Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks

Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review

Amid the worldwide increase in spinal surgery rates, a significant proportion of patients continue to experience refractory chronic pain, resulting in reduced quality of life and escalated healthcare demands. Failed back surgery syndrome (FBSS) is a clinical condition characterized by persistent or recurrent pain after one or more spinal surgeries. The diverse characteristics and stigmatizing descriptions of FBSS necessitate a reevaluation of its nomenclature to reflect its complexity more accurately. Accurate identification of the cause of FBSS is hampered by the complex nature of the syndrome and limitations of current diagnostic labels. Management requires a multidisciplinary approach that may include pharmacological treatment, physical therapy, psychological support, and interventional procedures, emphasizing realistic goal-setting and patient education. Further research is needed to increase our understanding, improve diagnostic accuracy, and develop more effective management strategies.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

Ultrasound-guided axial facet joint interventions for chronic spinal pain: A narrative review

Background

Axial facet joint interventions (e.g., medial branch block and radiofrequency ablation, facet joint intra-articular injection) are commonly performed for managing chronic spinal pain. Although traditionally performed with fluoroscopy or computed tomography (CT) guidance, ultrasound-guided techniques have also been developed for these interventions.

Aims

The aim of this study is to present contemporary ultrasound-guided techniques for facet joint interventions and synthesize data addressing their accuracy, safety, and efficacy.

Methods

The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of ultrasound-guided facet joint interventions with human subjects from November 1, 1992, to November 1, 2022. Additional sources were drawn from reference lists and citations of relevant studies.

Results

We found 48 studies assessing ultrasound-guided facet joint interventions. Ultrasound guidance for injection of the cervical facet joints and their innervating nerves had favorable accuracy (78%-100%), with lower procedural time compared to fluoroscopy or CT guidance and comparable pain relief. Accuracy with ultrasound-guided lumbar facet joint intra-articular injection (86%-100%) was more reliable than medial branch block (72%-97%); analgesia was comparable to fluoroscopy and CT guidance. In general, these procedures were more challenging for patients with obesity, and deeper structures were more difficult to accurately target (e.g., lower cervical levels, L5 dorsal ramus).

Conclusions

Ultrasound-guided facet joint interventions continue to evolve. Some technically challenging interventions may be impractical for widespread usage or require further technical refinement. The utility of ultrasound guidance with obesity and abnormal anatomy may be reduced.

A comparison of pulsed radiofrequency and radiofrequency denervation for lumbar facet joint pain

BACKGROUND

Lumbar facet joint pain is a common disorder. The main symptom is chronic lumbar pain, which can reduce quality of life. Radiofrequency has often been used to treat lumbar facet joint pain. However, the effectiveness of this technique has been controversial. This study was conducted to compare the effectiveness of pulsed radiofrequency (PRF) and radiofrequency denervation (RD) for lumbar facet joint pain.

METHODS

One hundred and forty-two patients with lumbar facet joint pain were allocated to two treatment groups: PRF group (N = 72) and RD group (N = 70). Patients enrolled in the study were assessed using a visual analogue scale (VAS), Roland-Morris questionnaire (RMQ), Oswestry disability index (ODI) and Short-Form 36 (SF-36) questionnaire before therapy, 3 months and 12 months later.

RESULTS

There were no significant differences in VAS, RMQ score, ODI score and SF-36 score at 3 months (p > 0.05). Significant differences in pain control were observed in both groups at 12 months (3.09 ± 1.72 vs. 2.37 ± 1.22, p = 0.006). There was a significant difference in RMQ score (11.58 ± 3.58 vs. 8.17 ± 2.34, p < 0.001) and ODI score (43.65 ± 11.01 vs. 35.42 ± 11.32, p < 0.001) at 12 months. The total SF-36 score was higher in the RD group than in the PRF group at 12 months (58.45 ± 6.97 vs. 69.36 ± 6.43, p < 0.001). In terms of complications, skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group.

CONCLUSION

Radiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up.

Lumbar facet joint osteoarthritis as the underlying reason for persistent low back pain after minimally invasive discectomy

INTRODUCTION

A post-hoc subgroup analysis of prospective collected data in a randomized controlled trial (RCT) of minimally invasive discectomy was conducted, to find out the possible underlying reasons for patients with persistent low back pain (LBP) following surgery.

MATERIALS AND METHODS

Patients who were diagnosed with lumbar disc herniation (LDH) and underwent either percutaneous transforaminal endoscopic discectomy or microendoscopic discectomy in our RCT were analyzed. Patients with persistent LBP in 2-year follow-up were compared with the non-LBP patients to determine the underlying reasons. Then, the demographic characteristics, clinical outcomes and radiological parameters of patients with preoperative lumbar facet joint osteoarthritis (LFJOA) were assessed and compared with the non-LFJOA subgroup.

RESULTS

18 patients (8.1%) were reported to have persistent LBP in 2-year follow-up. Significantly higher proportion of preoperative LFJOA were found in the persistent LBP subgroup and was considered to be a risk factor using multivariate analysis. The prevalence of LFJOA is strongly associated with older age, female, high BMI and heavy labor in the LDH population. All of the clinical outcomes including ODI, SF36-PF, SF36-BP, EQ-5D, VAS-back and VAS-leg were worse in LFJOA subgroup in 2-year follow-up. LFJOA subgroup was associated with more adjacent segment degeneration and more lateral recess stenosis.

CONCLUSIONS

LFJOA is a possible underlying reason for patients with persistent LBP after minimally invasive discectomy. Surgeons should carefully review the preoperative radiological images to find out whether there is LFJOA in the LDH segment, and kindly diminish the expectation of back pain relief for those patients.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov at November 14, 2013, registration number NCT01997086. ( https://clinicaltrials.gov/ct2/show/NCT01997086 ).

Risk Factors for Poor Outcomes Following Minimally Invasive Discectomy: A Post Hoc Subgroup Analysis of 2-Year Follow-up Prospective Data

Objective

A post hoc subgroup analysis of prospectively collected data from a randomized controlled trial was conducted to identify risk factors related to poor outcomes in patients who underwent minimally invasive discectomy.

Methods

Patients were divided into satisfied and dissatisfied subgroups based on Oswestry Disability Index (ODI), visual analogue scale (VAS) back pain score (VAS-back) and leg pain score (VAS-leg) at short-term and midterm follow-up according to the patient acceptable symptom state threshold. Demographic characteristics, radiographic parameters, and clinical outcomes between the satisfied and dissatisfied subgroups were compared using univariate and multivariate analysis.

Results

A total of 222 patients (92.1%) completed 2-year follow-up, and the postoperative ODI, VAS-back, and VAS-leg were significantly improved after surgery as compared to preoperatively. Multivariate analysis indicated older age (p=0.026), lateral recess stenosis (p=0.046), and lower baseline ODI (p=0.027) were related to poor short-term functional improvement. Higher baseline VAS-back (p=0.048) was associated with poor short-term relief of back pain, while absence of decreased sensation (p=0.019) and far-lateral disc herniation (p=0.004) were associated with poorer short-term relief of leg pain. Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement (p=0.003) and relief of back pain (p=0.031). Disc protrusion (p=0.036) predicted poorer relief of back pain at midterm follow-up.

Conclusion

In this study, several factors were identified to be predictive of poor surgical outcomes following minimally invasive discectomy. (ClinicalTrials.gov number: NCT01997086).

Predictors of Pain Recurrence After Lumbar Facet Joint Injections

Introduction

Facet joint injections (FJIs) of anesthetic and corticosteroids are useful for the diagnosis and treatment of low back pain (LBP). In the current study, we evaluated the efficacy of FJI on LBP treatment and the predictive variables of pain recurrence after FJI.

Methods

We included and followed prospectively forty-three consecutive patients with chronic LBP treated with FJI. Clinical assessments were carried out at a baseline 1 week before FJIs and after a 6-month follow-up visit using the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for disability-specific measure and MacNab criteria for global effectiveness, and compared through analysis using paired-samples “t” tests. Multiple cox-regression analysis was used to identify the presurgical variables independently associated with pain recurrence anytime during the follow-up. In addition to the demographic, clinical, and surgical data, we also analyzed psychometric scales: Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI).

Results

After a 6-month follow-up, thirty-two patients (74.4%) showed a clinically significant reduction of pain and twenty-seven (62.8%) reported a clinically significant improvement of disability. Presurgical catastrophizing (PCS score ≥ 5, adjusted HR 4.4, CI 95% 1.7–11.3, p = 0.002) and smoking (Adjusted HR 12.5, CI 95% 1.1–138.9, p = 0.04) remains associated with pain recurrence.

Conclusion

FJI reduces LBP and disability of patients with unresponsive LBP. Pain-related cognitive and behavioral factors determined by pain catastrophizing and smoking were independently associated with pain recurrence after lumbar FJI. The results support the need of a multidisciplinary approach for presurgical evaluation of patients with chronic pain.

Comparison of the Effectiveness of Radiofrequency Neurotomy and Endoscopic Neurotomy of Lumbar Medial Branch for Facetogenic Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

To compare the effectiveness of radiofrequency neurotomy (RN) and endoscopic neurotomy (EN) of lumbar medial branch (MB) for facetogenic chronic low back pain (FCLBP).

METHODS

Forty patients with FCLBP were included and randomly assigned to the control group and the experimental group. The control group (20 cases) underwent X-ray-assisted RN and the experimental group (20 cases) underwent EN of the lumbar MB. The patients' Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated and compared preoperatively, and at 3 weeks, 6 months, 1 year, and 2 years postoperatively.

RESULTS

First, the RN group demonstrated successful treatment results (P < 0.05) at 3 weeks, 6 months, and 1 year after surgery. At 2 years, patients reported no significant effectiveness (P > 0.05). Second, the EN group demonstrated more prolonged successful treatment outcomes compared with the RN group. At 2 years, although the efficacy declined further, the VAS and ODI scores showed significant improvements compared with the preoperative data (P < 0.05). Third, there was no difference in VAS and ODI scores between the 2 groups at 3 weeks after surgery (P > 0.05). At 6 months and later, the EN group demonstrated better outcomes (P < 0.05).

CONCLUSIONS

For FCLBP, EN and X-ray-assisted RN of lumbar MB are both effective treatments. However, endoscopic lumbar MB neurotomy has the better and longer effectiveness.

[Diagnosis and interventional treatment of pain syndromes after surgery for degenerative lumbar spine diseases]

Postoperative pain accompanies up to 20% of interventions for degenerative spine diseases (DSDs). The epidemiologic data are contradictory; clinical and radiological diagnostics is often low efficient; capabilities of interventional diagnosis and treatment techniques are poorly understood.

PURPOSE

The study purpose was to investigate the structure of pain syndromes after surgery for DSDs of the lumbar spine, based on complex diagnostics, as well as to evaluate the capabilities of interventional treatment.

MATERIAL AND METHODS

We examined 310 patients with postoperative pain syndromes. Patients with obvious indications for repeated surgery were excluded from the analysis; the remaining patients underwent selective diagnostic blockades followed by interventional (puncture) treatment. A positive outcome was defined as a reduction in pain by 50% on the numerical rating scale (NRS-11), by 20% in the Oswestry index (ODI), and by 8 points in the sciatica bothersomeness index (SBI), with the effect lasting for 12 months. Predictive factors for the risk of pain syndromes were analyzed.

RESULTS

Out of 310 patients, 162 (52.6%) patients had no obvious indications for surgery. Radicular pain was detected in 56 (18.6%) of 310 patients; the positive treatment outcome was achieved in 38 (67.86%) of 56 patients. Facet pain was present in 29 (9.35%) patients; the positive treatment outcome was achieved in 23 (79.31%) patients. Discogenic pain was found in 12 (3.87%) patients; the positive treatment outcome was achieved in 5 (41.63%) patients. sacroiliac joint (SIJ) pain was present in 42 (13.55%) patients; the positive treatment outcome was achieved in 36 (85.71%) patients. Myofascial and competing pain was detected in 12 (3.87%) patients; the causes were not identified in 11 (3.55%) cases. The main risk factors were sagittal balance parameters.

CONCLUSION

Complex diagnostics revealed postoperative pain not associated with surgical causes in 52.6% of cases; the origin of pain was identified in 49.95% of cases. Interventional treatment was effective in 64.81% of cases; failed back surgery syndrome was diagnosed in 16.13% of patients.

Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration

The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.

Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: A retrospective comparative study

The aim of this study was to compare the mid-term effects and benefits of ultrasound (US)-guided and fluoroscopy (FL)-guided medial branch blocks (MBBs) for chronic lower lumbar facet joint pain through pain relief, functional improvement, and injection efficiency evaluation.Patients with chronic lumbar facet joint pain who received US (n = 68) or FL-guided MBBs (n = 78) were included in this retrospective study. All procedures were performed under FL or US guidance. Complication frequency, therapeutic effects, functional improvement, and the injection efficiency of MBBs were compared at 1, 3, and 6 months after the last injection.Both the Oswestry Disability Index (ODI) and the verbal numeric pain scale (VNS) improved at 1, 3, and 6 months after the last injections in both groups. Statistical differences were not observed in ODI and VNS between the groups (P > .05). The proportion of patients who reported successful treatment outcomes showed no significant differences between the groups at different time points. Logistic regression analysis showed that sex, pain duration, injection methods, number of injections, analgesic use, and age were not independent predictors of a successful outcome. US guidance was associated with a significantly shorter performance time.US-guided MBBs did not show significant differences in analgesic effect and functional improvement compared with the FL-guided approach. Therefore, by considering our data from this retrospective study, US-guided MBBs warrant consideration in the conservative management of lower lumbar facet joint pain.

Evaluation of Efficacy of Bone Scan With SPECT/CT in the Management of Low Back Pain: A Study Supported by Differential Diagnostic Local Anesthetic Blocks

INTRODUCTION

Conventional radiologic modalities provide details only about the anatomic aspect of the various structures of the spine. Frequently the structures that show abnormal morphology may not be the cause of low back pain (LBP). Functional imaging in the form of bone scan along with single photon emission computerized tomography (SPECT/CT) may be helpful in identifying structures causing pain, whether morphologically normal or not. The objective of this study is to evaluate the role of bone scan with SPECT/CT in management of patients with LBP.

METHODS

This is randomized double-blinded controlled study performed on 80 patients with LBP aged 20 to 80 years, ASA physical status I to III. Patients were randomized into bone scan and control groups consisting of 40 patients each. On the basis of the clinical features and radiologic findings a clinical diagnosis was made. After making a clinical diagnosis, the patients in bone scan group were subjected to bone scan with SPECT/CT. On the basis of the finding of the bone scan and SPECT/CT, a new working diagnosis was made and intervention was performed according to the new working diagnosis. Diagnostic blocks in the control group were given based on clinical diagnosis. Controlled comparative diagnostic blocks were performed with local anesthetic. The pain score just after the diagnostic block and at the time of discharge (approximately 4 h later) was recorded; the pain relief was recorded in percentage.

RESULTS

In both the groups, sacroilitis was the most common diagnosis followed by facet joint arthropathy. The number of patients obtaining pain relief of >50% was significantly higher in the bone scan-positive group as compared with the control group. Three new clinical conditions were identified in the bone scan group. These conditions were multiple myeloma, avascular necrosis of the femoral head, and ankylosing spondylitis.

CONCLUSIONS

Bone scan with SPECT/CT was found to complement the clinical workup of patients with LBP. Inclusion of bone scan with SPECT/CT in LBP management protocol can help in making a correct diagnosis. At times it might bring out some new information that may be vital for further management of the patients with LBP.

Comparison of facet joint activity on 99mTc-MDP SPECT/CT with facet joint signal change on MRI with fat suppression

PURPOSE

We compared signal change on magnetic resonance imaging (MRI) with fat suppression and bone scan activity of lumbar facet joints to determine if these two imaging findings are correlated.

METHODS

We retrospectively identified all patients who underwent imaging of the lumbar spine for pain evaluation using both technetium-99m methylene disphosphonate single-photon emission computed tomography/computed tomography (99mTc-MDP SPECT/CT) and MRI with at least one fat-suppressed T2- or T1-weighted sequence with gadolinium enhancement within a 180-day interval, at our institution between 1 January 2008 and 19 February 2013. Facet joint activity on 99mTc-MDP SPECT/CT and peri-facet signal change on MRI were rated as normal or increased. Agreement between the two examination types were determined with the κ and prevalence-adjusted bias-adjusted κ (PABAK) statistics.

RESULTS

This study included 60 patients (28 male, 47%), with a mean age of 49±19.7 years (range, 12-93 years). The κ value indicated no agreement between 99mTc-MDP SPECT/CT and MRI (κ=-0.026; 95% confidence interval: -0.051, 0.000). The PABAK values were fair to high at each spinal level, which suggests that relatively low disease prevalence lowered the κ values. Together, the κ and PABAK values indicate that there is some degree of intermodality agreement, but that it is not consistent.

CONCLUSION

Overall, facet joint signal change on fat-suppressed MRI did not always correlate with increased 99mTc-MDP SPECT/CT activity. MRI and 99mTc-MDP SPECT/CT for facet joint evaluation should not be considered interchangeable examinations in clinical practice or research.

Efficacy of Percutaneous Adhesiolysis in the Treatment of Lumbar Post Surgery Syndrome

Context

Lumbar post-surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous adhesiolysis is often contemplated in managing lumbar post surgery syndrome. Recent guidelines and systematic reviews have reached different conclusions about the level of evidence for the efficacy of epidural injections and percutaneous adhesiolysis in managing lumbar post surgery syndrome. The objective of this systematic review was to determine the efficacy of all 3 percutaneous adhesiolysis anatomical approaches (caudal, interlaminar, and transforaminal) in treating lumbar post-surgery syndrome.

Evidence Acquisition

Data Sources: A literature search was performed from 1966 through October 2014 utilizing multiple databases. Study Selection: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and percutaneous adhesiolysis in managing lumbar post-surgery syndrome was performed including methodological quality assessment utilizing Cochrane review criteria, Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB), and grading of evidence using 5 levels of evidence ranging from Level I to Level V. Data Extraction: The search strategy emphasized post-surgery syndrome and related pathologies treated with percutaneous adhesiolysis procedures.

Results

The search criteria yielded 16 manuscripts on percutaneous adhesiolysis assessing post-surgery syndrome. Of these, only 4 randomized trials met inclusion criteria for methodological quality assessment, 3 of them were of high quality; and the fourth manuscript was of low quality. Based on these 3 randomized controlled trials, 2 of them with one-day procedure and one with a 3-day procedure, the level of evidence for the efficacy of percutaneous adhesiolysis is Level II based on best evidence synthesis.

Conclusions

Based on this systematic review, percutaneous adhesiolysis is effective in managing patients with lumbar post-surgery syndrome after the failure of conservative management including fluoroscopically directed epidural injections.

Zygapophysial joint pain in selected patients

The zygapophysial joints (z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can cause pain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain (10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks (MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.

Lumbar Zygapophyseal (Facet) Joint Pain

Lumbar zygapophyseal joints act as primary pain generators in at least 10-15% of patients with chronic low back pain.Diagnostic nerve blocks are the most reliable way to diagnose lumbar zygapophyseal joint pain.IASP recommends either controlled or comparative blocks for diagnosis of zygapophyseal joint pain as there is a significant incidence of false positives with single blocks.Management should be multimodal comprising education, exercises, analgesics and procedural interventions to achieve functional restoration.There is a need for further RCTs with standardised diagnostic criteria and outcome measures as well as long-term data to determine the efficacy of radiofrequency denervation.

Utility of single photon emission computed tomography/computed tomography imaging in evaluation of chronic low back pain

Introduction:

Abnormal morphologic findings in imaging were thought to explain the etiology of low back pain (LBP). However, it is now known that variety of morphologic abnormalities is noted even in asymptomatic individuals. Single photon emission computed tomography/computed tomography (SPECT/CT) could be used to differentiate incidental findings from clinically significant findings.

Objective:

This study was performed to define the SPECT/CT patterns in patients with LBP and to correlate these with clinical and magnetic resonance imaging (MRI) findings.

Materials and Methods:

Thirty adult patients with LBP of duration 3 months or more were prospectively evaluated in this study. Patients with known or suspected malignancy, trauma or infectious processes were excluded. A detailed history of sensory and motor symptoms and neurologic examination was performed. All the patients were subjected to MRI and bone scintigraphy with hybrid SPECT/CT of the lumbo-sacral spine within 1 month of each other. The patients were classified into those with and without neurologic symptoms, activity limitation. The findings of clinical examination and imaging were compared. MRI and SPECT/CT findings were also compared.

Results:

Thirty patients (18 men and 12 women; mean age 38 years; range 17-64 years) were eligible for the study. Clinically, 14 of 30 (46%) had neurologic signs and or symptoms. Six of the 30 patients (20%) had positive straight leg raising test (SLRT). Twenty-two of the 30 patients (73%) had SPECT abnormality. Most frequent SPECT/CT abnormality was tracer uptake in the anterior part of vertebral body with osteophytes/sclerotic changes. Significant positive agreement was noted between this finding and MRI evidence of degenerative disc disease. Only 13% of patients had more than one abnormality in SPECT. All 30 patients had MRI abnormalities. The most frequent abnormality was degenerative disc disease and facet joint arthropathy. MRI showed single intervertebral disc abnormality in 36% of the patients and more than one intervertebral disc abnormality in remaining 64% patients. Fifteen of the 30 patients had facet joint arthropathy. 60% of these patients had involvement of more than one level facet joints while 38% had associated inter vertebral disc disease. 83% of the patients with positive SLRT had SPECT and MRI abnormalities. 100% of patients with neurologic symptoms had SPECT and MRI abnormalities.

Conclusion:

Addition of hybrid SPECT/CT data will help differentiate incidental from significant MRI abnormalities as all patients with LBP have MRI abnormalities and most have MRI abnormalities at multiple sites. Tracer uptake in the anterior part of the vertebral body represents degenerative disc disease. MRI is sensitive and SPECT/CT is specific for facet joint arthropathy. Both investigations are best used complementary to each other.

Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial

Background

The literature is replete with evaluations of failed surgery, illustrating a 9.5%–25% reoperation rate. Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, recurrent disc herniation, sacroiliac joint pain, and facet joint pain among other causes.

Methods

Patients (n = 120) were randomly assigned to two groups with a 2-year follow-up. Group I (control group, n = 60) received caudal epidural injections with catheterization up to S3 with local anesthetic (lidocaine 2%, 5 mL), nonparticulate betamethasone (6 mg, 1 mL), and 6 mL of 0.9% sodium chloride solution. Group II (intervention group, n = 60) received percutaneous adhesiolysis of the targeted area, with targeted delivery of lidocaine 2% (5 mL), 10% hypertonic sodium chloride solution (6 mL), and nonparticulate betamethasone (6 mg). The multiple outcome measures included the Numeric Rating Scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as 50% improvement in pain and Oswestry Disability Index scores.

Results

Significant improvement with at least 50% relief with pain and improvement in functional status was illustrated in 82% of patients at the 2-year follow-up in the intervention group compared to 5% in the control group receiving caudal epidural injections. The average number of procedures over a period of 2 years in Group II was 6.4 ± 2.35 with overall total relief of approximately 78 weeks out of 104 weeks.

Conclusion

The results of this study show significant improvement in 82% of patients over a period of 2 years with an average of six to seven procedures of 1-day percutaneous adhesiolysis in patients with failed back surgery syndrome.

Zygapophysial joint pain in post lumbar surgery syndrome. The efficacy of medial branch blocks and radiofrequency neurotomy

OBJECTIVE

To investigate the prevalence of zygapophysial joint pain in patients after disc surgery, and to determine the effectiveness of radiofrequency neurotomy for its treatment.

DESIGN

Retrospective practice audit.

SETTING

Review of charts of all patients who underwent lumbar disc surgery during a time period of 2 years.

INTERVENTIONS

Patients with persistent back pain after surgery were tested with repeated medial branch blocks. Those patients who consistently report at least 80% pain relief underwent radiofrequency neurotomy. A successful outcome was defined as at least 50% pain reduction enduring for 6 months.

RESULTS

In a population of 479 patients who underwent microsurgical lumbar disc operations, persistent axial back pain occurred in 120, of whom 34 had positive responses to diagnostic blocks and were treated with radiofrequency neurotomy. Twenty patients (58.8%) achieved at least 50% reduction in pain for a minimum of 6 months.

CONCLUSIONS

The prevalence of zygapophysial joint pain appears to be 7% in patients with failed back surgery syndrome. Patients with this condition can be treated with a radiofrequency neurotomy with a success rate of 58.8%.

The application of percutaneous lysis of epidural adhesions in patients with failed back surgery syndrome

PURPOSE

To investigate the efficacy and the feasibility of application of percutaneous lysis of epidural adhesions in failed back surgery syndrome (FBSS) using a stiff type guide wire and 4F vascular catheter.

METHODS

Ninety two patients with FBSS were randomly divided into two groups, the control group (treated by injection dexamethasone only) and percutaneous lysis of epidural adhesions group. Visual analog scale scores (VAS) and therapeutic evaluation were observed in the preoperative, seven days postoperative, one month and six months postoperative.

RESULTS

VAS scores for pain were significantly reduced in both groups at seven days. The VAS scores were in controlled group at one month, six months was significantly higher than that in epidural lysis group. However, there was no statistical difference in VAS scores of one month and six months when respectively compared to that of before operation in controlled group. Patients on epidural lysis reported clinical effectiveness rate was 50%. Patients on control was 5.26%, there was a statistical difference between two groups.

CONCLUSION

Percutaneous lysis of epidural adhesions by using a stiff type guide wire and 4F vascular catheter is an effective method in the treatment of FBSS and it has a value in clinical application.

Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: two-year results of a randomized, double-blind, active-control trial

STUDY DESIGN

A randomized, active control, double-blind trial.

OBJECTIVE

To evaluate the effectiveness of fluoroscopically directed caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to post lumbar surgery syndrome.

SUMMARY OF BACKGROUND DATA

There is a paucity of evidence concerning caudal epidural injections for managing chronic persistent low back pain with or without lower extremity pain caused by post lumbar surgery syndrome.

METHODS

This active control randomized study included 140 patients with 70 patients in each group. Group I received 0.5% lidocaine, 10 mL; Group II received 9 mL of 0.5% lidocaine mixed with 1 mL of 6 mg of nonparticulate betamethasone. The multiple outcome measures included the numeric rating scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as at least 50% improvement in pain and Oswestry Disability Index scores. Patients with a positive response to the first 2 procedures with at least 3 weeks of relief were considered to be successful. All others were considered as failures.

RESULTS

Overall in Group I, 53% and 47% of the patients and in Group II, 59% and 58% of the patients, showed significant improvement with reduction in pain scores and disability index at 12 months and 24 months. In contrast, in the successful groups, significant pain relief and improvement in function were observed in 70% and 62% of Group I at one and 2 years; in 75% and 69% of Group II at one and 2 years. The results in the successful group showed that at the end of the first year patients experienced approximately 38 weeks of relief and at the end of 2 years Group I had 62 weeks and Group II had 68 weeks of relief. Overall total relief for 2 years was 48 weeks in Group I and 54 weeks in Group II. The average procedures in the successful groups were at 4 in one year and 6 at the end of 2 years.

CONCLUSION

Caudal epidural injections of local anesthetic with or without steroid might be effective in patients with chronic persistent low back and/or lower extremity pain in patients with post lumbar surgery syndrome.

Avaliação clínica da infiltração facetaria no tratamento da dor lombar crônica por síndrome facetaria: estudo prospectivo

OBJETIVO: Avaliar os resultados do bloqueio facetário lombar com anestésico local e corticóide em pacientes com lombalgia crônica por síndrome facetária. MÉTODOS: Realizou-se um estudo prospectivo em 30 pacientes com lombalgia crônica por síndrome facetária, os quais foram submetidos à infiltração facetária com bupivacaína a 0,25% e acetato de metilpredinisolona sob controle radioscópico, e foram seguidos e avaliados seguindo as escalas Visual Analógica da Dor, Oswestry Disability Index e os Critérios de MacNab nos quais 17 foram do sexo feminino e 13 do sexo masculino. RESULTADOS: Foi observada diminuição significativa (p<0,05) da dor pela Escala Visual Analógica. Obtivemos 73,3% de resultados satisfatórios na primeira semana, 63,3% no primeiro mês, 43,3% em 3 meses, e 36,6% no final de 6 meses. O índice de complicações foi muito baixo. CONCLUSÃO: O bloqueio facetário utilizando corticóide e anestésico local se mostrou-se efetivo, seguro e de fácil realização. No entanto houve recidiva em mais de 50% dos casos dentro de 6 meses.

Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up

STUDY DESIGN

A randomized, double-blind, controlled trial.

OBJECTIVE

To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin.

SUMMARY OF BACKGROUND DATA

Lumbar facet joints have been shown as the source of chronic pain in 21% to 41% of low back patients with an average prevalence of 31% utilizing controlled comparative local anesthetic blocks. Intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin.

METHODS

The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids. The inclusion criteria was based upon a positive response to diagnostic controlled, comparative local anesthetic lumbar facet joint blocks.Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months.

RESULTS

Significant improvement with significant pain relief of >or= 50% and functional improvement of >or= 40% were observed in 85% in Group 1, and 90% in Group II, at 2-year follow-up.The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks, requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment.

CONCLUSIONS

Therapeutic lumbar facet joint nerve blocks, with or without steroids, may provide a management option for chronic function-limiting low back pain of facet joint origin.

The provocative lumbar facet joint

Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.

Inter-tester Reliability in Classifying Acute and Subacute Low Back Pain Patients into Clinical Subgroups: A Comparison of Specialists and Non-Specialists. A Pilot Study

Many systems have been suggested for classifying low back pain (LBP); the most commonly used among physiotherapists involves a pathoanatomical/pathophysiological tissue classification system. Few studies have examined whether this form of classification of LBP disorders can be performed in a reliable manner between specialists with advanced training, or between specialists with advanced training and non-specialists who lack advanced training. The purpose of this paper was to examine the inter-tester reliability of two specialists, and the ability of a specialist and non-specialist to independently classify patients with LBP, utilizing clinical tests and history-based classification methods after a short educational course on the classification system. Subjects were acute or sub-acute patients with LBP who visited their occupational healthcare or municipal healthcare center. Inter-tester reliability between the specialist and non-specialists was at almost the same level: overall Kappa 0.60 (95%CI; 0.40 to 0.85), overall agreement 70%, as between the two specialists: overall Kappa 0.65 (95%CI; 0.33-0.86), overall agreement 77%. The findings suggest that a short educational course can provide rather reliable examination tools to allow non-specialized physiotherapists to classify patients according to tissue origination.

Spinal injection procedures: a review of concepts, controversies, and complications

The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

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.