ degeneration progressed, except for grade III. Additionally, the median T2* values obtained using all-inclusive method were generally higher than those from four-area method, except for grade 0. Four-area method demonstrated excellent inter-observer reliability with ICC of 0.992 ([0.99, 0.993], p < 0.001), higher than that of all-inclusive method (0.942 [0.931, 0.951], p < 0.001).

CONCLUSIONS

Compared to all-inclusive method, four-area method provides higher reproducibility and accuracy in measuring T2* values. Thus, it is a more reliable approach for assessing biochemical changes in LFJ degeneration on T2* mapping.

Image-guided injections for facet joint pain: evidence-based Delphi conjoined consensus paper from the European Society of Musculoskeletal Radiology and European Society of Neuroradiology

OBJECTIVES

To perform a Delphi-based consensus on published evidence on image-guided injections for facet joint pain (FJP) and provide clinical indications.

METHODS

We report the results of an evidence-based Delphi consensus of 38 experts from the European Society of Musculoskeletal Radiology and the European Society of Neuroradiology, who reviewed the published literature for evidence on image-guided injections for FJP. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when ≥ 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the consensus were used to write the paper.

RESULTS

Twenty statements on image-guided FJP treatment have been drafted. Eighteen statements received strong consensus, while two received broad consensus. Three statements reached the highest level of evidence, all of them regarding the lumbar spine. All radiological methods are used for image-guided injections for FJP, and regardless of the radiological method used, all show good safety and efficacy. Facet joint injections and medial branch blocks are used in all spinal regions to treat FJP, and both show similar clinical outcomes. Advanced technological solutions have been studied in the field of lumbar FJP; however, the level of evidence for these is low.

CONCLUSION

Despite promising results reported by published papers on image-guided injections for FJP, there is still a lack of evidence on injection efficacy, appropriateness of imaging methods, and optimal medication.

KEY POINTS

Question Image-guided injections to treat facet joint pain (FJP) are performed throughout the spine; however, the highest level of evidence exists for the lumbar spine. Findings Regardless of the imaging method used, image-guided injections for facet joint pain treatment are safe, with only minor adverse events in rare cases. Clinical relevance All imaging methods are used for injection guidance to treat FJP, each with advantages and disadvantages. These statements on image-guided injections for FJP provide a concise and up to date overview on the topic, serving as a list of clinical indications.

Mechanical Load-Induced Upregulation of Talin2 through Non-Canonical Deubiquitination of OTUB1 Drives Facet Joint Osteoarthritis Pathogenesis

Facet joint osteoarthritis (FJOA) is a prevalent degenerative condition in the aging population; however, the underlying pathophysiological mechanisms remain poorly understood and current therapeutic strategies remain limited to palliative pain management. In this study, novel potential therapeutic targets and prevention paradigms for FJOA are systematically explored. Proteomic screening and validation show that Talin2 is specifically upregulated in FJOA samples. Immunoprecipitation-mass spectrometry, transcriptome RNA sequencing, and bioinformatics simulation analyses, combined with in vitro and in vivo experiments, are conducted to elucidate the molecular mechanism of the role of Talin2 in FJOA. Increased expression levels of Talin2 in FJOA promote the degradation of the extracellular matrix and inhibit its synthesis. Talin2 is found to be stabilized via non-canonical deubiquitination and direct interaction with ovarian tumor domain-containing ubiquitin aldehyde-binding protein 1 (OTUB1). C-C motif ligand 2 (CCL2), an inflammatory chemoattractant, is identified to be a target gene of Talin2. Furthermore, mechanical loading potentiates the Talin2/OTUB1 interaction, resulting in the stabilization of Talin2 and enhances non-canonical deubiquitination. Therefore, Talin2 regulates CCL2 expression and promotes FJOA. Given that Talin2 is stabilized and deubiquitinated by OTUB1, especially under mechanical load, the Talin2/OTUB1 interaction may be a promising therapeutic target for FJOA.

Impact of temperature on the magnitude and duration of relief after lumbar facets medial branch nerves radiofrequency ablation: a randomized double-blinded study

INTRODUCTION

There are numerous studies appraising the variables that may influence the clinical outcomes after lumbar thermal radiofrequency ablation (RFA). Expanding the lesion size may increase the likelihood of capturing the target nerves in the lesion, thereby increasing the technical success rate of RFA. However, our literature search has failed to identify a consensus on the optimal target temperature. A retrospective study demonstrated that there seems to be significant functional improvement associated with the temperature of 90°C compared with 80°C. The authors prospectively studied the subject in a double-blinded randomized fashion.

METHODS

Patients undergoing RFA for lumbar facetogenic pain were randomized in two cohorts (80°C and 90°C). Physicians and patients were blinded to the temperature used. The primary outcome was self-reported pain scores up to 12 months. Secondary outcomes included: self-reported functional improvement, duration of relief as measured by the time before repeat ablation of the same medial branches nerves, opioids' consumption, and patient satisfaction.

RESULTS

Both groups reported pain improvement in all follow-up time points. Overall, both groups achieved statistically significant pain reduction (p<0.05). The median time to repeat RFA in the 80°C group was 112 (49-252) days, while it was 217 (198-348) days in the 90°C group (p<0.04). The univariate analysis emphasized that the RFA temperature is a statistically significant factor for pain improvement of more than 50%, OR 2.7 (1.1 to 6.6) p value=0.031.

CONCLUSION

RFA has been demonstrated as an effective therapeutic modality for lumbar facetogenic back pain. Yet, the several factors involved in determining a favorable outcome of this procedure require further research and optimization. This prospective double-blinded randomized trial demonstrated that RFA at both temperatures (80°C, 90°C) provided significance at all the time periods examined. However, RFA at 90°C was superior to 80°C in regard to the duration of relief.

Does the severity of facet joint osteoarthritis affect facet medial branch radiofrequency thermocoagulation results?

OBJECTIVES

To assess how facet medial branch radiofrequency thermocoagulation (FMB-RFT) outcomes are affected by severe facet joint osteoarthritis (FJO).

METHODS

This retrospective study involved 91 individuals with lumbar facet joint disease-related chronic lower back pain (CLBP), all of whom underwent FMB-RFT. The patients were assigned to 3 groups using the Weishaupt facet grading system (WFGS). Pain scores were assessed prior to treatment, as well as at the 1-, 6-, and 12-month marks.

RESULTS

Based on the WFGS, 38 of the 91 patients were assigned a grade 1 FJO, 28 a grade 2 FJO, and 25 a grade 3 FJO. The percentage of patients in each group who saw a 50% or greater improvement in their pain scores at 1, 6, and 12 months did not differ significantly.

CONCLUSION

For patients with CLBP, FMB-RFT has been shown to be safe and effective in both the short and long terms. The results from FMB-RFT do not seem to be affected by the severity of FJO.

Therapeutic Effectiveness of Lumbar Medial Branch Block and Lumbar Intra-Articular Facet Injections: A Propensity-Matched Cohort Study

BACKGROUND

Chronic low back pain is a prevalent condition that is treated commonly with radiofrequency neurotomy (RFN) after diagnostic targeting with medial branch blocks (MBB) or intra-articular (IA) injection.

PURPOSE

We evaluated the long-term therapeutic value of MBB and IA injection of steroids for relief from chronic low back pain beyond the current diagnostic utility.

METHODS AND OUTCOME MEASURES

This was a retrospective propensity-matched cohort study from a single physician injection census at a tertiary care hospital. A total of 460 patients receiving MBB (n=383) or IA injection (n=77) in 2013-2020 were included. Primary outcome measures were patient-reported outcomes (PROs) at the time of injection, and follow-up at three and six months with the Numerical Rating Scale (NRS), PRO Measurement Information System (PROMIS)-Mental Health (MH), PROMIS-Physical Health (PH), and the Patient Health Questionnaire (PHQ)-9 scores. The same PROs at the one-year follow-up were the secondary outcome measures. Propensity weighting was performed to balance MBB and IA injection groups over several demographic and clinical categories.

RESULTS

Significant improvements in NRS (p=<0.001) were reported at the three-month, six-month, and one-year follow-ups, while significant improvements in PROMIS-PH scores (p=0.015) were identified at three and six months post injection.

CONCLUSIONS

Our results suggest that MBB and IA injection have potential therapeutic benefits for chronic low back pain for at least six months post injection. These results suggest that there is value in these diagnostic modalities therapeutically beyond the acute time frame. These results lay the groundwork for additional investigations into treatment options for patients affected by chronic low back pain.

The Impact of Spinopelvic Alignment on the Facet Joint Degeneration

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

This study aims to evaluate the relations between facet joint degeneration (FD) and sagittal spinopelvic parameters. Second, the association of FD with degenerative disc disease (DDD) and lumbar disc herniations (LDH) was assessed.

METHODS

The radiologic data of 192 patients was retrospectively analyzed. Total, proximal, and distal lumbar lordosis (LL, PLL, and DLL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and sacral table angle (STA) were measured on lumbar x-ray plates. DDD and FD was graded on the MRI images. The apex of lumbar lordosis and PI-LL imbalance were noted in each patient. Correlation analyses were performed.

RESULTS

Age and body mass index (BMI) were correlated with FD. LL and DLL are positively associated with upper-level FDs (L1-2 and L2-3) (P < 0,05). PLL were positively associated with lower level FD (L5-S1) (P < 0,05). A significant increase in PI was associated with FD in L2-3 and L4-5. A larger PT was found in FD in L4. The PI-LL imbalance was not correlated with the FD. Correlation between DDD and LDH and FD was observed in each level (P < 0,01). The level of FD is not affected by the apex of the curve.

CONCLUSION

Age and BMI have a direct impact on FD. However, spinopelvic parameters influence the severity of FD rather than its occurrence. In addition to the effects of lumbar lordosis as a single entity, it is essential to consider separately the effects of proximal and distal lumbar lordosis at the FD level.

Efficacy of Steroid Facet Joint Injections for Axial Spinal Pain and Post Radiofrequency Ablation Neuritis: A Systematic Review

PURPOSE OF REVIEW

Chronic axial spinal pain is a leading cause of disability and healthcare spending in the United States. A common source of axial spinal pain is the facet joint. Current treatments for facet joint-mediated pain include conservative treatments and interventions such as intra-articular facet joint injections (FJI), medial branch blocks (MBB), and radiofrequency ablation (RFA). While facet joint interventions are one of the most common spinal procedures, current scientific literature demonstrates conflicting results regarding the use of corticosteroids in these interventions.

RECENT FINDINGS

A systematic review was conducted to determine the efficacy of local corticosteroid usage in facet joint interventions for treating chronic axial spinal pain. Separate literature searches were performed using PubMed, Google Scholar, Embase, and Cochrane Library to evaluate the use of local corticosteroids in intra-articular FJI, MBB, and for the prevention of post-neurotomy neuritis (PNN). Inclusion criteria included a randomized clinical trial (RCT) or control trial while unique inclusion criteria was used for the differing uses of local corticosteroids. The exclusion criteria for studies included (i) studies written in a non-English language; (ii) articles without full-text access or abstract-only papers; (iii) and studies focused on non-human subjects. Final literature searches were conducted in August 2024. Two studies with 131 patients, four studies with 440 patients, and two studies with 203 patients were selected for the assessment of local corticosteroid use on intra-articular FJI, MBB, and PNN, respectively. A quality assessment tool recommended by The Cochrane Collaboration was used to assess bias risk in included studies. Results were synthesized through a meta-analysis to evaluate intra-articular FJI while a literature analysis was completed to investigate MBB and PNN. This study found that the use of corticosteroid intra-articular FJI and MBB provides significant improvement in pain relief and functionality from baseline for the treatment of lower back pain and chronic axial spinal pain, respectively. However, the use of corticosteroids post-RFA has not been proven to reduce the occurrence of PNN. Limitations to the studies used included blinding bias, absence of placebo groups, subjective inclusion criteria, limited generalizability and small sample sizes.

The trunk segmental motion complexity and balance performance in challenging seated perturbation among individuals with spinal cord injury

BACKGROUND

Motion complexity is necessary for adapting to external changes, but little is known about trunk motion complexity during seated perturbation in individuals with spinal cord injury (SCI). We aimed to investigate changes following SCI in trunk segmental motion complexity across different perturbation directions and how they affect postural control ability in individuals with SCI.

METHODS

A total of 17 individuals with SCI and 18 healthy controls participated in challenging sagittal-seated perturbations with hand protection. Upper arm activation was measured using surface electromyography for trial consistency. Motion complexity parameters, quantified across three degrees of freedom, was assessed using relative angular acceleration from six trunk segments obtained through motion capturing system. Motion performance parameters were assessed using center of pressure (CoP) measurements from a force plate, including settling time, maximum CoP displacement (MD) variability, and steady-state error. Statistical analyses examined group and direction differences, while complexity-performance relationships were evaluated using multiple response least partial squares regression.

RESULTS

Compared to healthy controls, individuals with SCI showed significantly lower motion complexity in the lumbar and upper thoracic segments (approximately10% - 20%), with identical settling time and higher MD variability. Backward perturbations, as opposed to forward perturbations, resulted in reduced complexity in the aforementioned segments and increased steady-state error. Lower lumbar rotation complexity negatively correlated with MD variability (β = -0.240) and steady-state error (β = -0.485) in individuals with SCI, while showing a minor positive correlation with settling time (β = 0.152) during backward perturbation.

CONCLUSION

Simplified motion control in individuals with SCI may arise from uncoordinated lumbar and overactive thoracic neuromuscular control, compromising stability despite maintaining speed. Increasing lumbar motion complexity could enhance postural stability and accuracy during backward perturbation, representing a potential target for developing seated balance rehabilitation strategies and promoting more adaptive trunk control.

Does Baseline Facet Arthropathy Influence Early Clinical and Radiographic Outcomes After Cervical Disc Replacement?

BACKGROUND AND OBJECTIVES

Severe facet arthropathy is generally a contraindication to undergoing cervical disc replacement (CDR) due to associated instability and potentially limited improvement in neck pain caused by arthropathy. This study evaluates the influence of facet arthropathy on radiographic/early clinical outcomes after CDR.

METHODS

One/two-level CDR patients from a single surgeon's prospectively maintained database created 2 cohorts based on facet arthropathy: grade 0-1 or 2-3 (milder/moderate arthropathy). Patient-reported outcome measures for neck disability, neck/arm pain, depressive burden, mental/physical health/function were obtained preoperatively and through final follow-up (average follow-up: 8.5 ± 6.5 months). Preoperative/postoperative radiographs measured segmental lordosis and C2-C7/segmental range of motion (ROM) and determined facet grade for each operative level. Demographic differences, perioperative variables, baseline patient-reported outcomes, and intercohort differences/changes for postoperative patient-reported/radiographic outcomes were determined.

RESULTS

Of 161 patients, 100 were in the milder arthropathy group. There were no differences in baseline patient-reported outcomes. Patients with moderate arthropathy reported superior 6-week 12-Item Veterans Rand Mental/Physical Composite Scores ( P ≤ .047, all). By final follow-up, moderate patients reported better 12-Item Veterans Rand Mental/Physical Composite Scores/Patient-Reported Outcome Measurement Information System-Physical Function/Patient-Health Questionnaire-9 ( P ≤ .049, all). Cohorts reported similar improvements in all patient-reported outcomes by 6 weeks/final follow-up. Those with more severe facet arthropathy had significantly shorter preoperative disc heights ( P < .001). Accounting for baseline disc height differences, by final follow-up, moderate patients had lower segmental ROM ( P = .036). There were no significant differences in radiographic measurement changes ( P ≥ .264, all).

CONCLUSION

Postoperatively, patients with moderate facet arthropathy reported lower depressive burden, better mental health/physical function, and lower segmental ROM. However, this did not translate to inferior short-term clinical outcomes. Further study should be conducted on the relationship between clinical/radiographic outcomes in CDR patients with facet arthropathy.

Unveiling MiR-3085-3p as a modulator of cartilage degeneration in facet joint osteoarthritis: A novel therapeutic target

Background

Low back pain (LBP) is generally caused by lumbar degeneration without effective treatment. Lumbar degeneration is influenced by aberrant axial mechanical stress (MS), with facet joint osteoarthritis (FJOA) representing one of its primary pathological manifestations. MicroRNA (miRNA), functioning as an early intermediate in the transcription process, has frequently been demonstrated to serve as a critical mediator linking mechanical stress perception with cellular processes such as growth, development, aging, and apoptosis. We hypothesized that miR-3085-3p regulates chondrocyte apoptosis under mechanical stress, influencing FJOA and serving as a key regulator.

Methods

The severity of cartilage degeneration in bipedal standing models (BSM) was established and validated through micro-CT and histopathology. Cyclic tensile strain experiments (CTS) were conducted on the ATDC5 cell line to simulate MS. In situ hybridization was utilized to assess the expression levels of miR-3085-3p in degraded facet articular cartilage. The role of miR-3085-3p and its interaction with the downstream mRNA target Hspb6 were investigated through a combination of bioinformatic analysis, quantitative real-time polymerase chain reaction, western blotting, immunofluorescence, and luciferase assay. In vivo experiments on BSM, the functional impact of miR-3085-3p was further examined through transfection with adeno-associated virus (AAV).

Results

It was observed that miR-3085-3p induced endoplasmic reticulum (ER) stress and apoptosis in chondrocytes and cartilage tissues under MS. The detrimental impact of miR-3085-3p was associated with the downregulation of Hspb6 expression, resulting in disruption of endoplasmic reticulum folding function. Additionally, intra-articular transfection of AAV miR-3085-3p mimics in mice facet joints led to spontaneous cartilage loss, while AAV miRNA-3085-3p sponge administration mitigated FJOA in the murine BSM model.

Conclusion

Mechanical stress-regulated miR-3085-3p up regulation induced the ER stress and aggravates FJOA development through targeting HSPB6, suggesting miR-3085-3p may be a novel therapeutic target for FJOA.Translational potential of this article: Our study confirmed the elevated expression of miR-3085-3p in lumbar facet joints following mechanical stress loading, suggesting that miR-3085-3p may serve as a biomarker for the clinical management of FJOA. Additionally, we demonstrated that the knockdown of miR-3085-3p in animal facet joints mitigated facet joint degeneration, thereby identifying a potential therapeutic target for FJOA.

Indication and Technical Consideration for Nerve Blocks and Neurolysis for Pain Control

Pain management in interventional radiology (IR) encompasses a variety of advanced image-guided techniques to deliver minimally invasive treatments for various pain conditions. Key procedures include nerve blocks and neurolysis, which target specific nerves to provide substantial pain relief. Effective pain management in IR relies on a thorough understanding of regional anatomy, precise technique, and careful administration of local anesthetics, neurolytic agents, and corticosteroids. Complications are minimized through strict adherence to dosage guidelines and meticulous procedural protocols. These interventions significantly improve patient outcomes, reduce recovery times, and minimize the risk of chronic pain, underscoring the pivotal role of IR in contemporary pain management. In the present review, we will report the most common nerve blocks and neurolytic interventions performed in the IR field, by focusing on anatomy, imaging guidance, major procedural points, and expected complications.

Comparing the efficacy of intra-articular injection of Platelet Rich Plasma (PRP) with corticosteroids (CS) in patients with chronic zygapophyseal joint low back pain confirmed by double intra-articular diagnostic blocks: A triple-blinded randomized multicentric controlled trial with a 6-month follow-up

Objective

To compare the safety and effectiveness in improving function and reducing pain of autologous PRP to corticosteroid (CS) zygapophyseal (Z-joint) intra-articular (IA) injections at six months for patients with chronic osteoarthritis Z-joint mediated low back pain (LBP).

Design

Prospective triple-blinded multicentric randomized controlled trial.

Methods

Fifty participants with radiological signs of Z-joint OA and chronic Z-joint mediated LBP confirmed by a ≥80 % pain improvement after two IA local anesthetic injections were randomized into PRP and CS groups, using a 1:1 ratio. Participants completed questionnaires at baseline, and at 1-, 3- and 6-month post-treatment, with adverse effect data collected at 1 month. Function (Oswestry disability index (ODI)), pain (Numeric Rating Scale (NRS)), treatment satisfaction (modified MacNab criteria), and quality of life (Short Form survey 36 (SF-36)) were assessed at each follow-up. The primary outcome was the percentage of participants improving their function (ODI score) above the minimal clinically important difference (MCID) of 17 points. The secondary outcomes were the percentage of participants with a >50 % NRS improvement, satisfaction to treatment and mean score improvement. Proportions were compared between groups using a chi-square test. Mean scores were compared using a two-way ANOVA or the nonparametric Brunner & Langer test.

Results

Both groups were similar at baseline, no major adverse effects occurred, and no participants were lost at follow-up. The proportion of participants improving their ODI scores above the MCID, the proportion of participants with a >50 % NRS improvement, and mean ODI scores were significantly different between groups in favor of PRP at 6 months. Modified MacNab satisfaction scale, NRS and SF36 mean scores were not statistically different between groups, but all followed the same pattern: the CS groups had a greater improvement a one month, both groups were equivalent at three months and the PRP group had a greater improvement at six months.

Conclusion

This first triple-blinded multicentric RCT demonstrates the safety of PRP IA Z-joint injections and its superiority in improving pain and function at six months post-treatment compared to CS for patients with chronic OA Z-joint mediated LBP. To perform a blinded control study, two intra-articular treatments were compared. However, knowing that radiofrequency neurotomy (RFN) of the medial branch diagnosed by branch blocks has been standard of care for pain originating from Z-joints, further studies comparing PRP to RFN are still needed.

Clinicaltrials gov registry number

NCT05188820.

Lumbar Facet Joint Disease: What, Why, and When?

Low back pain (LBP) affects over 60% of individuals in their lifetime and is a leading cause of disability and increased healthcare expenditure. Facet joint pain (FJP) occurs in 27% to 40% of LBP patients but is often overlooked or misdiagnosed. Additionally, there is no clear correlation between the clinical examination, radiological findings, and clinical presentation, complicating the diagnosis and treatment of FJP. This narrative review aims to provide an overview of the literature regarding facet joint pain and discusses the utility of medial branch blocks (MBBs) and intra-articular (IA) injections as diagnostic and therapeutic tools prior to radiofrequency ablation (RFA). RFA is considered the gold standard for managing FJP, employing techniques that include precise needle placement and stimulation parameters to disrupt pain signals. Promising alternatives such as cooled RFA and cryodenervation require further research on their long-term efficacy and safety. Endoscopic denervation and multifidus stimulation are emerging therapies that may benefit chronic LBP patients, but additional research is needed to establish their effectiveness. When conservative management fails, RFA provides significant and lasting relief in well-selected patients and has a favourable safety profile. The current literature does not support surgical interventions for FJP management.

Ultrasound-guided retromammillary injections in dogs: a feasibility, descriptive and anatomical study

OBJECTIVE

To evaluate the feasibility of an ultrasound-guided technique targeting the medial branches of the dorsal ramus of the spinal nerves (DRSN) by injecting a dye solution at the caudal aspect of the base of lumbar mammillary processes [i.e. the retromammillary (RM) space].

STUDY DESIGN

Feasibility, descriptive, anatomical study.

ANIMALS

Eleven canine cadavers.

METHODS

Using anatomical dissections, the relationship between the mammillary processes and the branches of the DRSN of the thoracolumbar and lumbar spine was studied in two cadavers. Subsequently, ultrasound-guided RM injections were administered in nine cadavers, randomly assigned to low volume (LV; 0.01 mL kg-1) of a dye solution at multiple points from L3 to L6 on one side, and high volume (HV; 0.4 mL kg-1) at a single L4 point on the contralateral side. Gross anatomical dissections were immediately performed after the injections. The RM injections were feasible if ultrasonographic landmarks were identifiable in at least 80% of cases, and 80% of LV injections showed medial branch staining. A one-sample binomial test was used for testing feasibility.

RESULTS

The medial branches emerged shortly after the DRSN exited the intervertebral foramen and traveled towards the caudal aspect of the base of the mammillary process, which served as the target injection point. With LV, 36 out of 36 (100%) injected medial branches were stained, meeting the criteria of feasibility (p < 0.001). The median (range) number of stained medial branches per cadaver were 4 (4-4) and 2 (1-3), with LV and HV, respectively. Although no lateral branches were stained with LV, 1 (0-2) was stained with HV. Neither ventral branch staining nor epidural spread was noted in any cadaver.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided RM injections are feasible and allow for selective staining of the medial branch of the DRSN in canine cadavers at the lumbar spine.

Bushen Huoxue decotion-containing serum prevents chondrocyte pyroptosis in a m6A-dependent manner in facet joint osteoarthritis

BACKGROUND

Facet joint osteoarthritis (FJOA) is a common lumbar osteoarthritis characterized by degeneration of small joint cartilage. Bushen Huoxue decotion (BSHXD) has good therapeutic effects on OA. Our work aimed to further probe the pharmacological effects of BSHXD-containing serum (BSHXD-CS) on FJOA and define underlying the mechanisms invovled.

METHODS

To establish a FJOA cell model, primary rat chondrocytes were treated with LPS. The mRNA and protein expressions were assessed using qRT-PCR and western blot, respectively. The secretion levels of pro-inflammatory cytokines were measured by ELISA. Cell viability was determined by CCK8 assay. The global m6A level was detected by the kit, and NLRP3 mRNA m6A level was determined by Me-RIP assay. The molecular interactions were analyzed by RIP and RNA pull-down assays.

RESULTS

BSHXD-CS treatment relieved LPS-induced cell injury, inflammation, NLRP3 inflammasome and pyroptosis in chondrocytes (all p < 0.05). LPS-induced NLRP3 upregulation in chondrocytes was related to its high m6A modification level (p < 0.05). It was also observed that BSHXD-CS reduced LPS-induced m6A modification in chondrocytes via repressing STAT3 (all p < 0.05), suggesting BSHXD-CS could repress NLRP3 expression via m6A-dependent manner. Moreover, DAA, a m6A specific inhibitor, was proved to strengthen the protectively roles of BSHXD-CS on LPS-challenged pytoptosis (all p < 0.05).

CONCLUSION

BSHXD-CS inhibited NLRP3 inflammasome activation and pyroptosis in chondrocytes to repress OA progression by reducing RNA m6A modification.

Efficacy and Accuracy of Ultrasound Guided Injections in the Treatment of Cervical Facet Joint Syndrome: A Systematic Review

Background/Objectives: Cervical facet joint syndrome (CFJS) is a frequent cause of neck pain and motor disability. Among the available therapies for CFJS, ultrasound (US)-guided injections are becoming more and more widespread, but the evidence about their accuracy and effectiveness is still debated in the scientific literature. The aim of this systematic review is to assess efficacy, accuracy and feasibility of US-guided cervical facet injections for the related chronic neck pain treatment. Methods: This review was conducted following the preferred reporting items for systematic reviews and meta-analysis 2020 (PRISMA) statement guidelines. The scientific articles were identified through the PubMed, Google Scholar and Cochrane Library databases. Qualitative assessment of the selected studies was carried out using the modified Oxford quality scoring system. Nine studies with a total of 958 patients were included in this review. The risk of bias was assessed using the Cochrane Collaboration tool. The protocol was registered at PROSPERO 2024 (n°CRD42024512214). Results: The results of this review suggest that the US-guided cervical facet injection for CFJS treatment is an effective technique in terms of accuracy (using the lateral technique it ranges from 92% to 98%), and efficiency (it grants pain relief with a decrease in the procedure time and fewer needle passes in comparison with the X-ray-guided technique, which also involves radiation exposure). Conclusions: US-guided injections are a safe and effective method to treat this musculoskeletal disease, granting a high functional recovery and long-lasting pain relief, net of the used drugs. However, these procedures are strictly operator-dependent and require important training to acquire good expertise.

Radiofrequency vs Steroid Injections for Spinal Facet and Sacroiliac Joint Pain: A Systematic Review and Meta-Analysis

Purpose

Pain management for spinal facet joint (SFJ) and sacroiliac joint (SIJ) pain is challenging, often requiring interventions like radiofrequency ablation (RFA) or corticosteroid injections (CI). This study aims to assess and compare the effectiveness of CI and RFA in treating SFJ and SIJ pain. We combine these treatments due to their shared pathophysiology, similar therapeutic interventions, and the necessity for an integrated approach to spinal pain management.

Patients and methods

Literature search from PubMed, Scopus, CENTRAL and Google Scholar for published studies upto 31st December 2023, and reporting data of patients who were treated using CI of RFA for SFJ and SIJ pain. Pooled standardized mean difference (SMD) with a 95% Confidence Interval (CI) was calculated.

Results

Our meta-analysis incorporated thirteen studies. Overall, patients, treated with CI had a higher pain intensity score compared to patients treated with RFA (SMD=0.92; 95% CI: 0.19 to 1.65) at 3 months, and at 6 months (SMD=1.53; 95% CI: 0.66 to 2.40) after the treatment. No significant association was reported at 12 months (SMD=1.47; 95% CI: -0.03 to 2.97). Subgroup analysis based on joint types revealed increased pain intensity scores in patients who were treated with CI for SIJ (SMD=1.25; 95% CI: 0.39 to 2.11) and SFJ (SMD=1.33; 95% CI: 0.09 to 2.57) pain. A negative but not significant effect was detected in patients, treated with CI for cervical joint pain (SMD=-0.40; 95% CI: -0.90 to 0.10). Patients treated with CI exhibited higher functional disability score compared to patients treated with RFA at 3 months (SMD=1.28; 95% CI: 0.20 to 2.35) post-treatment.

Conclusion

This study suggests that RFA may offer superior pain relief with longer duration compared to steroid injections for spinal facet and sacroiliac joint pain. Decision regarding specific interventions should be individualized and consider patient preferences, clinical context, and potential risks.

Osteoarthritis of zygapophysial joints as a cause of back pain and neck pain: a scoping review

BACKGROUND

Zygapophysial joints (Z joints) can be a source of back pain and of neck pain, but the cause of pain is not known. Some authors attribute the pain to osteoarthritis but without citing evidence.

OBJECTIVES

The present review was undertaken to determine if there was sufficient evidence of association between spinal pain and osteoarthritis of Z joints to justify osteoarthritis being held to be the cause of pain. The null hypothesis was that osteoarthritis of Z joints does not cause back pain or neck pain.

ELIGIBILITY CRITERIA

Relevant studies were ones that provided primary data on the association between pain and osteoarthritis of Z joints. These could be population studies, diagnostic studies, or case-control studies.

SOURCES OF EVIDENCE

The database of PubMed was searched using the terms: Lumbar or cervical, zygapophysial or facet, pain, and osteoarthritis or degeneration or degenerative.

CHARTING METHODS

Data pertinent to the research question were extracted from original articles and tabulated for reporting. Odds ratios for associations were calculated, as were the prevalence rates of osteoarthritis in subjects with pain, and conversely the prevalence rates of pain in subjects with osteoarthritis.

RESULTS

The searches retrieved 11 population studies, 4 diagnostic studies, and 3 cases control studies. No study showed any positive association between osteoarthritis of Z joints and pain. All studies found pain to be independent of the presence or severity of osteoarthritis. Osteoarthritis was as common in subjects with no pain as in subjects with pain. The null hypothesis was not refuted.

CONCLUSION

The published evidence does not support the belief that osteoarthritis causes Z joint pain. All the evidence contradicts this belief.

Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method

BACKGROUND

Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain.

METHODS

The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios.

RESULTS

For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well-selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e-health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region.

CONCLUSIONS

A multidisciplinary European expert panel established patient-specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.

High spinal anaesthesia during local anaesthetic skin infiltration at the cervical facet joint

Facet joint injections are generally safe to perform with a low incidence of adverse events. There are few published reports of neurological complications occurring following procedures at the facet joint or cervical epidural space. However, complications from local anaesthetic infiltration to the skin and surrounding tissue have not been reported. We report a case of transient tetraplegia after local anaesthetic infiltration to the skin in preparation for cervical facet joint injection. We discuss potential reasons for this complication and suggest practice modifications which could reduce the risk.

Facet joint involvement in the inflammatory rheumatic disease

BACKGROUND

The involvement of facet joints (FJ) in patients with inflammatory rheumatic disorders remains underexplored. This review aims to look at FJ disease from a rheumatologist's perspective, with the emphasis given to the clinical presentations and patterns of FJ engagement in axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and crystal-related arthropathies, and discussion of challenges in studying FJ in rheumatic disease.

METHODS

A systematic PubMed search using the pertinent keywords was performed, relevant articles extracted, and the acquired data critically assessed, interpreted, and organized according to the authors' experience and judgment.

RESULTS

FJ involvement is common in patients with radiographic axSpA, occurs throughout the spine, but is more frequently seen in the thoracic segment. The existing data suggests that the FJ are primarily affected by the disease process, while altered spine biomechanics due to the presence of syndesmophytes at the same vertebral level contributes to the FJ fusion. Predominant involvement of FJ of the cervical spinal segment has been suggested in PsA; however, prevalence and clinical significance of FJ involvement in PsA is still markedly underexplored. RA-related FJ disease of the cervical spine in patients with poorly controlled RA is not uncommon and can be related to significant morbidity, while the burden of FJ involvement in the thoracic and lumbar spinal segments in RA is also underexplored. FJ disease is possible in the course of crystal-related arthropathies, but the high level of suspicion is a prerequisite for the timely diagnosis.

CONCLUSIONS

The involvement of FJ in the course of inflammatory rheumatic disease is not uncommon. Prospective studies are needed to understand the epidemiology and significance of FJ disease in inflammatory rheumatic conditions.

Beyond the Back: The Science of Lumbar Epidural Steroid Injections

Chronic low back pain causes significant morbidity and increases the global burden of disability. It has been shown to increase psychological, physical, and monetary load on the world population, In the USA alone, it causes an economic burden of 100 billion dollars/year [1]. Low back pain has been referred to as sciatica pain, lumbar radiculopathy, lumbar nerve entrapment, and neurogenic claudication. It is basically pain arising from the lower back region and radiating like a current to the lower limbs. The two prime causes of this low back pain with radiculopathy are intervertebral disc disease and facet joint arthritis [2]. The pathological aging changes happening in intervertebral disk cause disk herniation and other degenerative diseases such as lumbar canal stenosis and chronic instability. Lumbar radiculopathy or sciatica is mainly caused by compression of the nerve by protruded nucleus pulposus, which is the jelly like material of intervertebral disk [3,4]. Most of the patients with intervertebral disk disease and sciatica can be managed with conservative measures. These include anti-inflammatory analgesics, neuropathic medications such as pregabalin and gabapentin, regular exercises, and epidural steroid injections [5-7]. These measures help to prevent surgery. Significant compression of nerves with no relief from conservative measures qualifies to surgical intervention [2]. ESI, which has been used since 1952, is mainly used for lumbar and neck pain with radicular pain. It has shown excellent and quick results with minimal adverse effects. The ESI consists of injecting the steroids with or without local anesthetic medication in the epidural space to decrease the discogenic source of pain [8-11]. LSEI can be divided according to the needle route (interlaminar, transforaminal, or caudal). In this article, we will go over the various approaches for intralaminar (between the 2 adjacent laminae of lumbar vertebrae), transforaminal (through the intervertebral foramen), and caudal (through the sacral hiatus) epidural steroid injections [12-14].

Traditional versus cooled-radiofrequency neurotomy for the treatment of chronic lumbar facet (zygapophyseal) joint pain

Aim: Traditional radiofrequency ablation (TRFA) effectively treats facet joint-related pain, while water-cooled radiofrequency ablation (CRFA) may offer benefits like larger lesions and easier nerve access. Our goal is to assess the effectiveness of TRFA and CRFA for facet joint-related pain.Materials & methods: This retrospective study included an evaluation of 346 RFA interventions performed on 190 patients suffering from long-term low-back pain. The primary outcome was defined as a decrease of ≥50% of the mean numeric rating scale.Results: The primary outcome was achieved at the first follow-up (FU) for both TRFA and CRFA, with pain relief of 55.2 and 60.5%, respectively. At the second FU, the primary outcome was achieved only in the CRFA group (54.1%), although the TRFA group also showed a good improvement (48.6%). In both groups, pain relief was under 50% during the third FU.Conclusion: Our study indicates that both CRFA and TRFA modalities are effective and safe treatments.

Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

Efficacy of radiofrequency in lumbar facet joint pain: a systematic review and meta-analysis of placebo-controlled randomized controlled trials

BACKGROUND

Lumbar facet joint pain (LFJP) is one of the main causes of chronic low back pain (LBP) and can be treated using radiofrequency (RF) sensory denervation. The aim of this work is to analyze the efficacy of RF in LFJP through a systematic review and meta-analysis of randomized controlled trials (RCTs) with placebo control.

MATERIALS AND METHODS

A systematic search was conducted in the Medline (PubMed), Scopus, Web of Science databases, and the Cochrane Central Register of Controlled Trials (CENTRAL). The variables of interest were pain, functional status, quality of life (QoL), and global perceived effect (GPE) measured at different time intervals: short (< 3 months), medium (> 3 and < 12 months), and long term (> 12 months).

RESULTS

Eight RCTs with placebo control were included. RF showed significant benefits over placebo in pain relief in the short (MD - 1.01; 95% CI - 1.98 to -0.04; p = 0.04), medium (MD - 1.42; 95% CI - 2.41 to - 0.43; p = 0.005), and long term (MD - 1.12; 95% CI - 1.57 to - 0.68; p < 0.001), as well as improvement in functional disability in the short (SMD - 0.94; 95% CI - 1.73 to - 0.14; p = 0.02) and long term (SMD - 0.74; 95% CI - 1.09 to - 0.39; p < 0.001). No statistically significant differences were observed in QoL or quantitative GPE, but benefits for RF were observed in dichotomous GPE in the medium (OR 0.19; 95% CI 0.07-0.52; p = 0.001) and long term (OR 0.22; 95% CI 0.06-0.78; p = 0.02). Subgroup analyses showed more benefits for RF in LBP < 1 year in the short term and in RCTs that did not require performing an MRI for patient selection.

CONCLUSIONS

RF demonstrated significant improvement in pain and functionality, but the benefits in terms of QoL and GPE are inconclusive. Future clinical trials should investigate the long-term effects of RF, its impact on quality of life, and define appropriate criteria for patient selection.

Cervical intervertebral disc disease in 307 small-breed dogs (2000-2021): Breed-characteristic features and disc-associated vertebral instability

OBJECTIVE

To evaluate the breed-characteristic features of cervical intervertebral disc disease (C-IVDD) and associated vertebral instability in small-breed dogs and to present the concept of intervertebral disc degeneration and associated instability stage, method of diagnosis, treatment and outcomes.

ANIMALS

In total, 307 client-owned dogs with C-IVDD treated with spinal cord decompression with or without vertebral stabilization (2000-2021).

METHODS

Information on age, sex, affected sites, stabilized sites, diagnostic methods for vertebral instability and outcomes were retrieved. The patient's age, affected sites (cranial vs caudal discs), and frequency of vertebral stabilization were compared in six CD and five NCD breed. Multivariable analyses of the chondrodystrophic (CD) vs non-CD (NCD) groups, and vertebral stabilization (dogs stabilized vs dogs not stabilized) were performed.

RESULTS

In total, 222 (72.3%) and 77 (25.1%) were CD and NCD breeds, respectively. Vertebral instabilities were diagnosed based on the survey radiographs with computed tomography/magnetic resonance imaging (n = 2), dynamic myelography (n = 29), intraoperative spinal manipulation (n = 11) or second surgery in dogs with persistent postoperative paraspinal pain (n = 3). Of these dogs, 295 (96.1%) recovered (median follow-up: 8.5 [range, 1-119] months). Significant differences in age, affected sites and frequency of stabilization were noted among the breeds. Older age and frequent vertebral stabilization were the associated factors for the NCD breed dogs. Male dogs, caudal discs affected (C5-T1) and the NCD breed dogs were risk factors for the dogs with vertebral stabilization.

CONCLUSION

Vertebral stabilization is indicated for small-breed dogs with cervical disc-associated vertebral instability.

Minimally Invasive Treatment of Facet Osteoarthritis Pain in Spine: A Clinical Approach Evaluating Cryotherapy

BACKGROUND

Chronic pain management remains a challenging aspect of neurosurgical care, with facet arthrosis being a significant contributor to the global burden of low back pain. This study evaluates the effectiveness of cryotherapy as a minimally invasive treatment for patients with facet arthrosis. By focusing on reducing drug dependency and pain intensity, the research aims to contribute to the evolving field of pain management techniques, offering an alternative to traditional pain management strategies.

METHODS

Through a retrospective longitudinal analysis of patients with facet osteoarthritis treated via cryotherapy between 2013 and 2023, we evaluated the impact on medication usage and pain levels, utilizing the Visual Analog Scale for pre- and posttreatment comparisons.

RESULTS

The study encompassed 118 subjects, revealing significant pain alleviation, with Visual Analog Scale scores plummeting from 9.0 initially to 2.0 after treatment. Additionally, 67 patients (56.78%) reported decreased medication consumption. These outcomes underscore cryotherapy's potential as a pivotal tool in chronic pain management.

CONCLUSIONS

The findings illuminate cryotherapy's efficacy in diminishing pain and curtailing medication dependency among patients with facet arthrosis. This study reaffirms cryotherapy's role in pain management and propels the discourse on nontraditional therapeutic avenues, highlighting the urgent need for personalized and innovative treatment frameworks.

Exosomes for the Management of Low Back Pain: A Review of Current Clinical Evidence

Low back pain affects millions of people, creating an enormous financial burden on the global healthcare system. Traditional treatment modalities are short-lived and have shortcomings. Recently, orthobiologics, including extracellular vesicles or exosomes derived from mesenchymal stem cells, have markedly increased for managing musculoskeletal conditions. Here, the primary aim is to review the outcomes of clinical studies using extracellular vesicles or exosomes for treating low back pain. Numerous databases (Scopus, PubMed, Web of Science, Embase, and Google Scholar) were searched using terms for the intervention 'exosomes' and the treatment 'low back pain' for studies published in English to March 18, 2024. Articles utilizing exosomes for the management of low back pain were included. Articles not utilizing exosomes, not explicitly stating the presence of exosomes in their formulation, or not targeting low back pain were excluded. Two articles that met our pre-defined criteria were included in this review. The results showed that administering extracellular vesicles or exosomes is safe and potentially effective in patients suffering from low back pain. Yet, more sufficiently powered, multi-center, prospective, randomized, and non-randomized trials with longer follow-up are essential to assess the long-term safety and efficacy of extracellular vesicles or exosomes derived from various sources and to support its routine clinical use for managing low back pain.

"Percutaneous Ultrasound Treatment of Lumbar Facet Syndrome: A Systematic Review."

OBJECTIVE

Lumbar facet syndrome is a cause of pain. The diagnosis iconfirmation is achieved through a selective block. Although this procedure is standardized under fluoroscopic or computed tomography (CT) guidance, the current use of ultrasound may provide an alternative to its implementation.

METHODS

A systematic literature search was conducted. "ultrasound-guided lumbar" and "lumbar facet joint."

RESULTS

Twenty articles were included. Five randomized clinical trials, 4 observational studies, 2 clinical trials, 1 retrospective study, 2 metanalysis and 5 cadaveric studies, and 1 feasibility study. The studies demonstrated a improvement in pain with ultrasound. However, no significant differences in these outcomes were found when comparing ultrasound with fluoroscopy or CT. It was also observed that the procedural time was longer with ultrasound. Finally, success rates in correctly locating the injection site ranged from 88% to 100% when confirmed with fluoroscopy or CT.

CONCLUSIONS

Although the use of ultrasound for regional anesthesia is on the rise, there are no results that can replace those found with fluoroscopy or CT for performing the dorsal and medial branch block of the spinal root in the treatment of lumbar facet syndrome.

Biochemical changes in lumbar facet joint and disc degeneration by T2* mapping

BACKGROUND

To investigate the biochemical changes in lumbar facet joint (LFJ) and intervertebral disc (IVD) with different degenerative grade by T2* mapping.

METHODS

Sixty-eight patients with low back pain (study group) and 20 volunteers (control group) underwent standard MRI protocols and axial T2* mapping. Morphological evaluation of LFJ and IVD were performed on T2-weighted imaging according to Weishaupt and Pfirrmann grading system, respectively. T2* values of LFJ and of AF (anterior annulus fibrosus), NP (nucleus pulposus), and PF (posterior annulus fibrosus) in IVD were measured. Kruskal-Wallis test and Wilcoxon rank-sum test were used to compare T2* values of subjects with different degenerative grade.

RESULTS

The mean T2* value of grade 0 LFJ (21.68[17.77,26.13]) was higher than those of grade I (18.42[15.68,21.8], p < 0.001), grade II (18.98[15.56,22.76], p = 0.011) and grade III (18.38[16.05,25.07], p = 0.575) LFJ in study group, and a moderate correlation was observed between T2* value and LFJ grade (rho=-0.304, p < 0.001) in control group. In the analysis of IVD, a moderate correlation was observed between AF T2* value and IVD grade (rho=-0.323, p < 0.001), and between NP T2* value and IVD grade (rho=-0.328, p < 0.001), while no significant difference was observed between the T2* values of PF in IVD of different grade in study group.

CONCLUSIONS

Downward trend of T2* values can be found in LFJ, AF and NP as the degenerative grade rised. But in elderly patients with low back pain, no change trend was found in LFJ due to increased fluid accumulation in the joint space.

Septic Arthritis of the Spinal Facet Joint: Review of 117 Cases

Background

Septic arthritis of the spinal facet joints is increasingly recognized in the era of magnetic resonance imaging, but its epidemiology, clinical features, management, and prognosis are ill-defined.

Methods

We review 101 previously published cases and report 16 cases occurring at our institutions between 2006 and 2018.

Results

Most patients presented with fever (60%) and back or neck pain (86%). Radiation into the hip, buttock, or limb was present in 34%. The lumbosacral vertebral segments were involved in 78% of cases. Most cases (64%) were due to Staphylococcus aureus. Bacteremia was present in 66% and paraspinal muscle abscesses in 54%. While epidural abscesses were present in 56%, neurologic complications were seen in only 9%, likely because most abscesses arose below the conus medullaris. Neurologic complications were more common with cervical or thoracic involvement than lumbosacral (32% vs 2%, P < .0001). Extraspinal infection, such as endocarditis, was identified in only 22% of cases. An overall 98% of patients survived, with only 5% having neurologic sequelae.

Conclusions

Septic arthritis of the facet joint is a distinct clinical syndrome typically involving the lumbar spine and is frequently associated with bacteremia, posterior epidural abscesses, and paraspinal pyomyositis. Neurologic outcomes are usually good with medical management alone.

A Case Series Depicting PSMA Expression in Nonmalignant Lesions

Prostate-specific membrane antigen (PSMA) is a widely accepted and used tracer in staging and biochemical recurrences of prostate cancer. PSMA is extensively expressed in normal prostatic epithelial cells and prostate cancer cells, with some amount of expression also in nonprostatic cells. False-positive PSMA uptake in nonmalignant lesions creates ambiguity in disease detection. In such cases, histopathological correlation and radiological follow-up assist in clinical decision-making. In this case series, we illustrate a few cases where PSMA uptake was incidentally found in some of the commonly occurring benign conditions.

Spinal calcifying pseudoneoplasm of the neuraxis (CAPNON) associated with facet joint pathologies: CAPNON diagnostic and pathogenic insights

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumor-like fibro-osseous lesion that can develop anywhere in the neuraxis. Approximately a half of reported CAPNONs developed in the spinal region, mostly close to the facet joint (FJ). The diagnosis of spinal CAPNONs is challenging given the existence of mimics and associated pathologies including calcific degeneration of the FJ ligaments (DFJL) and synovial cysts (SCs). The pathogenesis of CAPNON remains elusive, although there have been a few hypotheses including degenerative, reactive, proliferative and immune-mediated processes. Our present study examined clinical, radiological and pathological features of 12 spinal CAPNONs in comparison to 9 DFJL foci, and diagnostic and pathogenic relationship between CAPNONs and FJ pathologies. On imaging, CAPNONs were all tumor-like and typically bigger than DFJL foci. All CAPNONs showed pathologically diagnostic features including characteristic cores, consistently identifiable core-surrounding/peripheral palisading of macrophages and other cells including multinucleated giant cells, variable infiltration of CD8+ T-cells, and multifocal immunopositivity of neurofilament light chain (NF-L). These features were absent or limited in the DFJL foci with statistically significant differences from CAPNONs, except calcifications. Spinal CAPNONs co-existed with DFJL foci in all cases; some had transitional foci with overlapping focal CAPNON and DFJL-like features. These findings, along with our previously reported relationship between CAPNONs and SCs, suggest that spinal CAPNONs may occur in association with or in transition from calcifying/calcified degenerative lesions of FJ ligaments and/or SCs when a reactive proliferative process is complemented by other pathogenic changes such as immune-mediated pathology and NF-L deposition/expression.

Comparative Efficacy of Ultrasound-Guided Cervical Fascial Infiltration versus Periarticular Administration of Autologous Conditioned Serum (Orthokine) for Neck Pain: A Randomized Controlled Trial Protocol Description

BACKGROUND Neck pain is a prevalent and burdensome health issue, with autologous conditioned serum (ACS), like Orthokine, being a recognized treatment for musculoskeletal conditions due to its anti-inflammatory effects. However, the optimal ACS administration method for neck pain remains unclear. The existing literature lacks robust evidence, especially for different injection techniques. This study aimed to compare ACS infiltration into cervical fascia with periarticular administration to determine if the former is as effective in alleviating neck pain, offering a novel approach to its management. MATERIAL AND METHODS Our study is designed to be a single-center, prospective, randomized trial involving 100 patients. Group A (n=50) will receive ACS through fascial infiltration at tender points under ultrasound guidance, with 4 doses administered every 3 days. Group B (n=50) will receive ACS injections in the articular column (facet joints) using the same dosing schedule. We will collect data at T0 (before therapy), T1 (6 weeks after therapy), and T2 (12 weeks after therapy), assessing outcomes with the Numerical Pain Scale (NRS), Neck Disability Index (NDI), and Dynamic Proprioception Test (DPT). RESULTS Enrollment begins in August 2023, and the study is set to conclude in July 2024. If data analysis, manuscript preparation, and peer review proceed smoothly, we anticipate publishing the results in late 2024 or early 2025. CONCLUSIONS If fascial infiltration with ACS proves equally effective as the standard periarticular method, it offers promise for patients on long-term anticoagulant treatment. Paravertebral injections in such cases carry a significant risk of bleeding, making ACS infiltration a potentially safer alternative for managing neck pain in these individuals.

Percutaneous radiofrequency ablation and endoscopic neurotomy for lumbar facet joint syndrome: are they good enough?

OBJECTIVE

Lumbar facet joint (LFJ) syndrome is one of the common causes of low back pain (LBP). There are different views on percutaneous and endoscopic radiofrequency. The purpose of this systematic review and meta-analysis is to explore the therapeutic effect of radiofrequency ablation on LBP originating from LFJ and compare the therapeutic effect of percutaneous radiofrequency ablation and endoscopic neurotomy.

METHODS

We included randomized controlled trials which compared the efficiency of percutaneous radiofrequency ablation and conservative treatment (sham procedures, facet joint injection, physiotherapy, exercise, or oral medication) or compared the efficiency of percutaneous radiofrequency ablation and endoscopic neurotomy for LFJ syndrome. We searched in PubMed and Web of Science from inception to March 27, 2023. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

A total of 11 randomized controlled trials were included. Among them, nine studies were used for evaluating efficiency of percutaneous radiofrequency ablation, and two studies were used for evaluating efficiency of endoscopic neurotomy. Pooled data from two studies reporting outcomes at 1 year did not show a benefit from facet joint denervation by comparing the percutaneous radiofrequency ablation and conservative treatment (standardized mean difference (SMD) = -0.87, 95% confidence interval (CI) [-2.10, 0.37], P = 0.17). There was no significant difference between percutaneous radiofrequency ablation and endoscopic neurotomy at 1-month follow-up (mean difference (MD) = -0.13, 95%CI [-0.18, -0.44], P = 0.41). At 12-month follow-up the pain relief in the endoscopic neurotomy was significantly better than that in the percutaneous radiofrequency ablation group (MD = 1.98, 95%CI [1.60, 2.36], P < 0 .0001).

CONCLUSION

The LBP was significantly relieved shortly after percutaneous radiofrequency ablation. Compared with percutaneous radiofrequency ablation, endoscopic neurotomy seems to have a longer effect. A longer follow-up period is needed to confirm its effectiveness.

SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series

OBJECTIVE

The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery.

METHODS

A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies.

RESULTS

A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine.

CONCLUSIONS

PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.

Does intervertebral disc degeneration in adolescent idiopathic scoliosis correlate with patient-reported pain scores? A review of 968 cases

PURPOSE

Report the rate and severity of degenerative disc disease (DDD) in non-surgical adolescent idiopathic scoliosis (AIS) patients and correlate these findings with patient-reported symptomatology scores. Additionally, to quantify the rate of concurrent pathological radiological findings in this group.

METHODS

This was a retrospective chart review study at a single tertiary centre. AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention to their spine were included. MRI scan reports were screened to extract those who had evidence of DDD. These were then reviewed by a blinded second reviewer who graded every disc using the Pfirrmann grading system. SRS-22 scores were extracted for patients when available.

RESULTS

In total, 968 participants were included in the study. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥ 3 in 28 (2.9%). The most commonly affected level was L5/S1 (59.1% of DDD cases). A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration. Spondylolisthesis and bilateral pars defects were more common in patients with DDD identified on MRI scan (p < 0.001 and p = 0.04, respectively). Function (p = 0.048) and pain (p = 0.046) scores were worse in patients with DDD.

CONCLUSION

We present a baseline for the rate and severity of DDD in the non-operative AIS cohort. This should assist in decision-making and counselling of patients prior to surgery.

LEVEL OF EVIDENCE

III.

Preoperative Adjacent Facet Joint Osteoarthritis Is Associated with the Incidence of Adjacent Segment Degeneration and Low Back Pain after Lumbar Interbody Fusion

STUDY DESIGN

A retrospective cohort study.

PURPOSE

To analyze the association between preoperative adjacent facet joint osteoarthritis (FJOA) and outcomes of lumbar interbody fusion (LIF).

OVERVIEW OF LITERATURE

Whether preoperative adjacent FJOA is associated with the incidence of radiological adjacent segment degeneration (RASD) and low back pain (LBP) relief after lumbar fusion remains unknown.

METHODS

The study included patients who underwent LIF. The demographic characteristics and radiographic and surgical data were collected and evaluated. The included patients were divided into control group and FJOA group based on the preoperative adjacent facet joint Pathria grade. Preoperative and last follow-up LBP Visual Analog Scale (VAS) score, leg pain (LP) VAS, Oswestry Disability Index (ODI) and RASD were evaluated and compared. The improvement rates in VAS and ODI were calculated and compared between the two groups. Logistic regression was used to analyze the risk factors of LBP relief and incidence of RASD.

RESULTS

In total, 197 patients (control group, 86; FJOA group, 111) were included, and the median follow-up was 46 months. The VAS and ODI in both groups significantly improved after surgery. At the last follow-up, the FJOA group had higher VAS and lower VAS improvement rates of LBP than the control group (p<0.05). However, no significant difference in the LP VAS and ODI was found between the two groups. The incidence of RASD in the FJOA group was significantly higher than that in the control group (48.6% vs. 30.2%, p=0.034). Multivariate logistic regression analysis showed that preoperative adjacent FJOA was significantly associated with LBP relief (odds ratio [OR], 0.691; 95% confidence interval [CI], 0.498-0.958) and the postoperative incidence of RASD (OR, 1.406; 95% CI, 1.020-1.939).

CONCLUSIONS

The preoperative FJOA in the adjacent segments was significantly associated with LBP following LIF. Patients with preoperative FJOA were more likely to have RASD following lumbar fusion surgery.

Facet joint disorders: from diagnosis to treatment

One of the most common sources of spinal pain syndromes is the facet joints. Cervical, thoracic, and lumbar facet joint pain syndromes comprise 55%, 42%, and 31% of chronic spinal pain syndromes, respectively. Common facet joint disorders are degenerative disorders, such as osteoarthritis, hypertrophied superior articular process, and facet joint cysts; septic arthritis; systemic and metabolic disorders, such as ankylosing spondylitis or gout; and traumatic dislocations. The facet pain syndrome from osteoarthritis is suspected from a patient's history (referred pain pattern) and physical examination (tenderness). Other facet joint disorders may cause radicular pain if mass effect from a facet joint cyst, hypertrophied superior articular process, or tumors compress the dorsal root ganglion. However, a high degree of morphological change does not always provoke pain. The superiority of innervating nerve block or direct joint injection for diagnosis and treatment is still a controversy. Treatment includes facet joint injection in facet joint osteoarthritis or whiplash injury provoking referred pain or decompression in mass effect in cases of hypertrophied superior articular process or facet joint cyst eliciting radicular pain. In addition, septic arthritis is treated using a proper antibiotic, based on infected tissue or blood culture. This review describes the diagnosis and treatment of common facet joint disorders.

[Method of manual-physical correction in the treatment of hypertensive disease and normalization of psychoneurological status in patients with degenerative-dystrophic processes of the musculoskeletal system]

There are some non-communicable diseases (NCD) associated with arterial hypertension (AHT) that are cured after recovery from AHT. Recently confirmed the theory of centralized aerobic-anaerobic energy balance compensation (TCAAEBC) originated some NCDs with the obstructions of arterial blood flow access to the rhomboid fossa. For some sergeants, this has already been demonstrated. Since neurological NCDs are similarly considered by TCAAEBC, it is logical to analyze dynamics of such musculoskeletal neurological problem as isolated musculoskeletal chest pain (IMCP) in connection with the therapy based on TCAAEBC. We retrospectively evaluated the medical records of adult patients with AHT, simultaneously suffering from IMCP. All these patients underwent complex treatment including manual techniques that restore arterial blood flow to the rhomboid fossa, followed by therapy that strengthens the muscular corset primarily of the cervical region. This, in addition to the normalization of AHT, led to a decrease in the musculoskeletal pain syndrome. The dynamic of pain was recorded according to four questionaries - Oswestry Disability Index (ODI) Hospital Anxiety and Depression Scale (HADS), Numerical Rating Scale (NRS), and the Quality-of-life assessment questionnaire (SF-12). The collected data were analyzed with the Wilcoxon signed-rank test, which confirms the recovery of the patients from both AHT and IMCP.

Safety of bone marrow derived mesenchymal stem cell extracellular vesicle injection for lumbar facet joint pain

Aim: A 3-month pilot study to evaluate the safety of injecting a bone marrow-derived mesenchymal stem cell extracellular vesicle advanced investigational product (IP) into the lumbar facet joint space as a treatment for chronic low back pain. Methods: 20 healthy adults were treated with IP injections (0.5 ml/joint) and evaluated by three functional assessments 1, 3, 7, 14, 30, 60 and 90 days later. Results: No adverse effects or complications occurred across the 3-month follow-up. There were no reports of worsening pain. After 3 months group average scores improved significantly (p < 0.0001) in the Severity Index (65.04%), Interference Index (72.09%) and Oswestry Disability Index (58.43%) assessments. Conclusion: IP injections were safe and associated with significant functional improvements.

The Relationship of Radiographic Parameters and Morphological Changes at Various Stages of Degeneration of the Lumbar Facet Joints: Cadaver Study

STUDY DESIGN

Cadaveric specimens.

OBJECTIVE

To perform a pathomorphological analysis of the degree of facet joint (FJ) degeneration utilizing fresh cadaveric models and correlating these structural changes with imaging findings.

METHODS

L1-L5 FSU including all tissue between the anterior longitudinal ligament to the posterior spinal structures were obtained on 28 patients at a mean of 5.7 hours post-mortem. The samples were fixed in an agar medium and CT and MRI were performed. The level of FJ degeneration was identified based on prior classifications Osteoarthritis Research Society International (OARSI), as was the facet angle and tropism. Pathomorphological assessment including articular cartilage cell density was performed according to prior established methodology.

RESULTS

Radiographically, a direct association was identified between FJ degeneration and patient age. Facet angle and tropism did not significantly vary by patient age. Pathomorphologically, there was a decrease in the cellular density of articular cartilage with increasing patient age. Similarly, there was a significant direct correlation between radiographic degree of degenerative changes in FJs with the age of cadavers and the degree of degeneration of FJs according to the morphological classification of OARSI, as well as a significant inverse correlation with cell density.

CONCLUSION

A comprehensive assessment of various signs of FJ degeneration using cadaveric material has established that, based on radiographic imaging, it is possible to assess the microstructural state of FJ, including at an early stage of the disease. This data may be useful for surgeons in guiding therapeutic strategies based on individual biometric parameters of the FJ.

Mechanical Needling With Sterile Water Versus Lidocaine Injection for Lumbar Spinal Stenosis

Study Design: This was a retrospective observational study that assessed the clinical outcome of ageing patients who received ultrasound-guided (USG) mechanical needling with sterile water injection. In addition, the clinical outcome of age-and gender matched patients randomly selected from patients who received needling with sterile water was compared to the patients injected with lidocaine in a 1:1 ratio.Objective: This present study aimed to explore the clinical effects of USG mechanical needling with sterile water injection for lumbar spinal stenosis (LSS).Methods: The data was extracted from the medical records of ageing patients with LSS who received USG injection at the lumbosacral spine by the first author. Low back pain or axial pain, and leg pain or radicular pain were assessed by the visual analogue scale, and gait ability with walking distance were obtained at six different time points.Results: A total of 4328 medical records were examined. Four thousand two hundred and twenty-eight ageing patients received mechanical needling with sterile water injection and found the efficacy lasted up to 6 months. One hundred patients were compared with 100 patients who received lidocaine injection. Those who received lidocaine had pain returned at 3 months and 6 months post-injection.Conclusions: USG mechanical needling with sterile water injection could help relieve axial and radicular pain for at least 6 months. Removal of calcification and fibrosis as well as reduction of sensitization are all possible mechanisms.

Well-known polypeptides of deer antler velvet with key actives: modern pharmacological advances

Deer antler velvet, with kidney tonifying, promoting the production of essence and blood, strengthening tendons and bones, not only has a thousand-year medicinal history but also its modern pharmacology mainly focuses on its active polypeptides on motor, nerve, and immune systems. The purpose of this report is to fill the gap in the comprehensive, systematic, and detailed review of polypeptides during the recent 30 years (1992-2023). The research method was to review 53 pharmacological articles from the Public Medicine, Web of science, ACS, and Science Direct database sources by searching the keywords "pilose antler," "deer velvet," "Pilose Antler Peptide (PAP) and Velvet Antler Polypeptide (VAP)." The results showed that deer antler polypeptides (DAPs), by regulating EGF, EGFR, MAPK, P38, ERK, NF-κB, Wnt, PI3K, Akt, MMP, AMPK, Stir1, NLRP3, HO-1, Nrf, Rho, TLR, TGF-β, Smad, Ang II, etc., revealed their effects on seven system-related diseases and their mechanisms, including osteoarthritis, intervertebral disc degeneration, osteoporosis, Alzheimer's, Parkinson's, triple-negative breast cancer, liver injury, liver fibrosis, cardiovascular disease, acute lung injury, and late-onset hypogonadism. In conclusion, DAPs have good effects on motor and other system-related diseases, but the secondary and tertiary structures of DAPs (0.5-1800 KDa) need to be further elucidated, and the structure-activity relationship study is still unavailable and needs to be covered. It is expected that this review may provide the necessary literature support for further research. The activities and mechanisms of polypeptides from the past 30 years (1992-2023) are summarized covering seven systems, related diseases, and its regulatory genes and proteins.

3. Pain originating from the lumbar facet joints

INTRODUCTION

Pain originating from the lumbar facets can be defined as pain that arises from the innervated structures comprising the joint: the subchondral bone, synovium, synovial folds, and joint capsule. Reported prevalence rates range from 4.8% to over 50% among patients with mechanical low back pain, with diagnosis heavily dependent on the criteria employed. In well-designed studies, the prevalence is generally between 10% and 20%, increasing with age.

METHODS

The literature on the diagnosis and treatment of lumbar facet joint pain was retrieved and summarized.

RESULTS

There are no pathognomic signs or symptoms of pain originating from the lumbar facet joints. The most common reported symptom is uni- or bilateral (in more advanced cases) axial low back pain, which often radiates into the upper legs in a non-dermatomal distribution. Most patients report an aching type of pain exacerbated by activity, sometimes with morning stiffness. The diagnostic value of abnormal radiologic findings is poor owing to the low specificity. SPECT can accurately identify joint inflammation and has a predictive value for diagnostic lumbar facet injections. After "red flags" are ruled out, conservatives should be considered. In those unresponsive to conservative therapy with symptoms and physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic medial branch block can be performed which remains the most reliable way to select patients for radiofrequency ablation.

CONCLUSIONS

Well-selected individuals with chronic low back originating from the facet joints may benefit from lumbar medial branch radiofrequency ablation.

Determining the Most Suitable Ultrasound-Guided Injection Technique in Treating Lumbar Facet Joint Syndrome

(1) Background: Lower back pain is often caused by lumbar facet joint syndrome. This study investigated the effectiveness of three different injection methods under ultrasound guidance in treating elderly patients with lumbar facet joint syndrome. The difficulty in performing these injections was also evaluated; (2) Methods: A total of 60 elderly patients with facet joint syndrome as the cause of lower back pain were recruited and divided into 3 groups. Group 1 received medial branch block (MBB). Group 2 received intra-articular facet joint injections. Group 3 received injection into the multifidus muscle portion that covers the facet joint. Five percent dextrose water (D5W) was used as the injectant. The visual analog scale (VAS) was used to measure the degree of lower back pain; (3) Results: Before the injection treatments, the VAS score averaged about 7.5. After three consecutive injection treatments (two weeks interval), the VAS score decreased significantly to an average of about 1 in all 3 groups, representing mild to no pain. Between group analyses also did not reveal significant statistical differences, suggesting that these procedures are equally effective; (4) Conclusions: Ultrasound-guided injection of the multifidus muscle may be a feasible option in treating elderly patients with lower back pain caused by facet joint syndrome as it is easier to perform as compared to MBB and intra-articular facet joint injection.

Amniotic membrane and/or umbilical cord tissue for treatment of facet joint syndrome: a narrative review

Musculoskeletal spine disorders, especially low back pain, induce enormous amounts of stress and financial burden on individuals and healthcare systems throughout the world. Disorders of the facet joints in the lumbar spine are the most predominant cause of back pain, resulting in facet joint syndrome (FJS). Conventional treatments for FJS are short-lived and have limitations and side effects. Thus, safer and more effective alternatives that can reduce pain and improve patient-reported outcomes are needed. Recently, the utilization of biologics, including the ones derived from perinatal tissue such as amniotic membrane (AM) and umbilical cord (UC), has significantly increased for regenerative medicine applications. This manuscript summarizes the outcomes of preclinical and clinical studies utilizing AM and/or UC for FJS. We identified no preclinical studies and 3 retrospective studies utilizing the search terms "amniotic membrane" and/or "umbilical cord" and "facet joint syndrome". The administration of AM + UC is safe and potentially efficacious for patients with FJS. However, more preclinical studies and appropriately powered, multi-center, prospective non-randomized and randomized controlled studies with longer follow-up are warranted to further evaluate the efficacy of AM + UC to justify its clinical use.