The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain

5. Sacroiliac joint pain

INTRODUCTION

Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%.

METHODS

In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized.

RESULTS

Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false-positive and false-negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first-line therapies (eg, pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra- and extra-articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low.

CONCLUSIONS

SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.

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.

Percutaneous Spinal Interventions for Chronic Pain Management

Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.

Radiofrequency denervation and cryoablation of the lumbar zygapophysial joints in the treatment of positive lumbar facet joint syndrome – a report of three cases

Radiofrequency denervation of the zygapophysial (facet) joints is a frequently performed procedure for chronic low back pain. However, cryoablation represents a novel therapeutic approach for this condition. We observed and analyzed 3 cases with confirmed positive lumbar facet joint syndrome. Our results show a significant improvement in the clinical state of the patients in the first and third months after the procedure. The 6-month follow-up examination demonstrates a recurrence of pain and a gradual deterioration in the quality of life with a lasting partial pain-relief effect. Thermal radiofrequency denervation and cryoablation of the lumbar zygapophysial joints represent an effective, albeit temporary treatment option for lumbar facet joint syndrome patients, resulting from the pathophysiology of sensory nerve regeneration after destructive procedures. This type of treatment can be used repeatedly in the case of a positive response.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

Background

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

Methods

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

Results

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

Conclusions

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

The Prevalence of "Pure" Lumbar Zygapophysial Joint Pain in Patients with Chronic Low Back Pain

BACKGROUND

Estimates of the prevalence of lumbar zygapophysial joint (Z joint) pain differ in the literature, as do case definitions for this condition. No studies have determined the prevalence of "pure" lumbar Z joint pain, defined as complete relief of pain following placebo-controlled diagnostic blocks.

OBJECTIVE

The objective of this study was to estimate the prevalence of "pure" lumbar Z joint pain.

METHODS

In a private practice setting, 206 patients with possible lumbar Z joint pain underwent controlled diagnostic blocks using one of two protocols: placebo-controlled comparative blocks and fully randomized, placebo-controlled, triple blocks.

RESULTS

In the combined sample, the prevalence of "pure" lumbar Z joint pain was 15% (10-20%).

CONCLUSIONS

The prevalence of "pure" lumbar Z joint pain is substantially and significantly less than most of the prevalence estimates of lumbar Z joint pain reported in the literature.

Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints

OBJECTIVES

The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine.

METHODS

Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield.

RESULTS

In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%.

CONCLUSIONS

Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.

Fluoroscopic Findings of Extra-Cervical Facet Joint Flow and Its Incidence on Cervical Facet Joint Arthrograms

Cervical facet joint (CFJ) syndrome is a common cause of neck pain. For its diagnosis and treatment, CFJ injection with arthrogram is generally performed. This study aimed to investigate the frequency of extra-CFJ flow on CFJ arthrograms during injections and its differences according to age, sex, and cervical vertebral level. We analyzed 760 CFJ arthrograms administrated to 208 patients diagnosed with CFJ syndrome. Arthrograms at each vertebral level were collected to evaluate the normal CFJ and extra-CFJ flow. The primary and secondary outcomes were frequency of extra-CFJ flow according to cervical vertebral level, age, and sex and according to pairwise cervical levels, respectively. Extra-CFJ flow at the cervical spine occurred during 179 injections, and the overall incidence was 3.3–36.2% at different cervical levels. The incidence of extra-CFJ flow at each cervical vertebral level according to age and sex was not significant. Extra-CFJ flow was the highest at C6 and C7, but there was no statistical significance. Extra-CFJ flow was higher at lower vertebral levels (C5–C7) than at upper levels (C3 and C4). Additional clinical studies and anatomical evaluations are needed to support its clinical value and enable the development of new injection techniques.

Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation

A commonly disputed medicolegal issue is the documentation of the location, degree, and anatomical source of an injured plaintiff’s ongoing pain, particularly when the painful region is in or near the spine, and when the symptoms have arisen as result of a relatively low speed traffic crash. The purpose of our paper is to provide health and legal practitioners with strategies to identify the source of cervical pain and to aid triers of fact (decision makers) in reaching better informed conclusions. We review the medical evidence for the applications and reliability of cervical medial branch nerve blocks as an indication of painful spinal facets. We also present legal precedents for the legal admissibility of the results of such diagnostic testing as evidence of chronic spine pain after a traffic crash. Part of the reason for the dispute is the subjective nature of pain, and the fact that medical documentation of pain complaints relies primarily on the history given by the patient. A condition that can be documented objectively is chronic cervical spine facet joint pain, as demonstrated by medial branch block (injection). The diagnostic accuracy of medial branch blocks has been extensively described in the scientific medical literature, and evidence of facet blocks to objectively document chronic post-traumatic neck pain has been accepted as scientifically reliable in courts and tribunals in the USA, Canada and the United Kingdom. We conclude that there is convincing scientific medical evidence that the results of cervical facet blocks provide reliable objective evidence of chronic post-traumatic spine pain, suitable for presentation to an adjudicative decision maker.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Facet joint injections for management of low back pain: a clinically focused review

Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.

The Source and the Course of the Articular Branches to the T4-T8 Zygapophysial Joints

OBJECTIVE

To define the source and the course of the articular branches to the midthoracic zygapophysial ("z") joints.

DESIGN

Cadaveric dissection.

SETTING

The Gross Anatomy Laboratory of the Duke University School of Medicine.

SUBJECTS

Ten human cadaveric thoraces.

METHODS

Gross and stereoscopic dissection of dorsal rami T4-T8 was performed bilaterally on 10 adult embalmed cadavers. The medial and lateral branches were traced to their origins from the dorsal rami, and the course of the articular nerves was documented through digital photography. Radio-opaque wire (20 gauge) was applied to the nerves. Fluoroscopic images were obtained to delineate their radiographic course with respect to osseous landmarks.

RESULTS

Forty-eight inferior articular branches were identified. Three (6.3%) originated from the medial branch and 44 (91.7%) from the dorsal ramus. One was indeterminate. Fifty-one superior articular branches were identified. Eight (15.7%) originated from the medial branch and 43 (84.3%) from the dorsal ramus. In 12% of cases (6/50), there was side-to-side asymmetry in the origins of the articular branches. Nerves were commonly suspended in the intertransverse space. The articular branches contacted an osseous structure in only 39% of cases. As previously reported, a "descending branch" was not identified in any specimen.

CONCLUSIONS

Articular branches to the T4-T8 z-joints have substantial inter- and intraspecimen variability of origin. They typically arise from the dorsal ramus rather than the medial branch and frequently do not contact any osseous structure to allow percutaneous needle placement.

Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome

Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit.

Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care

Musculoskeletal disorders are the leading source of pain and disability globally but are especially prevalent in the industrialized nations including the U.S. In addition to the substantial individual suffering caused the rising monetary costs of these disorders are noteworthy. In the U.S. alone the annual costs have been estimated to be $874 billion 5.7% of the annual U.S. G.D.P. Despite these expenditures the care provided to patients with musculoskeletal disorders is highly variable and has regularly been shown to have suboptimal outcomes. The many reasons for this ineffective care include the mutable nature of the prevailing syndromes and their limited and variable understanding. The care rendered by a broad and incongruent group of providers who practice disparate methodologies and employ variable treatments. Disorderedly triage comprised of arbitrary selection of providers, care methodologies, and treatments, which is prone to a range of extraneous influences. Treatments that are unable to apprehend the causative pathological processes, which are therefore progressive, cause irreversible damage to the respective musculoskeletal structures, and result in enduring pain and disability. The overall lack of preventative care and the consequent prevalence of these disorders especially in specific work environments and with certain high-risk life styles. This article makes recommendations for better understanding, prevention, early recognition, timely employment of disease altering therapies, streamlining the existing care, and policy initiatives for waste confinement and improvement. These discernments may improve the overall quality of care provided to these patients, diminish the staggering pain and disability caused, and can reduce the immense costs incurred.

Radiofrequency techniques to treat chronic knee pain: a comprehensive review of anatomy, effectiveness, treatment parameters, and patient selection

Background

The use of radiofrequency ablation (RFA) procedures to treat chronic knee pain has surged in the past decade, though many questions remain regarding anatomical targets, selection criteria, and evidence for effectiveness.

Methods

A comprehensive literature review was performed on anatomy, selection criteria, technical parameters, results of clinical studies, and complications. Databases searched included MEDLINE and Google Scholar, with all types of clinical and preclinical studies considered.

Results

We identified nine relevant clinical trials, which included 592 patients, evaluating knee RFA for osteoarthritis and persistent postsurgical pain. These included one randomized, placebo-controlled trial, one randomized controlled trial evaluating RFA as add-on therapy, four comparative-effectiveness studies, two randomized trials comparing different techniques and treatment paradigms, and one non-randomized, controlled trial. The results of these studies demonstrate significant benefit for both reduction and functional improvement lasting between 3 and 12 months, with questionable utility for prognostic blocks. There was considerable variation in the described neuroanatomy, neural targets, radiofrequency technique, and selection criteria.

Conclusion

RFA of the knee appears to be a viable and effective treatment option, providing significant benefit to well-selected patients lasting at least 3 months. More research is needed to better identify neural targets, refine selection criteria to include the use of prognostic blocks, optimize treatment parameters, and better elucidate relative effectiveness compared to other treatments.

Regional anesthesia in pain management

PURPOSE OF REVIEW

The study focuses on neural blocks with local anesthetics in postoperative and chronic pain. It is prompted by the recent publication of several systematic reviews and guidelines.

RECENT FINDINGS

For postoperative pain, the current evidence supports infusions of local anesthetics at the surgical site, continuous peripheral nerve blocks, and neuraxial analgesia for major thoracic and abdominal procedures. Ultrasound guidance can improve the performance of the blocks and different patient outcomes, although the incidence of peripheral nerve damage is not decreased. For chronic pain, the best available evidence is on nerve blocks for the diagnosis of facet joint pain. Further research is needed to validate diagnostic nerve blocks for other indications. Therapeutic blocks with only local anesthetics (greater occipital nerve and sphenopalatine ganglion) are effective in headache. A possible mechanism is modulation of central nociceptive pathways. Therapeutic nerve blocks for other indications are mostly supported by retrospective studies and case series.

SUMMARY

Recent literature strongly supports the use of regional anesthesia for postoperative pain, whereby infusions at peripheral nerves and surgical site are gaining increasing importance. Local anesthetic blocks are valid for the diagnosis of facet joint pain and effective in treating headache. There is a need for further research in diagnostic and therapeutic blocks for chronic pain.

Pharmacological and Interventional Management of Pain After Whiplash Injury

Synopsis Whiplash-associated disorder (WAD) is a group of symptoms and clinical manifestations resulting from rear-end or side impact. Despite the wide use of medications in WAD, the published research does not allow recommendations based on high evidence level. It may be meaningful to use nonsteroidal anti-inflammatory drugs in the acute posttraumatic phase. In chronic WAD, the use of nonsteroidal anti-inflammatory drugs is more concerning due to potential gastrointestinal and renal complications with prolonged use and lack of evidence for long-term benefits. Antidepressants can be used in patients with clinically relevant hyperalgesia, sleep disorder associated with pain, or depression. Anticonvulsants are unlikely first-choice medications, but can be considered if other treatments fail. The use of opioids in patients with chronic pain has become the object of severe concern, due to the lack of evidence for long-term benefits and the associated risks. Extreme caution in prescribing and monitoring opioid treatment is mandatory. Nerve blocks of the zygapophyseal (facet) joints have validity for the diagnosis of facet joint pain, which is one of the possible manifestations of WAD. One randomized sham-controlled trial and several high-quality prospective studies support the efficacy of radiofrequency neurotomy for the treatment of facet joint pain. The efficacy of trigger point treatments is uncertain. They can be offered due to possible efficacy and limited risks. Any medication or procedure has to be considered in the frame of a comprehensive patient evaluation. As for any chronic pain condition, concomitant consideration of rehabilitation and psychosocial interventions is mandatory. J Orthop Sports Phys Ther 2016;46(10):845-850. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6906.

Morphology of Cervical Spine Meniscoids in Individuals With Chronic Whiplash-Associated Disorder: A Case-Control Study

Study Design Case-control study. Background Cervical spine meniscoids are thought to contribute to neck pain and hypomobility in individuals with chronic whiplash-associated disorder (WAD); however, their morphology has not been studied in a clinical population. Objectives To investigate cervical spine meniscoid morphology in individuals with chronic WAD. Methods Twenty volunteers with chronic WAD (mean ± SD age, 39.3 ± 11.0 years; 10 female) and 20 age- and sex-matched controls (age, 39.1 ± 10.6 years) underwent cervical spine magnetic resonance imaging. Lateral atlantoaxial and zygapophyseal joints (C2-3 to C6-7) were inspected for meniscoids. Length of meniscoid protrusion was measured and composition (adipose/fibrous/fibroadipose) assessed. Data were analyzed using Wilcoxon signed-rank tests and linear and logistic regression (P<.05). Results Meniscoids were identified in the chronic WAD (n = 317) and control (n = 296) groups. At the lateral atlantoaxial joints, median meniscoid length was greater in the control group (ventral, 6.07 mm; dorsal, 7.24 mm) than the WAD group (ventral, 5.01 mm; P = .06 and dorsal, 6.48 mm; P<.01). At the dorsal aspect of zygapophyseal joints, meniscoids were more frequently fibrous in the chronic WAD group (odds ratio = 2.38, P<.01; likelihood ratio test: χ²₂, 9.02; P = .01). Conclusion In individuals with chronic WAD, lateral atlantoaxial meniscoids were shorter and dorsal cervical zygapophyseal meniscoids were more fibrous, suggesting alterations in meniscoid composition. This may have pathoanatomical implications in chronic WAD. J Orthop Sports Phys Ther 2016;46(10):902-910. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6702.

Percutaneous Radiofrequency Facet Rhizotomy – Experience with 118 Procedures and Reappraisal of its Value

Background:

There have been many reports of percutaneous radiofrequency facet rhizotomy, perhaps better referred to as facet denervation, usually performed under general anaesthesia, with inconsistent success rates.

Objectives:

To report the authors' outcome data using both general and local anaesthesia and to reassess the value of this controversial procedure.

Methods:

Our experience with 118 consecutive percutaneous radiofrequency facet rhizotomies performed on 90 patients in the Toronto Western Hospital was analyzed. Sixty percent of the procedures were performed under general anaesthesia, 40% under local anaesthesia. All patients had been temporarily virtually relieved of pain after local anaesthetic blockade of the subject facets by an independent radiologist.

Results:

The patients were monitored from 1 - 33 (mean 5.6) months after surgery, with complete elimination or a greater than 50% subjective reduction of pain considered the criteria for success. For the first or only procedure this was 41% overall, 37% in cases done under local anaesthesia, 46% in cases done under general anaesthesia (difference not statistically significant p=0.52). There was no statistically significant difference in success rates for procedures performed in the cervical, thoracic or lumbosacral facets, with unilateral versus bilateral denervations, when two to three as compared with more than three facets were denervated, nor for operations done in patients who had had previous spinal surgery compared with those who had not. Results were not better regardless of whether hyperextension of the spine aggravated the patient's preoperative pain or not, and when the procedures were repeated in the same patient outcomes tended to be consistent, arguing against repetition of failed facet denervations. The morbidity was low, the chief problem being sensory loss and transient neuropathic pain in the distribution of cutaneous branches of posterior rami in the cervical and thoracic areas; mortality was zero.

Conclusions:

Percutaneous radiofrequency facet denervation is simple and safe, still worth considering in patients with disabling spinal pain that fails to respond to conservative treatment. The use of general anaesthesia shortens the operating time and the patient's discomfort without impairing success rate.

The Effectiveness and Risks of Fluoroscopically-Guided Cervical Medial Branch Thermal Radiofrequency Neurotomy: A Systematic Review with Comprehensive Analysis of the Published Data

OBJECTIVE

To determine the effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy (CMBTRFN) for treating chronic neck pain of zygapophysial joint origin.

DESIGN

Systematic review of the literature with comprehensive analysis of the published data.

INTERVENTIONS

Four reviewers formally trained in evidence-based medicine searched the literature on CMBTRFN. Each assessed the methodologies of studies found and appraised the quality of evidence presented.

OUTCOME MEASURES

The primary outcomes assessed were 100% relief of pain 6 and 12 months after treatment. Other outcomes were noted if reported. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The searches yielded eight primary publications on the effectiveness of the procedure. The evidence shows a majority of patients were pain free at 6 months and over a third were pain free at 1 year. The number needed to treat for complete pain relief at 6 months is 2. The evidence of effectiveness is of high quality according to the GRADE system. Twelve papers were found reporting unwanted effects, most of which are minor and temporary. No serious complications have ever been reported from procedures performed according to the published guidelines. The evidence of risks is of low quality according to the GRADE system.

CONCLUSIONS

If performed as described in the International Spine Intervention Society Guidelines, fluoroscopically-guided CMBTRFN is effective for abolishing zygapophysial joint pain and carries only minor risks.

Interventional pain management for spinal disorders: a review of injection techniques

Chronic spinal pain has a high prevalence and a severe economic, societal and health impact. In the last decades the practice and research of interventional techniques for the diagnosis and treatment of spinal pain has increased sharply. The level of evidence of the most common techniques is well documented. With image-guided precise diagnostic blocks it is possible to identify the source of chronic spinal pain in well over 60% of the cases. Nonsurgical specialties such as PM&R increasingly resort to the possibilities of interventional pain management for musculoskeletal disorders. For many forms of spinal pain there is at least fair evidence for long-term pain relief after a guided therapeutic injection often reducing the intake of analgesic medication or the need for surgery. This review focuses on the evidence, the application spectrum and special considerations of injection techniques for the treatment of spinal disorders.

Efficacy of needle-placement technique in radiofrequency ablation for treatment of lumbar facet arthropathy

Background

Many studies have assessed the efficacy of radiofrequency ablation to denervate the facet joint as an interventional means of treating axial low-back pain. In these studies, varying procedural techniques were utilized to ablate the nerves that innervate the facet joints. To date, no comparison studies have been performed to suggest superiority of one technique or even compare the prevalence of side effects and complications.

Materials and methods

A retrospective chart review was performed on patients who underwent a lumbar facet denervation procedure. Each patient’s chart was analyzed for treatment technique (early versus advanced Australian), preprocedural visual numeric scale (VNS) score, postprocedural VNS score, duration of pain relief, and complications.

Results

Pre- and postprocedural VNS scores and change in VNS score between the two groups showed no significant differences. Patient-reported benefit and duration of relief was greater in the advanced Australian technique group (P=0.012 and 0.022, respectively). The advanced Australian technique group demonstrated a significantly greater median duration of relief (4 months versus 1.5 months, P=0.022). Male sex and no pain-medication use at baseline were associated with decreased postablation VNS scores, while increasing age and higher preablation VNS scores were associated with increased postablation VNS scores. Despite increasing age being associated with increased postablation VNS scores, age and the advanced Australian technique were found to confer greater patient self-reported treatment benefit.

Conclusion

The advanced Australian technique provides a significant benefit over the early Australian technique for the treatment of lumbar facet pain, both in magnitude and duration of pain relief.

An Expedited Diagnostic Algorithm for Lumbosacral Pain: "The Best Likelihood Scenario Approach"

INTRODUCTION

The logic behind diagnostic blocks is very straightforward. What has not been determined is the way diagnostic blocks can be best used.

STUDY DESIGN

Philosophical essay.

DISCUSSION

The interventional pain management physician would serve as the diagnostic expert by efficiently determining the source of the patient's pain.

CONCLUSION

"The Best Likelihood Scenario" might improve diagnostic accuracy while decreasing societal costs.

WITHDRAWN: Botulinum toxin for subacute/chronic neck pain

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Medicinal and injection therapies for mechanical neck disorders

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

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Controlled medial branch anesthetic block in the diagnosis of chronic lumbar facet joint pain: the value of a three-month follow-up

OBJECTIVES

To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables.

METHODS

Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients.

RESULTS

A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05).

CONCLUSION

Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives.

A comparison of physical and psychological features of responders and non-responders to cervical facet blocks in chronic whiplash

Background

Cervical facet block (FB) procedures are often used as a diagnostic precursor to radiofrequency neurotomies (RFN) in the management of chronic whiplash associated disorders (WAD). Some individuals will respond to the FB procedures and others will not respond. Such responders and non-responders provided a sample of convenience to question whether there were differences in their physical and psychological features. This information may inform future predictive studies and ultimately the clinical selection of patients for FB procedures.

Methods

This cross-sectional study involved 58 individuals with chronic WAD who responded to cervical FB procedures (WAD_R); 32 who did not respond (WAD_NR) and 30 Healthy Controls (HC)s. Measures included: quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test); nociceptive flexion reflex (NFR); motor function (cervical range of movement (ROM); activity of the superficial neck flexors during the cranio-cervical flexion test (CCFT). Self-reported measures were gained from the following questionnaires: neuropathic pain (s-LANSS); psychological distress (General Health Questionnaire-28), post-traumatic stress (PDS) and pain catastrophization (PCS). Individuals with chronic whiplash attended the laboratory once the effects of the blocks had abated and symptoms had returned.

Results

Following FB procedures, both WAD groups demonstrated generalized hypersensitivity to all sensory tests, decreased neck ROM and increased superficial muscle activity with the CCFT compared to controls (p < 0.05). There were no significant differences between WAD groups (all p > 0.05). Both WAD groups demonstrated psychological distress (GHQ-28; p < 0.05), moderate post-traumatic stress symptoms and pain catastrophization. The WAD_NR group also demonstrated increased medication intake and elevated PCS scores compared to the WAD_R group (p < 0.05).

Conclusions

Chronic WAD responders and non-responders to FB procedures demonstrate a similar presentation of sensory disturbance, motor dysfunction and psychological distress. Higher levels of pain catastrophization and greater medication intake were the only factors found to differentiate these groups.

Long-term follow-up of cervical facet medial branch radiofrequency treatment with the single posterior-lateral approach: an exploratory study

BACKGROUND

Over 50% of patients presenting to pain clinic with neck pain have the cervical facet joints as the source of pain. Radiofrequency (RF) treatment of the medial branch, innervating the facet joint, is a therapeutic option. The objectives of this study were to evaluate the therapeutic effect and its duration of RF treatment, using the single posterior-lateral approach in patients suffering from facet joint degeneration and to identify predictors for a long-term effect.

METHODS

Of the 130 consecutive patients with axial neck pain referred to the University Pain Center Maastricht, 67 fulfilled the inclusion criteria. The therapeutic effect was measured using the Patients' Global Impression of Change (PGIC) scale. Retrospective data were made complete using newly collected PGIC follow-up data. A Kaplan-Meier curve evaluated the long-term therapeutic effect. Possible predictors of outcome were evaluated.

RESULTS

Two patients refused to participate and in the remaining 65 patients, overall pain relief was reported in 55.4% at 2-month follow-up. Moderately, important change of improvement and substantial change of improvement were seen in 50.8% of patients. At 3-year follow-up, 30% still reported pain reduction. Spinal treatment level was the only predictor found.

CONCLUSIONS

Radiofrequency treatment of the cervical facet joints using a single posterior-lateral approach is a promising technique in patients with chronic neck pain due to facet degeneration. The short-term and long-term therapeutic effects of this intervention justify a randomized controlled trial to estimate the efficacy of cervical facet joint RF treatment in a chronic neck pain population.

Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome

OBJECTIVE

We sought an optimal medial branch block (MBB) cutoff value for both single and double MBB protocols that would best correlate with a positive outcome of medial branch neurotomy (MBN).

OUTCOME MEASURES

We analyzed the percentage of subjective pain relief following MBB, confirmed by numerical rating scale (NRS) in aggravating positions before and 45 minutes after MBB. The percentage of overall pain relief following MBB was plotted against the following outcome variables: degree of subjective pain relief, duration of relief, patient satisfaction and activity level, no other doctor's visits, and reduction in medications use.

RESULTS

Using the percent of pain relief post-MBB plotted in 10% increments in the double-MBB group, patients reporting 70% or greater pain relief following MBB showed statistically favorable outcome for the following four criteria: percentage of pain relief, duration of relief, patient satisfaction, and pain medications reduction. In the single MBB group, patients reporting 80% or greater pain relief following MBB had favorable outcomes for improvement in activity level and patient satisfaction.

CONCLUSIONS

The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.

Validation of self-reported pain reduction after diagnostic blockade

OBJECTIVE

The criterion commonly used to determine whether radiofrequency neurotomy may be recommended is based on patient-reported, short-term pain relief following facet block injections. This study evaluated the concordance between two commonly used outcomes for pain relief: the pain numerical rating scale (NRS) and the global perceived improvement (GPI) scale.

DESIGN

This is a retrospective cohort study.

METHODS

Data were obtained from a consecutive cohort of patients through a review of the electronic medical records, with the following inclusion criteria: medial branch facet blocks at either cervical or lumbar spinal regions.

OUTCOME MEASURES

Pain NRS (baseline, postprocedure, and hourly up to 6 hours) and GPI scale are expressed as percent improvement at 6 hours, relative to baseline.

RESULTS

The percent improvement in pain NRS corresponded to 49%, 43%, 34%, 21%, and 36% for baseline vs immediately post-block, 1 hour, 3 hours, 6 hours and average of all postscores, respectively. Average GPI reported at 6 hours was 44%, and differed significantly only to the baseline vs 6 hours percent improvement on the NRS (P < 0.01). Multiple regression analysis indicated that there were no demographic or baseline factors that accounted for the discrepancy between GPI vs NRS.

CONCLUSIONS

Asking patients about their pain relief in retrospect can be misleading. It is possible that patients' report on the GPI is weighed by their total experience of pain reduction and retrospective recall. Therefore, when choosing to address percent improvement on NRS measures, it is important to take into account multiple instances of NRS measures following treatment.