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Yoo YM, Kim KH. Facet joint disorders: from diagnosis to treatment. Korean J Pain 2024; 37:3-12. [PMID: 38072795 PMCID: PMC10764212 DOI: 10.3344/kjp.23228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/30/2023] Open
Abstract
One of the most common sources of spinal pain syndromes is the facet joints. Cervical, thoracic, and lumbar facet joint pain syndromes comprise 55%, 42%, and 31% of chronic spinal pain syndromes, respectively. Common facet joint disorders are degenerative disorders, such as osteoarthritis, hypertrophied superior articular process, and facet joint cysts; septic arthritis; systemic and metabolic disorders, such as ankylosing spondylitis or gout; and traumatic dislocations. The facet pain syndrome from osteoarthritis is suspected from a patient's history (referred pain pattern) and physical examination (tenderness). Other facet joint disorders may cause radicular pain if mass effect from a facet joint cyst, hypertrophied superior articular process, or tumors compress the dorsal root ganglion. However, a high degree of morphological change does not always provoke pain. The superiority of innervating nerve block or direct joint injection for diagnosis and treatment is still a controversy. Treatment includes facet joint injection in facet joint osteoarthritis or whiplash injury provoking referred pain or decompression in mass effect in cases of hypertrophied superior articular process or facet joint cyst eliciting radicular pain. In addition, septic arthritis is treated using a proper antibiotic, based on infected tissue or blood culture. This review describes the diagnosis and treatment of common facet joint disorders.
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Affiliation(s)
- Yeong-Min Yoo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Kyung-Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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2
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McCormick ZL, Sperry BP, Boody BS, Hirsch JA, Conger A, Harper K, Lotz JC, Burnham TR. OUP accepted manuscript. PAIN MEDICINE 2022; 23:S14-S33. [PMID: 35856332 PMCID: PMC9297150 DOI: 10.1093/pm/pnac069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Zachary L McCormick
- Correspondence to: Zachary L. McCormick, MD, Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT 84108, USA. Tel: 801-587-5458; Fax: 801-587-7111; E-mail:
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, California, USA
| | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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3
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Mustafa R, Kissoon NR. Approach to Radiculopathy. Semin Neurol 2021; 41:760-770. [PMID: 34826877 DOI: 10.1055/s-0041-1726363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Low back pain and neck pain, often with associated radiculopathy, are two of the most common reasons for referral to the outpatient neurology clinic. A thorough clinical evaluation remains paramount in establishing an accurate diagnosis and subsequently an appropriate treatment plan. In this article, we review anatomic considerations for spondylotic radiculopathy; outline the clinical approach for the evaluation of these patients, including discussion of electrodiagnostic and imaging modalities; and address treatment options based on a stratified treatment approach.
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Affiliation(s)
- Rafid Mustafa
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Narayan R Kissoon
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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4
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Tay M, Sian SCSH, Eow CZ, Ho KLK, Ong JH, Sirisena D. Ultrasound-Guided Lumbar Spine Injection for Axial and Radicular Pain: A Single Institution Early Experience. Asian Spine J 2021; 15:216-223. [PMID: 32872762 PMCID: PMC8055452 DOI: 10.31616/asj.2019.0399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/07/2020] [Accepted: 03/15/2020] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Clinical audit via retrospective review of a database. PURPOSE To report an early experience using ultrasound-guided lumbar spinal injection for axial and radicular pain in an Asian multiethnic cohort. OVERVIEW OF LITERATURE Ultrasound-guided spine injection therapy is a comparatively new technique in the management of axial and radicular pain from degenerative lumbar spinal conditions, which may be a reasonable alternative to conventional fluoroscopic or computed tomography-guided injection. METHODS A retrospective review was conducted, involving all patients who underwent ultrasound-guided lumbar spine injection therapy at a single institution over 1 year. Patients were evaluated by two interventionists, who then performed standardized ultrasound-guided lumbar facet joint and pararadicular spinal injections. RESULTS There were 42 patients treated at our Sports Medicine Centre; with 27 patients (64.3%) receiving facet joint injections and 18 patients (42.9%) receiving nerve root injections. The majority (90.5%) of patients experienced an improvement of >30% in pain intensity at 3 months post-injection, using the Numerical Rating Scale pain score (p<0.001); with 40 patients (95.2%) reporting a reduction in Oswestry Disability Index score (p<0.001). No complications were reported. CONCLUSIONS Our initial experience confirms the safety, feasibility, and effectiveness of ultrasound-guided lumbar spinal injection for the treatment of axial and radicular pain in an Asian multiethnic cohort.
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Affiliation(s)
- Matthew Tay
- Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore
| | | | - Chen Zhi Eow
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Kelvin Lor Kah Ho
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - Joo Haw Ong
- Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
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5
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Kanakarajan S, Fernando K, Dharmavaram S, Galley HF. Sensory mapping of lumbar facet joint pain: a feasibility study. Br J Pain 2021; 15:64-68. [PMID: 33633853 DOI: 10.1177/2049463719886890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the feasibility of sensory mapping of lumbar facet joint pain in patients scheduled to undergo radiofrequency (RF) denervation. Design Prospective cohort study. Setting University teaching hospital. Subjects A total of 15 participants listed for RF denervation of lumbar facet joint. Method After written informed consent, participants were recruited to the study. Participants completed a pain diagram prior to their procedure. After successful image-guided placement of RF cannulas, the sensory detection threshold using 50 Hz stimulation was obtained, followed by application of suprathreshold stimulation. Participants mapped their stimulated area in comparison to their pre-procedure pain diagram. Results All 15 participants had previously undergone diagnostic blocks. All participants were able to report either pain or paraesthesia during suprathreshold stimulation. In total, 14 out of 15 participants reported complete coverage of their usual painful area with suprathreshold stimulation of nerves scheduled for RF denervation. In one of the participants, an area of upper lumbar pain was not covered during suprathreshold stimulation. Nearly two-thirds of the participants (n = 9), reported either pain or paraesthesia, outside their normal painful area during suprathreshold stimulation. A total of 71 nerves were scheduled for RF denervation. Sensory electrical stimulation was successfully achieved in 68 out of 71 nerves (96%). The average sensory detection threshold was found to be 0.3 V while the suprathreshold stimulation was 0.6 V. Conclusion Lumbar facet joint pain can be mapped using suprathreshold sensory stimulation, which has the potential to introduce objectivity during RF denervation.
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The why, where, and how clinical reasoning model for the evaluation and treatment of patients with low back pain. Braz J Phys Ther 2020; 25:407-414. [PMID: 33371952 DOI: 10.1016/j.bjpt.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/19/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients who have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients. OBJECTIVE The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases. METHODS This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm. CONCLUSIONS This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.
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Rachold W. Rationale manuelle Therapie in der Akutsprechstunde am Beispiel des akuten unspezifischen unteren Rückenschmerzes. MANUELLE MEDIZIN 2020. [DOI: 10.1007/s00337-020-00739-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Peterson S. Physical therapy management of a patient with persistent groin pain after total hip arthroplasty and iliopsoas tenotomy: a case report. Physiother Theory Pract 2020; 38:481-491. [PMID: 32544015 DOI: 10.1080/09593985.2020.1768458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hip impingement syndrome can occur after total hip arthroplasty (THA). Nonoperative treatment is inconsistently recommended, and surgical options include iliopsoas tenotomy. The current case report describes the unique case of a patient with persistent groin pain after THA and iliopsoas tenotomy. CASE DESCRIPTION The 72-year-old male had persistent groin pain after right THA and an unsuccessful iliopsoas tenotomy. He had pain and limited right hip range of motion during active and passive hip flexion, abduction, and external rotation. Treatment consisted of high-grade joint mobilization to improve the range of motion of the right hip and an exercise program. OUTCOMES The patient was treated for six visits over 3 weeks. Clinically important improvements were noted in pain, function, and perceived level of improvement. Pain during hip flexion improved on the Numeric Pain Rating Scale, and function improved on the Lower Extremity Functional Scale. Improvements in the range of motion and strength were also observed. At 6-month follow-up, he reported maintenance of improvements. DISCUSSION Joint mobilization and exercise were effective for improving range of motion, groin pain, and function in a patient with a 4-year history of persistent groin pain after THA and subsequent iliopsoas tenotomy.
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Affiliation(s)
- Seth Peterson
- Physical Therapy, The Motive, Oro Valley, AZ, USA.,Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA
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9
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French HP, Deasy M, Gallagher R, O'Grady A, Doyle F. Prevalence of Hip or Groin Pain in Adolescents: A Systematic Review and Meta-Analysis. Pain Pract 2020; 20:792-811. [PMID: 32362057 DOI: 10.1111/papr.12907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 04/01/2020] [Accepted: 04/26/2020] [Indexed: 12/25/2022]
Abstract
Musculoskeletal pain is a common cause of pain in adolescence and can be an important predictor of future pain. The prevalence of hip or groin pain that could potentially affect different adolescent populations has not yet been systematically reviewed. This systematic review aimed to determine the prevalence of hip or groin pain in this population. Five electronic databases were searched until January 2019 for eligible studies that included males and females 13 to 19 years of age. Study selection, data extraction, and risk of bias assessments were completed by 2 independent researchers. Based on inclusion criteria, 8 population-based, 8 clinical, and 4 sports populations were included. Studies were conducted in Europe, North America, and Australia. The prevalence was dichotomized into "0 to 3 months" and "3 months and above." Meta-analyses were performed to estimate the prevalence from 0 to 3 months, and individual estimates were reported for studies of 3 months and above. The overall prevalence of hip or groin pain in all adolescents from 0 to 3 months was 12% (95% confidence interval [CI] 6%, 23%) based on 10 studies, and was 7% (95% CI 6%, 10%) based on 7 population studies. Caution should be applied to these estimates due to substantial study heterogeneity. The pain prevalence in cerebral palsy from 0 to 3 months based on 4 studies was 13% (95% CI 10%, 15%). Individual prevalence estimates were 6% and 31% in obese and 4% in hypermobility populations, respectively, and ranged from 6% to 100% in 4 sports studies. The validity of these estimates is compromised by poor methodological quality.
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Affiliation(s)
| | - Margaret Deasy
- Physiotherapy Department, Sports Surgery Clinic, Santry, Dublin, Ireland
| | | | | | - Frank Doyle
- Royal College of Surgeons in Ireland, Dublin, Ireland
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10
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Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul) 2020; 15:8-18. [PMID: 33329784 PMCID: PMC7713865 DOI: 10.17085/apm.2020.15.1.8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
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11
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de Andrés Ares J, Gilsanz F. Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:213-221. [PMID: 30683428 DOI: 10.1016/j.redar.2018.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- J de Andrés Ares
- Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, España.
| | - F Gilsanz
- Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, España
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12
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O’Neill S, Larsen JB, Nim C, Arendt-Nielsen L. Topographic mapping of pain sensitivity of the lower back – a comparison of healthy controls and patients with chronic non-specific low back pain. Scand J Pain 2018; 19:25-37. [DOI: 10.1515/sjpain-2018-0113] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/27/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims
The choice of testing site for quantitative sensory testing (QST) of pain sensitivity is important and previous studies have demonstrated patterns in pain sensitivity within discrete areas in different body regions. Some areas are characterized by a relatively high degree of spatial pain discrimination and recognizable patterns of pain referral, whilst others are not. The lumbar region is likely to have relatively low pain acuity and overlapping of pain referral. The current study was conducted to determine whether patterns of pain sensitivity (detection thresholds) could be identified in the lower back, whether differences in such patterns exist between different groups and whether such patterns could help identify a clinical source of pain and localized increased pain sensitivity.
Methods
Twenty-one patients with non-specific chronic low back pain and 21 healthy controls were tested for pressure and heat pain thresholds on 30 pre-defined locations over the mid and lower back. Topographical maps of mean pain thresholds and variability were produced, inspected visually and analyzed statistically. Between group differences in pain threshold were analyzed statistically as an indicator of widespread increased pain sensitivity. Evidence of segmental increased pain sensitivity was examined by group statistical comparison of mid-line lower range.
Results
A clear pattern of higher pain thresholds in the mid-line was evident in both groups and for both pain modalities. No discernible patterns were evident for variability within groups, but marked differences were seen between groups: variability for pressure pain thresholds appeared similar between groups, however for heat pain threshold, variability was uniformly low in the control group and uniformly high in the patient group. A highly significant (p<0.0001) difference in pain thresholds for pressure and heat was found with patients exhibiting lower thresholds than controls. No between group difference was found for mid-line lower range for either modality (p>0.05).
Conclusions
The current study supports previous findings of widespread, increased pain sensitivity in chronic non-specific low-back pain patients. It also indicates that there are discernible and similar topographical patterns of pain sensitivity in the dorsal area in both groups, but that this pattern is related to the lateral position of the test site and not the segmental level. Specific segments with increased pain sensitivity could not be identified in the patient group, which casts doubt on the utility of pressure and heat pain thresholds as indicators of the clinical source of spinal pain – at least in a population of chronic non-specific low-back pain.
Implications
In a cohort of chronic non-specific low-back pain patients and with the chosen methodology, topographical QST mapping in the lumbar region does not appear useful for identifying the spinal segment responsible for clinical pain, but it does demonstrate widespread group differences in pain sensitivity.
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Affiliation(s)
- Søren O’Neill
- Spinecenter of Southern Denmark, Lillebælt Hospital, Østre Hougvej 55 , Middelfart DK-5500 , Denmark
- Institute of Regional Health Research, University of Southern Denmark, Campusvej 55 , Odense M DK-5230 , Denmark , Phone: +45 4043 2004
| | - Johanne Brinch Larsen
- Institute of Regional Health Research, University of Southern Denmark , Odense M , Denmark
- Spinecenter of Southern Denmark, Lillebælt Hospital , Middelfart , Denmark
| | - Casper Nim
- Institute of Regional Health Research, University of Southern Denmark , Odense M , Denmark
- Spinecenter of Southern Denmark, Lillebælt Hospital , Middelfart , Denmark
| | - Lars Arendt-Nielsen
- Centre for Sensory-Motor Interaction, School of Medicine , University of Aalborg , Aalborg , Denmark
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Cohen SP, Doshi TL, Constantinescu OC, Zhao Z, Kurihara C, Larkin TM, Griffith SR, Jacobs MB, Kroski WJ, Dawson TC, Fowler IM, White RL, Verdun AJ, Jamison DE, Anderson-White M, Shank SE, Pasquina PF. Effectiveness of Lumbar Facet Joint Blocks and Predictive Value before Radiofrequency Denervation: The Facet Treatment Study (FACTS), a Randomized, Controlled Clinical Trial. Anesthesiology 2018; 129:517-535. [PMID: 29847426 PMCID: PMC6543534 DOI: 10.1097/aln.0000000000002274] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: With facet interventions under scrutiny, the authors' objectives were to determine the effectiveness of different lumbar facet blocks and their ability to predict radiofrequency ablation outcomes. METHODS A total of 229 participants were randomized in a 2:2:1 ratio to receive intraarticular facet injections with bupivacaine and steroid, medial branch blocks, or saline. Those with a positive 1-month outcome (a 2-point or more reduction in average pain score) and score higher than 3 (positive satisfaction) on a 5-point satisfaction scale were followed up to 6 months. Participants in the intraarticular and medial branch block groups with a positive diagnostic block (50% or more relief) who experienced a negative outcome proceeded to the second phase and underwent radiofrequency ablation, while all saline group individuals underwent ablation. Coprimary outcome measures were average reduction in numerical rating scale pain score 1 month after the facet or saline blocks, and average numerical rating scale pain score 3 months after ablation. RESULTS Mean reduction in average numerical rating scale pain score at 1 month was 0.7 ± 1.6 in the intraarticular group, 0.7 ± 1.8 in the medial branch block group, and 0.7 ± 1.5 in the placebo group; P = 0.993. The proportions of positive blocks were higher in the intraarticular (54%) and medial branch (55%) groups than in the placebo group (30%; P = 0.01). Radiofrequency ablation was performed on 135 patients (45, 48, and 42 patients from the intraarticular, medial branch, and saline groups, respectively). The average numerical rating scale pain score at 3 months was 3.0 ± 2.0 in the intraarticular, 3.2 ± 2.5 in the medial branch, and 3.5 ± 1.9 in the control group (P = 0.493). At 3 months, the proportions of positive responders in the intraarticular, medial branch block, and placebo groups were 51%, 56%, and 24% for the intraarticular, medial branch, and placebo groups, respectively (P = 0.005). CONCLUSIONS This study establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation.
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Affiliation(s)
- Steven P Cohen
- From the Department of Anesthesiology and Critical Care Medicine (S.P.C., T.L.D., M.A.-W.) the Department of Neurology and Physical Medicine and Rehabilitation (S.P.C.) The Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology (S.P.C., S.R.G.) Department of Physical Medicine and Rehabilitation (S.P.C., M.B.J., W.J.K., P.F.P.) Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany (O.C.C.) Department of Neurology, District of Columbia Veterans Affairs Hospital, Washington, District of Columbia (Z.Z.) Physical Medicine and Rehabilitation Service, Department of Orthopedic Surgery (P.F.P.) Pain Treatment Center, Anesthesia Service, Department of Surgery (A.J.V., C.K., D.E.J., S.R.G.) Walter Reed National Military Medical Center, Bethesda, Maryland; Parkway Neuroscience and Spine Institute, Hagerstown, Maryland (T.M.L., S.E.S.) Puget Sound Veteran's Hospital, Seattle, Washington (T.C.D.) Department of Pain Medicine, David Grant U.S. Air Force Medical Center, Travis Air Force Base, California (R.L.W.) Pain Medicine Center, Department of Anesthesiology, Naval Medical Center-San Diego, San Diego, California (I.M.F.) Department of Anesthesiology, University of Washington, Seattle, Washington (T.C.D.)
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14
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Facet joint syndrome: from diagnosis to interventional management. Insights Imaging 2018; 9:773-789. [PMID: 30090998 PMCID: PMC6206372 DOI: 10.1007/s13244-018-0638-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/06/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
Abstract Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15–45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail. Teaching points • Lumbar facet joints constitute a common source of pain accounting of 15–45%. • Facet arthrosis is the most frequent form of facet pathology. • There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes. • Diagnostic positive facet joint block can indicate facet joints as the source of pain. • After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.
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15
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Kang Y, Lee E, Lee JW, Kim SR, Kang MJ, Choi YW, Ahn JM, Kang Y, Kang HS. Effect of Poly(Lactide-Co-Glycolide) Nanoparticles on Local Retention of Fluorescent Material: An Experimental Study in Mice. Korean J Radiol 2018; 19:950-956. [PMID: 30174485 PMCID: PMC6082767 DOI: 10.3348/kjr.2018.19.5.950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/29/2018] [Indexed: 11/15/2022] Open
Abstract
Objective Poly(lactide-co-glycolide) (PLGA) nanoparticles are promising materials for the development of new drug-releasing systems. The purpose of this study was to evaluate the in vivo retention time of materials loaded in nanoparticles as compared with that of the material alone by in vivo imaging in nude mice. Materials and Methods Mice (n = 20) were injected with 0.1 mL fluorescent material 1,1'-dioctadecyl-3,3,3',3' tetramethylindotricarbocyanine iodide (DiR)-loaded PLGA nanoparticles (200 nm) into the right paraspinal muscle, and the same volume of pure DiR solution was injected into the left paraspinal muscle. Fluorescence images were obtained using an in vivo optical imaging system. Fluorescent images were taken 1 day after the injection, and seven more images were taken at 1-week intervals. Image analysis was done with ImageJ program, and one region of interest was chosen manually, which corresponded to the highest signal-intensity area of fluorescence signal intensity. Results After 7 weeks, 12 mice showed a right-sided dominant signal, representing the DiR loaded PLGA nanoparticles; 5 mice showed a left-side dominant signal, representing the free DiR solution; and 3 mice showed no signal at all beginning 1 day after the injection. During the 7-week period, the mean signal intensities of the free DiR solution and DiR-loaded PLGA nanoparticles diverged gradually. On day 1, the mean signal intensity of free DiR solution was significantly higher than that of DiR-loaded PLGA (p < 0.001). Finally, by week 7, DiR-loaded PLGA express significantly high signal intensity compared with free DiR solution (p = 0.031). Conclusion The results of the current study suggested that therapeutic agents bound to PLGA nanoparticles may exhibit prolonged retention times.
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Affiliation(s)
- Yeonah Kang
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul 07061, Korea.,Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Sung Rae Kim
- College of Pharmacy, Chung-Ang University, Seoul 06911, Korea
| | - Myung Joo Kang
- College of Pharmacy, Dankook University, Cheonan 31116, Korea
| | - Young Wook Choi
- College of Pharmacy, Chung-Ang University, Seoul 06911, Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
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Christe G, Hall T. The screening process of a patient with low back pain and suspected thoracic myelopathy: a case report. J Man Manip Ther 2018; 26:11-17. [PMID: 29456443 DOI: 10.1080/10669817.2017.1282189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background Thoracic disc herniations are rare and difficult to diagnose. Myelopathy is a potential consequence that can lead to irreversible neurological impairment if not treated appropriately. It is incumbent on all clinicians who see patients with low back pain (LBP) to be aware of such pathologies. This case describes a screening process in the detection of a rare serious spinal pathology and discusses the use of red flags and central nervous system signs and symptoms in the decision leading to immediate referral. Case Description The subject in this case was a 69-year-old male referred to physical therapy for the treatment of LBP after having seen two medical doctors. He presented with severe spinal pain with gait disturbance, postural balance deficits and bilateral loss of plantar flexor strength. Decreased sensation in the buttocks and a subtle episode of urinary incontinence were also present. Outcomes Based on the results of the history and physical examination, the patient was referred back to his medical practitioner, who ordered magnetic resonance imaging. A thoracic disc herniation associated with spondyloarthritis at T10-11 causing myelopathy was detected, and the patient underwent immediate decompressive surgery. One month following initial evaluation, the patient had completely recovered without any neurological compromise. Discussion This case highlights the importance of the screening of serious pathologies and the assessment of central nervous impairments in certain cases of LBP. The integration of a cluster of subjective and physical examination findings led to the prompt referral of this patient for urgent medical attention. Level of Evidence 4.
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Affiliation(s)
- Guillaume Christe
- Haute Ecole de Santé Vaud (HESAV)//HES-SO, Physiotherapy Department, University of Applied Sciences Western Switzerland, Lausanne, Switzerland
| | - Toby Hall
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
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Huygen F, Liem L, Cusack W, Kramer J. Stimulation of the L2-L3 Dorsal Root Ganglia Induces Effective Pain Relief in the Low Back. Pain Pract 2017; 18:205-213. [PMID: 28486758 DOI: 10.1111/papr.12591] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic low back pain affects millions of people worldwide and can arise through a variety of clinical origins. In the case of failed back surgery syndrome (FBSS), previous surgical procedures can contribute to low back pain that is often unresponsive to intervention. Although spinal cord stimulation (SCS) can be an effective treatment modality, it does not provide sufficient pain relief for some intractable cases. Recently, alternative neuromodulation options have been developed, including dorsal root ganglion (DRG) stimulation. The objective of this report is to further investigate these clinical observations. METHODS Twelve patients with significant chronic discogenic low back pain due to FBSS were included. All subjects underwent implantation of DRG stimulation systems that had at least 1 lead placed at L2 or L3. Subjects' pain ratings, mood, and quality of life were tracked prospectively for up to 12 months. RESULTS More than half of subjects reported 50% or better pain relief in the low back, and the average low back pain relief was 45.5% at 12 months. Concomitant reductions in overall pain, leg pain, pain interference, mood, and quality of life were also found. DISCUSSION For the studied population, DRG stimulation at the L2-L3 levels was effective at relieving low back pain. These reductions in pain were associated with improvements in quality of life. Thus, DRG stimulation at these levels may be effective for low back pain by recruiting both segmental and nonsegmental neural pathways that are not otherwise accessible via traditional SCS.
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Affiliation(s)
- Frank Huygen
- Erasmus University, Rotterdam, Maastricht, The Netherlands
| | - Liong Liem
- Maastricht University Medical Centre, Maastricht, The Netherlands
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Hofmann UK, Keller RL, Walter C, Mittag F. Predictability of the effects of facet joint infiltration in the degenerate lumbar spine when assessing MRI scans. J Orthop Surg Res 2017; 12:180. [PMID: 29162138 PMCID: PMC5699022 DOI: 10.1186/s13018-017-0685-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 11/12/2017] [Indexed: 12/13/2022] Open
Abstract
Background Imaging results are frequently considered as hallmarks of disease by spine surgeons to plan their future treatment strategy. Numerous classification systems have been proposed to quantify or grade lumbar magnetic resonance imaging (MRI) scans and thus objectify imaging findings. The clinical impact of the measured parameters remains, however, unclear. To evaluate the pathological significance of imaging findings in patients with multisegmental degenerative findings, clinicians can perform image-guided local infiltrations to target defined areas such as the facet joints. The aim of the present retrospective study was to evaluate the correlation of MRI facet joint degeneration and spinal stenosis measurements with improvement obtained by image-guided intraarticular facet joint infiltration. Methods Fifty MRI scans of patients with chronic lumbar back pain were graded radiologically using a wide range of classification and measurement systems. The reported effect of facet joint injections at the site was recorded, and a comparative analysis performed. Results When we allocated patients according to their reported pain relief, 27 showed no improvement (0–30%), 16 reported good improvement (31–75%) and 7 reported excellent improvement (> 75%). MRI features assessed in this study did, however, not show any relevant correlation with reported pain after facet joint infiltration: Values for Kendall’s tau ranged from τ = − 0.190 for neuroforaminal stenosis grading as suggested by Lee, to τ = 0.133 for posterior disc height as proposed by Hasegawa. Conclusion Despite the trend in evidence-based medicine to provide medical algorithms, our findings underline the continuing need for individualised spine care that, along with imaging techniques or targeted infiltrations, includes diagnostic dimensions such as good patient history and clinical examination to formulate a diagnosis. Trial registration ClinicalTrials.gov, NCT03308149, retrospectively registered October 2017 Electronic supplementary material The online version of this article (10.1186/s13018-017-0685-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulf Krister Hofmann
- Department of Orthopaedic Surgery, University Hospital of Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany.
| | - Ramona Luise Keller
- Faculty of Medicine, Julius-Maximilians University of Würzburg, Josef-Schneider-Str.2, 97080, Würzburg, Germany
| | - Christian Walter
- Department of Orthopaedic Surgery, University Hospital of Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Falk Mittag
- Department of Orthopaedic Surgery, University Hospital of Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
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Radiofrequency thermocoagulation in chronic low back pain from the facet joints: Literature review. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2017. [DOI: 10.1016/j.hgmx.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
Pseudo-radicular leg pain as initially described by Bruegger more than 55 years ago was at that time a genius explanation for so many non-radicular pain syndromes that needed not any kind of surgical intervention but in first line a manual treatment or a treatment by therapeutic local anesthetics. Today we describe this pain as a "referred pain" originating from other anatomic structures that may occur during the development of chronic pain. Nevertheless this pain is found in many patients and it still seems to be a big problem for many physicians and surgeons. Imaging does not help either. The history and the clinical symptoms, the examinations, the chain reactions in the motor system as well as the treatment options from the point of view of manual medicine are described.
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Affiliation(s)
- W von Heymann
- Orthopädische Praxis, Mendestr. 7, 28203, Bremen, Deutschland.
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Abstract
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.
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Affiliation(s)
- K Saravanakumar
- Consultants in Anaesthesia and Pain Medicine, Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom
| | - A Harvey
- Consultants in Anaesthesia and Pain Medicine, Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom
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Cooled Versus Conventional Thermal Radiofrequency Neurotomy for the Treatment of Lumbar Facet-Mediated Pain. PM R 2015; 7:1095-1101. [DOI: 10.1016/j.pmrj.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 02/05/2023]
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von Heymann W. Pseudoradikulärer/übertragener Beinschmerz. MANUELLE MEDIZIN 2015. [DOI: 10.1007/s00337-015-1213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Barbero M, Moresi F, Leoni D, Gatti R, Egloff M, Falla D. Test-retest reliability of pain extent and pain location using a novel method for pain drawing analysis. Eur J Pain 2015; 19:1129-38. [DOI: 10.1002/ejp.636] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 11/09/2022]
Affiliation(s)
- M. Barbero
- Department of Business, Health and Social Care; University of Applied Sciences and Arts of Southern Switzerland (SUPSI); Manno Switzerland
| | - F. Moresi
- Rehabilitation Department; San Raffaele Hospital; Milan Italy
| | - D. Leoni
- Department of Business, Health and Social Care; University of Applied Sciences and Arts of Southern Switzerland (SUPSI); Manno Switzerland
| | - R. Gatti
- Rehabilitation Department; San Raffaele Hospital; Milan Italy
| | - M. Egloff
- Department of Business, Health and Social Care; University of Applied Sciences and Arts of Southern Switzerland (SUPSI); Manno Switzerland
| | - D. Falla
- Pain Clinic; Center for Anesthesiology, Emergency and Intensive Care Medicine; University Hospital Göttingen; Germany
- Department of Neurorehabilitation Engineering; Bernstein Focus Neurotechnology (BFNT) Göttingen; Bernstein Center for Computational Neuroscience; University Medical Center Göttingen; Georg-August University; Göttingen Germany
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Jones LE, O'Shaughnessy DF. The Pain and Movement Reasoning Model: Introduction to a simple tool for integrated pain assessment. ACTA ACUST UNITED AC 2014; 19:270-6. [DOI: 10.1016/j.math.2014.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 01/20/2014] [Accepted: 01/29/2014] [Indexed: 02/08/2023]
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Van Zundert J, Van Boxem K, Vanelderen P, Puylaert M, De Vooght P, Mestrum R, Heylen R, Vissers K, van Kleef M. Establishing the diagnosis of low back pain: patient selection for interventional pain medicine. Pain Manag 2014; 3:129-36. [PMID: 24645997 DOI: 10.2217/pmt.13.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Low back pain is one of the most prominent healthcare problems but there is no gold standard for its diagnosis. Aspecific low back pain can be subdivided into radicular and mechanical pain. The diagnosis mainly relies on a combination of elements, such as medical history, physical examination, medical imaging and other possible additional tests. Once a working diagnosis has been established, confirmation of the causative structure and level is sought by means of diagnostic blocks. The use of the different diagnostic tests and blocks should be guided by the balance between the potential benefit (mainly in terms of improved treatment outcome, the possible burden for the patient and the chances of withholding potential effective treatment to patients) with false-negative test results.
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Affiliation(s)
- Jan Van Zundert
- Department of Anesthesiology, Critical Care & Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
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Tessitore E, Molliqaj G, Schatlo B, Schaller K. Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome. Eur J Radiol 2014; 84:765-70. [PMID: 24801263 DOI: 10.1016/j.ejrad.2014.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 03/11/2014] [Indexed: 12/11/2022]
Abstract
In industrialized countries, more than two thirds of the population suffers from low back pain (LBP) in their lifetime. LBP associated with lumbar disc herniation, stenosis, and instability is a well-known and documented entity. On the other hand, the lumbar discogenic pain and facet syndrome are difficult to be clearly identified, and they are not always detectable by imaging. This article describes the causes of these painful syndromes, which are typically without radicular component, explains the modern diagnostic procedures, and provides guidelines for surgical decision making.
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Affiliation(s)
- Enrico Tessitore
- Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Switzerland.
| | - Granit Molliqaj
- Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Switzerland.
| | - Bawarjan Schatlo
- Department of Neurosurgery, Georg-August University, University of Medicine Gottingen, 37075 Gottingen, Germany.
| | - Karl Schaller
- Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Switzerland.
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Robinson JR. Lower Extremity Pain of Lumbar Spine Origin: Differentiating Somatic Referred and Radicular Pain. J Man Manip Ther 2013. [DOI: 10.1179/106698103790825519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Galhom AE, al-Shatouri MA. Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures. Clin Imaging 2013; 37:649-56. [PMID: 23660156 DOI: 10.1016/j.clinimag.2013.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 01/16/2013] [Accepted: 02/21/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE To evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain. METHODS This prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment. RESULTS One hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures. CONCLUSION Lumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.
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Affiliation(s)
- Ayman E Galhom
- Department of Neurosurgery, Faculty of Medicine, Suez Canal, University Hospital, 41522, Ismailia, Egypt.
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Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther 2013; 43:118-27. [PMID: 23221367 DOI: 10.2519/jospt.2013.4221] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Randomized clinical trial. OBJECTIVE To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation (experimental group) versus cervical spine nonthrust manipulation alone (comparison group) in individuals with mechanical neck pain. BACKGROUND Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain. Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone. METHODS Sixty-four participants with mechanical neck pain were randomized into 1 of 2 groups, an experimental or comparison group. Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises, and the experimental group received additional thoracic spine thrust manipulations. Outcome measures were collected at baseline and at a 1-week follow-up, and included the numeric pain rating scale, the Neck Disability Index, and the global rating of change. RESULTS Participants in the experimental group demonstrated significantly greater improvements (P<.001) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group. In addition, 31 of 33 (94%) participants in the experimental group, compared to 11 of 31 participants (35%) in the comparison group, indicated a global rating of change score of +4 or higher at the 1-week follow-up, with an associated number needed to treat of 2. CONCLUSION Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change.
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Matar HE, Navalkissoor S, Berovic M, Shetty R, Garlick N, Casey ATH, Quigley AM. Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? INTERNATIONAL ORTHOPAEDICS 2013; 37:865-70. [PMID: 23412368 DOI: 10.1007/s00264-013-1811-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 01/23/2013] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to assess the value of SPECT/CT imaging in patients with chronic spinal pain. METHODS This was a retrospective consecutive study. Patients with chronic neck or back pain from outpatient spinal clinics with clinical features raising the possibility of a facetogenic pain generator and non-conclusive MRI/CT findings were included. Imaging was performed on a dual-headed, hybrid SPECT/CT γ-camera with a low-dose CT transmission scan acquired after the SPECT study. SPECT/CT studies were viewed in the coronal, axial, and sagittal planes and in 3-dimensional mode. Descriptive statistical analysis was performed. RESULTS Seventy-two patients were included (37 females, 35 males, mean age of 53.9 years). There were 25 cervical spine scans and 49 lumbar spine scans. In the cervical spine group, 13 (52 %) patients had scintigraphically active cervical facet joint arthropathy and ten (36 %) had other pathology identified. Two thirds of patients diagnosed with facet joint arthropathy received steroid guided injections following their scans. In the lumbar spine group 34 (69.4 %) patients had scintigraphically active lumbar facet joint arthropathy and eight had other pathology identified. Twenty patients (58.8 %) diagnosed with facet joint arthropathy subsequently received steroid guided injections. CONCLUSIONS Hybrid SPECT/CT imaging identified potential pain generators in 92 % of cervical spine scans and 86 % of lumbar spine scans. The scan precisely localised SPECT positive facet joint targets in 65 % of the referral population and a clinical decision to inject was made in 60 % of these cases.
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Affiliation(s)
- Hosam E Matar
- Nuclear Medicine, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
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Cohen SP, Huang JHY, Brummett C. Facet joint pain—advances in patient selection and treatment. Nat Rev Rheumatol 2012; 9:101-16. [DOI: 10.1038/nrrheum.2012.198] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2012. [PMID: 23147891 DOI: 10.1038/nrrheum] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Osteoarthritis (OA) of the spine involves the facet joints, which are located in the posterior aspect of the vertebral column and, in humans, are the only true synovial joints between adjacent spinal levels. Facet joint osteoarthritis (FJ OA) is widely prevalent in older adults, and is thought to be a common cause of back and neck pain. The prevalence of facet-mediated pain in clinical populations increases with increasing age, suggesting that FJ OA might have a particularly important role in older adults with spinal pain. Nevertheless, to date FJ OA has received far less study than other important OA phenotypes such as knee OA, and other features of spine pathoanatomy such as degenerative disc disease. This Review presents the current state of knowledge of FJ OA, including relevant anatomy, biomechanics, epidemiology, and clinical manifestations. We present the view that the modern concept of FJ OA is consonant with the concept of OA as a failure of the whole joint, and not simply of facet joint cartilage.
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Affiliation(s)
- Alfred C Gellhorn
- Department of Rehabilitation Medicine, University of Washington Medical Center, Box 354740, 4245 Roosevelt Way NE, Seattle, WA 98105, USA
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Abstract
Osteoarthritis (OA) of the spine involves the facet joints, which are located in the posterior aspect of the vertebral column and, in humans, are the only true synovial joints between adjacent spinal levels. Facet joint osteoarthritis (FJ OA) is widely prevalent in older adults, and is thought to be a common cause of back and neck pain. The prevalence of facet-mediated pain in clinical populations increases with increasing age, suggesting that FJ OA might have a particularly important role in older adults with spinal pain. Nevertheless, to date FJ OA has received far less study than other important OA phenotypes such as knee OA, and other features of spine pathoanatomy such as degenerative disc disease. This Review presents the current state of knowledge of FJ OA, including relevant anatomy, biomechanics, epidemiology, and clinical manifestations. We present the view that the modern concept of FJ OA is consonant with the concept of OA as a failure of the whole joint, and not simply of facet joint cartilage.
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Affiliation(s)
- Alfred C Gellhorn
- Department of Rehabilitation Medicine, University of Washington Medical Center, Box 354740, 4245 Roosevelt Way NE, Seattle, WA 98105, USA
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Suri P, Dharamsi AS, Gaviola G, Isaac Z. Are facet joint bone marrow lesions and other facet joint features associated with low back pain? A pilot study. PM R 2012; 5:194-200. [PMID: 23122893 DOI: 10.1016/j.pmrj.2012.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 08/23/2012] [Accepted: 09/02/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the frequency of facet joint (FJ) bone marrow lesions, high FJ periarticular signal intensity, and FJ effusions in a convenience sample of patients with axial low back pain (LBP). DESIGN A cross-sectional pilot study with retrospective data collection. SETTING Outpatient spine clinics. PATIENTS Sixty-four adults with axial LBP scheduled to receive an FJ intra-articular corticosteroid injection. METHODS Clinical data were abstracted from the medical record by 1 physician, who was blinded to results of the magnetic resonance imaging evaluations. A musculoskeletal radiologist blinded to clinical information performed standardized assessments of the L1-S1 spinal levels for FJ bone marrow lesions, effusions, and high periarticular signal intensity on lumbar magnetic resonance imaging, including short tau inversion recovery sequences. We calculated the frequency of these FJ features and used generalized estimating equations to examine side-specific associations between the location of FJ features and the side on which LBP was experienced. RESULTS The sample included 64 participants with a mean (standard deviation) age of 59.9 ± 14.5 years. FJ bone marrow lesions were present in 64.1%, effusions in 70.3%, and high periarticular signal intensity in 65.6% of participants. All the features were most common at the L4-L5 level. These FJ features showed significant associations with the side on which LBP was experienced or statistical trends toward an association, with or without adjustment for age, gender, and body mass index. The strongest side-specific associations were seen for the number of bone marrow lesions (odds ratio [OR] 1.60 [95% confidence interval {CI},1.05-2.43]), any FJ effusion (OR 2.23 [95% CI, 1.02-4.85]), and the number of joints with high periarticular signal intensity (OR 1.75 [95% CI, 1.16-2.63]). CONCLUSIONS FJ bone marrow lesions, effusions, and high periarticular signal intensity were common in this sample of patients with axial LBP and substantially more frequent than in prior reports from unselected samples of patients with or without radicular pain. These FJ features demonstrate side-specific associations with LBP. Further study of associations between these FJ features and LBP are warranted.
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Affiliation(s)
- Pradeep Suri
- Division of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, MA, USA.
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Abstract
This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.
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Affiliation(s)
- Gail Dean Deyle
- Army-Baylor University Doctoral Fellowship in Orthopaedic Manual Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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Zhou L, Schneck CD, Shao Z. The Anatomy of Dorsal Ramus Nerves and Its Implications in Lower Back Pain. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/nm.2012.32025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Schütz U, Cakir B, Dreinhöfer K, Richter M, Koepp H. Diagnostic value of lumbar facet joint injection: a prospective triple cross-over study. PLoS One 2011; 6:e27991. [PMID: 22140497 PMCID: PMC3226632 DOI: 10.1371/journal.pone.0027991] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 10/30/2011] [Indexed: 12/15/2022] Open
Abstract
The diagnosis “lumbar facet syndrome” is common and often indicates severe lumbar spine surgery procedures. It is doubtful whether a painful facet joint (FJ) can be identified by a single FJ block. The aim of this study was to clarify the validity of a single and placebo controlled bilateral FJ blocks using local anesthetics. A prospective single blinded triple cross-over study was performed. 60 patients (31 f, 29 m, mean age 53.2 yrs (22–73)) with chronic low back pain (mean pain persistance 31 months, 6 months of conservative treatment without success) admitted to a local orthopaedic department for surgical or conservative therapy of chronic LBP, were included in the study. Effect on pain reduction (10 point rating scale) was measured. The 60 subjects were divided into six groups with three defined sequences of fluoroscopically guided bilateral monosegmental lumbar FJ test injections in “oblique needle” technique: verum-(local anaesthetic-), placebo-(sodium chloride-) and sham-injection. Carry-over and periodic effects were evaluated and a descriptive and statistical analysis regarding the effectiveness, difference and equality of the FJ injections and the different responses was performed. The results show a high rate of non-response, which documents the lack of reliable and valid predictors for a positive response towards FJ blocks. There was a high rate of placebo reactions noted, including subjects who previously or later reacted positively to verum injections. Equivalence was shown among verum vs. placebo and partly vs. sham also. With regard to test validity criteria, a single intraarticular FJ block with local anesthetics is not useful to detect the pain-responsible FJ and therefore is no valid and reliable diagostic tool to specify indication of lumbar spine surgery. Comparative FJ blocks with local anesthetics and placebo-controls have to be interpretated carefully also, because they solely give no proper diagnosis on FJ being main pain generator.
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Affiliation(s)
- Uwe Schütz
- Department of Diagnostic and Interventional Radiology, University of Ulm, Ulm, Germany.
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Medial branch neurotomy in low back pain. Neuroradiology 2011; 54:737-44. [PMID: 22006423 DOI: 10.1007/s00234-011-0968-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 10/05/2011] [Indexed: 01/20/2023]
Abstract
INTRODUCTION This study aimed to assess the effectiveness of pulsed radiofrequency medial branch dorsal ramus neurotomy in patients with facet joint syndrome. METHODS From January 2008 to April 2010, 92 patients with facet joint syndrome diagnosed by strict inclusion criteria and controlled diagnostic blocks undergone medial branch neurotomy. We did not exclude patients with failed back surgery syndrome (FBSS). Electrodes (20G) with 5-mm active tip were placed under fluoroscopy guide parallel to medial branch. Patients were followed up by physical examination and by Visual Analog Scale and Oswestry Disability Index at 1, 6, and 12 months. RESULTS In all cases, pain improvement was statistically significant and so quality of life. Three non-FBSS patients had to undergo a second neurotomy because of non-satisfactory pain decrease. Complications were reported in no case. CONCLUSIONS Medial branch radiofrequency neurotomy has confirmed its well-established effectiveness in pain and quality of life improvement as long as strict inclusion criteria be fulfilled and nerve ablation be accomplished by parallel electrode positioning. This statement can be extended also to FBSS patients.
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DePalma M, Ketchum J, Saullo T, Schofferman J. Structural etiology of chronic low back pain due to motor vehicle collision. PAIN MEDICINE 2011; 12:1622-7. [PMID: 21958329 DOI: 10.1111/j.1526-4637.2011.01246.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To estimate prevalence rates of discogenic, facet, and sacroiliac joint pain, and describe clinical features of chronic low back pain patients whose symptoms were initiated by motor vehicle collisions. DESIGN Retrospective chart review. SETTING Academic spine center. PATIENTS Twenty-seven motor vehicle collision-induced chronic low back pain patients were included after undergoing diagnostic procedures. INTERVENTIONS Lumbar provocation discography, dual diagnostic facet joint blocks, and intra-articular sacroiliac joint injections. METHODS Enrolled patients underwent diagnostic procedures based on clinical presentation until the pain source was identified. The prevalence of each source of low back pain was estimated. Clinical, categorical, and continuous characteristics within the source groups were calculated with SAS v.9.2 (SAS Institute Inc., Cary, NC). OUTCOME MEASURES Etiology and prevalence were analyzed for each diagnosis group. RESULTS Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain. Seventy-eight percent were female. Mean age was 42.5 years (standard deviation = 10.4) with median duration of symptoms of 24 months (interquartile range = 6-48). CONCLUSIONS Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.
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Affiliation(s)
- Michael DePalma
- Virginia iSpine Physicians, PC, Richmond, Virginia 23235, USA.
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Froud R, Eldridge S, Kovacs F, Breen A, Bolton J, Dunn K, Fritz J, Keller A, Kent P, Lauridsen HH, Ostelo R, Pincus T, van Tulder M, Vogel S, Underwood M. Reporting outcomes of back pain trials: a modified Delphi study. Eur J Pain 2011; 15:1068-74. [PMID: 21596600 DOI: 10.1016/j.ejpain.2011.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 04/08/2011] [Accepted: 04/21/2011] [Indexed: 01/05/2023]
Abstract
BACKGROUND Low back pain is a common and expensive health complaint. Many low back pain trials have been conducted, but these are reported in a variety of ways and are often difficult to interpret. AIM To facilitate consensus on a statement recommending reporting methods for future low back pain trials. METHODS We presented experts with clinicians' views on different reporting methods and asked them to rate and comment on the suitability reporting methods for inclusion in a standardized set. Panellists developed a statement of recommendation over three online rounds. We used a modified Delphi process and the RAND/UCLA appropriateness method as a formal framework for establishing appropriateness and quantifying panel disagreement. RESULTS A group of 63 experts from 14 countries participated. Consensus was reached on a statement recommending that the continuous patient-reported outcomes commonly used in back pain trials, are reported using between-group mean differences (accompanied by minimally important difference (between-group/population-level) thresholds where these exist), the proportion of participants improving and deteriorating according to established and relevant minimally important change thresholds, and the number needed to treat; all with 95% confidence intervals. Outcomes may additionally be reported using alternative approaches (e.g. relative risks, odds ratios, or standardized mean difference) according to the needs of a particular trial. CONCLUSIONS A group of back pain experts reached a high level of consensus on a statement recommending reporting methods for patient-reported outcomes in future low back pain trials. The statement has the potential to increase interpretability and improve patient care.
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Affiliation(s)
- Robert Froud
- Centre for Health Sciences, Queen Mary University of London, Yvonne Carter Building, Turner Street, Whitechapel, London E12AT, UK.
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DePalma MJ, Ketchum JM, Saullo TR. Etiology of chronic low back pain in patients having undergone lumbar fusion. PAIN MEDICINE 2011; 12:732-9. [PMID: 21481166 DOI: 10.1111/j.1526-4637.2011.01098.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To estimate the prevalence of lumbar internal disc disruption, zygapohyseal joint pain, sacroiliac joint pain, and soft tissue irritation by fusion hardware in post-fusion low back pain patients compared with non-fused patients utilizing diagnostic spinal procedures. DESIGN Retrospective chart review. SETTING University spine center. PATIENT SAMPLE Patients presenting to a community-based, multidisciplinary, academic spine center (65.9% female, mean age 54.4 years, median pain duration 12 months). INTERVENTIONS Charts of consecutive low back pain cases completing diagnostic spinal procedures including provocation discography and zygapohyseal joint, sacroiliac joint, and fusion hardware blockade were retrospectively reviewed. OUTCOME MEASURES Based on the results of discography and/or diagnostic blockades, subjects were classified with internal disc disruption, zygapohyseal joint pain, sacroiliac joint pain, or fusion hardware related pain. RESULTS The diagnoses of 28 fusion cases identified from 170 low back pain patients undergoing diagnostic procedures included 12 with sacroiliac joint pain, seven with internal disc disruption, five with zygapohyseal joint pain, and four due to soft tissue irritation from fusion hardware. No significant differences were noted in zygapohyseal joint mediated pain with and without fusion history. Mean ages of patients were similar with and without fusion history for cases diagnosed as internal disc disruption. CONCLUSION In patients' recalcitrant to non-interventional care, the sacroiliac joint is the most likely source of low back pain after lumbar fusion followed by internal disc disruption, zygapohyseal joint pain, and soft tissue irritation due to fusion hardware. Sacroiliac joint pain is more common after fusion, while internal disc disruption is more common in non-fusion patients.
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Affiliation(s)
- Michael J DePalma
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University Spine Center, Virginia Commonwealth University/Medical College of Virginia Hospitals, Richmond, Virginia 23235, USA.
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Does the location of low back pain predict its source? PM R 2011; 3:33-9. [PMID: 21257131 DOI: 10.1016/j.pmrj.2010.09.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 09/03/2010] [Accepted: 09/10/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the predictive utility of the pattern of low back pain (LBP) in detecting the source of LBP as internal disk disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP). DESIGN Retrospective chart review. SETTING University spine center. PATIENT SAMPLE A total of 170 cases from 156 patients presenting with LBP whose low back disorder was definitively diagnosed. The mean age was 54.4 years (SD, 16.2) and median duration of LBP was 12 months (interquartile ranges, 6-32). METHODS Charts of consecutive LBP patients who underwent definitive diagnostic spinal procedures including provocation diskography, facet joint blocks, and sacroiliac joint blocks were retrospectively reviewed. Each patient with LBP was queried as to the exact location of their LBP: midline, defined as in-line with the spinous processes, and/or paramidline, defined as lateral to 1 fingerbreadth adjacent to the midline. OUTCOME MEASURES In patients with a definitive diagnosis for the source of LBP, the proportion of each diagnosed source of pain was calculated. χ(2) tests were used to identify differences in the percentages of midline and paramidline LBP among the groups of patients testing positive for IDD, FJP, or SIJP. Diagnostic measures of sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and likelihood ratios of positive and negative tests using the presence/absence of midline and paramidline pain for the diagnosis of IDD, FJP, and SIJP were estimated. RESULTS With cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). In cases of IDD, significantly lower percentages of patients reported paramidline pain (67.3%; χ(2) = 16.1, df = 2, P = .0003) as compared with cases of FJP (95.0%) or SIJ (96.0%). In cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). The specificity of midline LBP for IDD, FJP, and SIJP was 74.8% (95% CI = 65.0%-82.9%), 28.0% (20.1%-37.0%), and 36.0% (28.0%-44.5%), respectively. The negative predictive value of paramidline LBP for IDD, FJP, and SIJP was 29.2% (95% CI = 12.6%-51.1%), 91.7% (73.0%-99.0%), and 95.8% (78.9%-99.9%). The diagnostic accuracy of midline LBP for IDD, FJP, and SIJP was 83.5%, 24.1%, and 31.8%, respectively. CONCLUSIONS The presence of midline LBP increases the probability of lumbar IDD and reduces the probability of symptomatic FJ and SIJ dysfunction. The presence of isolated paramidline LBP increases the probability of symptomatic FJ or SIJ but mildly reduces the likelihood of lumbar IDD.
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van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. 12. Pain originating from the lumbar facet joints. Pain Pract 2011; 10:459-69. [PMID: 20667027 DOI: 10.1111/j.1533-2500.2010.00393.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although the existence of a "facet syndrome" had long been questioned, it is now generally accepted as a clinical entity. Depending on the diagnostic criteria, the zygapophysial joints account for between 5% and 15% of cases of chronic, axial low back pain. Most commonly, facetogenic pain is the result of repetitive stress and/or cumulative low-level trauma, leading to inflammation and stretching of the joint capsule. The most frequent complaint is axial low back pain with referred pain perceived in the flank, hip, and thigh. No physical examination findings are pathognomonic for diagnosis. The strongest indicator for lumbar facet pain is pain reduction after anesthetic blocks of the rami mediales (medial branches) of the rami dorsales that innervate the facet joints. Because false-positive and, possibly, false-negative results may occur, results must be interpreted carefully. In patients with injection-confirmed zygapophysial joint pain, procedural interventions can be undertaken in the context of a multidisciplinary, multimodal treatment regimen that includes pharmacotherapy, physical therapy and regular exercise, and, if indicated, psychotherapy. Currently, the "gold standard" for treating facetogenic pain is radiofrequency treatment (1 B+). The evidence supporting intra-articular corticosteroids is limited; hence, this should be reserved for those individuals who do not respond to radiofrequency treatment (2 B±).
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Affiliation(s)
- Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands.
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DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? PAIN MEDICINE 2011; 12:224-33. [PMID: 21266006 DOI: 10.1111/j.1526-4637.2010.01045.x] [Citation(s) in RCA: 296] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the prevalence, mean age, and association of prevalence and age of lumbar internal disc disruption (IDD), facet joint pain (FJP), sacroiliac joint pain (SIJP), spinal and pelvic insufficiency fractures, interspinous ligament injury/Baastrup's Disease, and soft tissue irritation by fusion hardware. DESIGN The study's design was a retrospective chart review. SETTING The study was set in an academic spine center. PATIENTS A total of 378 cases from 358 patients were reviewed of which 170 cases from 156 patients who underwent diagnostic procedures were included. INTERVENTIONS Discography, dual diagnostic facet joint blocks, intra-articular sacroiliac joint injections, anesthetic injections of painful interspinous ligaments/opposing spinous processes/posterior fusion hardware, or percutaneous augmentation were performed. OUTCOME MEASURES Prevalence and age were analyzed for each diagnosis group. METHODS Patients with recalcitrant low back pain underwent diagnostic procedures based on their clinical presentation until the pain source was identified. RESULTS The prevalence of internal disc disruption, facet joint pain and sacroiliac joint pain was 42%, 31%, and 18%, respectively. Patients with internal disc disruption were significantly younger than those with facet joint pain or sacroiliac joint pain. Increased age was associated with a decreased probability of internal disc disruption and increased probabilities of facet joint pain and sacroiliac joint pain as the source of low back pain until approximately age 70. CONCLUSION Our data confirm the intervertebral disc as the most common etiology of chronic low back pain in adults. Based on our sample, the younger the patient, the more likely low back pain is discogenic in origin. Facetogenic or sacroiliac joint pain is more likely in older patients.
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Affiliation(s)
- Michael J DePalma
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University/Medical College of Virginia Hospitals, Richmond, Virginia, USA.
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Isaac Z, Katz JN. Lumbar spine disorders. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00069-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Lumbar Facet Joint Blocks. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bogduk N. Lumbar Facet Syndrome. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00090-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
Pain that develops in the cervical, thoracic, lumbar, and sacral spine is typically initiated from a clinical condition called spondylosis. Radiofrequency ablation is a key element in the treatment protocol of patients with spondylosis of the cervical, thoracic, lumbar, and sacroiliac joint pain. A diagnosis can be made by blocking the median branch nerve that innervates each joint. Once this has been confirmed, an ablation procedure can be performed to increase the duration of pain relief desired by the patient with chronic pain originating from spondylosis. Radiofrequency neurolysis is a common technique used in the treatment of chronic pain, particularly facet (zygapophyseal joint) arthralgia. The technique involves an insulated needlelike cannula; x-rays passing through the patient show the projected relative radioopaque bony landmarks and the metallic cannula.
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Takahashi Y, Ohtori S, Takahashi K. Somatotopic organization of lumbar muscle-innervating neurons in the ventral horn of the rat spinal cord. J Anat 2010; 216:489-95. [PMID: 20136668 DOI: 10.1111/j.1469-7580.2009.01203.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The ventral horn of the rat spinal cord was investigated with respect to the somatotopic organization of the motor neurons that innervate the lumbar muscles. Neurotracer 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI) was applied to specific sites in lumbar muscles. Spinal cord segments at L1 through L4 levels were cut into 40-mum serial transverse sections. Labeled neurons were located in the ventromedial nucleus (VM) and lateromedial nucleus (LM) nuclei of Rexed's lamina IX. Motor neurons innervating the m. interspinales lumborum and m. multifidus were without exception present in the VM, whereas all motor neurons innervating the m. rectus abdominis were present in the LM. Forty percent of motor neurons innervating the m. quadratus lumborum were present in the VM and the other 60% were in the LM. Although most of the motor neurons innervating the m. psoas major were present in the LM, a few labeled neurons existed in the VM. These results suggest that the border zone demarcating the areas of innervation of the dorsal and ventral rami of spinal nerves crosses the m. quadratus lumborum.
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Affiliation(s)
- Yuzuru Takahashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
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