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

A Systematic Review of Regenerative Medicine Therapies for Axial Spine Pain of Facet Joint Origin

PURPOSE OF REVIEW

This review aims to assess the effectiveness of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) injections in treating axial spinal pain originating from the facet joints. A systematic evaluation of available evidence on these biological therapies was conducted to determine their clinical utility.

RECENT FINDINGS

Recent studies emphasize the therapeutic promise of intraarticular biologics, including MSCs, PRP, and alpha-2-macroglobulin, in managing facet joint-related axial spinal pain. Emerging evidence suggests improvements in pain relief, physical function, and quality of life following these treatments. Based on our search criteria, 20 publications were identified and considered for inclusion. Of these, 4 randomized controlled trials (RCTs) and 6 observational studies met the inclusion criteria. Among the RCTs, 3 trials involved lumbar facet joints, and one trial involved cervical facet joints using PRP. Among the observational studies, 4 studies used PRP, with 3 focusing on the lumbar spine and one study, with 2 publications, on the cervical spine, and only 2 studies evaluated stem cell treatments. The summary of evidence utilizing various criteria, including Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) evidence synthesis, the evidence for PRP injections in facet joints is Level II, or moderate, and Level IV, or limited, overall, with low certainty. For PRP, the recommendation is moderate, and for MSCs, the recommendation is weak.

Comprehensive Grading System of Inflammatory Features of the Lumbar Facet Joints on Magnetic Resonance Imaging

STUDY DESIGN

Retrospective.

OBJECTIVE

We aimed to describe a magnetic resonance imaging (MRI)-based grading system of inflammatory features of the lumbar facet joints using an atlas and assess its reliability.

SUMMARY OF BACKGROUND DATA

Chronic low back pain is often caused by facet joint arthropathy. Inflammatory features are often evident on MRI. While several grading systems of facet arthropathy have been described, there is scant data on the reliability of these systems, and none focus exclusively on inflammatory features.

MATERIALS AND METHODS

We describe a grading system that assesses facet joint effusion, bone marrow edema, and soft tissue edema. Each feature was graded from 0 to 3 (facet edema) or 0 to 2 (bone marrow edema intensity and extent, soft tissue edema intensity and extent). Four spine experts graded MRIs of 50 subjects at the bilateral L3/4, L4/5, and L5/S1 levels. All subjects had symptomatic facet arthropathy and received therapeutic facet joint injections. We assessed the intra-reader and inter-reader reliability of each feature at each joint and summarized across all six joints.

RESULTS

The mean age of subjects was 56 years (SD = 17), and 48% were female. The injections occurred at the L3/4 level in 12% of cases, at L4/5 in 88%, and at L5/S1 in 80% of cases. The intra-reader reliability kappa's for each feature ranged from 0.42 to 0.81. In contrast, the inter-reader reliability kappa values for each feature ranged from 0.37 to 0.54.

CONCLUSION

MRI inflammatory features of the lumbar facet joints are often noted in patients with low back pain. The proposed grading system is reliable and could serve as a research tool for studies assessing the clinical relevance and prognostic value of these features.

Comparative Outcome of Lidocaine Versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study

OBJECTIVE

This study evaluated the effect of prolonged concordant response and functional clinical improvement between lidocaine and bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet syndrome.

METHODS

Sixty-two patients diagnosed with chronic cervical facet syndrome were randomized into either lidocaine or bupivacaine groups. The therapeutic CMBB was performed under ultrasound guidance. Either 2% lidocaine or 0.5% bupivacaine with a volume of 0.5-1 mL per level was injected according to the patient's pain symptoms. The patients, pain assessor, and pain specialist were blinded. The primary outcome was the duration of pain reduction by at least 50%. The Numerical Rating Scale of 0-10 and the Neck Disability Index questionnaire were recorded.

RESULTS

There was no significant difference in the duration of 50% and 75% pain reduction and Neck Disability Index between the lidocaine and bupivacaine groups. Lidocaine provided significant pain reduction up to 16 weeks (P < 0.05) and significant improvement in neck functional outcomes up to 8 weeks (P < 0.01) compared to the baseline. While bupivacaine yielded significant pain alleviation for up to 8 weeks for pain upon neck mobilization (P < 0.05) and demonstrated notable improvement in neck function up to 4 weeks (P < 0.01) compared to the baseline.

CONCLUSION

CMBB using lidocaine or bupivacaine provided clinical benefits in prolonged analgesic effect and improving neck functions for chronic cervical facet syndrome. Lidocaine illustrated better performance and could be considered a local anesthetic of choice regarding the prolonged concordance response.

Interventional non-operative management of low back and neck pain

Background

Chronic neck and back pain are among the most commonly encountered health problems in neurosurgical practice. Many cases fail prolonged pharmacological and physical therapy and are not proper candidates for surgical interventions, or had refused proposed surgical treatment.

Objective

To provide an informative critical summary of the literature about the topic of interventional management of axial neck and low back pain and highlighting the new trends and pieces of evidence.

Methods

The English literature published over the last two decades was reviewed by the author for recent and relevant data about the principles of interventional management of chronic neck and low back pain. A PubMed search was performed through phrase searching and combined searching using Boolean operators. The articles thought to be most relevant to the study aim and the neurosurgeons’ practice were extracted.

Results

Neck and low back pain continue to be among the most common musculoskeletal health problems and the most common cause of disability worldwide. A detailed understanding of relevant spine anatomy is crucial for interventionists who should deal with the concept of “functional spine unit” with multiple potential pain generators. Chronic spinal pain is best managed through a dedicated multidisciplinary team in well-equipped healthcare facilities. An algorithmic approach for the diagnosis and management of spinal pain is the mainstay of providing the best patient care and should be based on the commonality and treatability of pain generators, values of patients and available resources.

Conclusion

Management of chronic neck and back pain can represent a clinical dilemma due to the multiplicity of pain generators that may coexist in the same individual resulting in a complex type and pattern of pain. Approach to these patients requires contributions from the members of a multidisciplinary team, implementing a standardized approach in a well-equipped healthcare facility.

A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain

Background

Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks.

Study Design

Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis.

Objective

The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain.

Methods

Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined.

Results

Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions.

Limitations

There was a paucity of literature and heterogeneity among the available studies.

Conclusion

This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-022-00455-0.

3D kinematic characteristics of lumbar facet joints in sitting position

BACKGROUND

Recognizing the kinematic characteristics of lumbar facet joints is important for the prevention and treatment of lumbar degenerative diseases. Previous studies have been conducted in either the supine or standing position, and there are no measurements regarding the kinematic characteristics of the lumbar facet joints while sitting. The aim of this study was to measure and analyze lumbar facet joint motion characteristics while sitting.

METHODS

Ten subjects (5 males and 5 females) performed the movements of flexion-extension, left bending-right bending, and left rotation-right rotation in a sitting position. Dual Fluoroscopic Image System and computed tomography technique were used to measure the displacement and rotation angle of the lumbar facet joints of the subjects for analysis. The movement characteristics of L3-S1 were measured.

RESULTS

When the subjects were in sitting position, the lumbar vertebra mainly changed in Z-axis and α, β angle when they performed flexion-extension activities. The displacement of the left facet joint was 4.65 ± 1.99 mm at L3-4, 1.89 ± 2.99 mm at L4-5, and 0.80 ± 2.27 mm at L5-S1 in the Z-axis, and the displacement of the right facet joint was 3.20 ± 2.61 mm at L3-4, 1.71 ± 3.00 mm at L4-5, and 0.31 ± 1.69 mm at L5-S1 in the Z-axis. The rotation in the α angle was 6.00 ± 4.49° at L3-4, 3.51 ± 5.24° at L4-5, and 0.97 ± 4.13° at L5-S1, which was significant different. The rotation in the β angle was 2.30 ± 2.94°at L3-4, 0.16 ± 2.06° at L4-5, and 0.35 ± 1.74°at L5-S1, which was significant different. When the lumbar spine performed the activity of left bending-right bending, there were changes in rotation mainly in the Z-axis and β angle. The displacement of left facet joint in the Z-axis was 1.34 ± 2.84 mm at L3-4, 2.11 ± 0.88 mm at L4-5, and 0.72 ± 0.81 mm at L5-S1; the rotation in the β angle was 5.66 ± 2.70°at L3-4, 7.89 ± 2.59° at L4-5, and 1.28 ± 2.07° at L5-S1; when the lumbar spine performed the activity of left rotation-right rotation, there were changes in the β angle. The rotation of β angle was 4.09 ± 2.86° at L3-4, 2.14 ± 3.38° at L4-5, and 0.63 ± 1.85° at L5-S1.

CONCLUSION

The lumbar facet joint motion in sitting position is different in each mode of motion. The horizontal displacement and rotation are predominant during flexion and extension activities, while there are different rotation in bending and rotation. The study shows the coupled motion of the lumbar facet joints while sitting, providing a new perspective on the kinematics of the lumbar spine and the etiology of lumbar degenerative diseases.

Patient-perceived duration of effect of lidocaine and bupivacaine following diagnostic medial branch blocks; a multicenter study

Objective

To quantify the duration of pain relief reported in association with lidocaine and bupivacaine in patients suffering from axial back pain, who reported a response of ≥80% relief lasting at least 30 ​min following medial branch blocks(MBB).

Design

A retrospective review.

Methods

Setting & Subjects: Four academic medical centers utilized a uniform pain diary. It was administered to consecutive patients after undergoing MBB. This pain diary included NRS pain score and percentage of pain relief (PPR) at 12 designated time points.

Results

One hundred and fifty pain diaries were collected and analyzed. 42 blocks were performed in the cervical spine, 7 in the thoracic spine, and 101 in the lumbar spine. By NRS, 32% of pain diaries indicated that the patient experienced ≥80% pain relief at the 30-min and 42.7% (64/150) did so by PPR. Mean duration of ≥80% pain relief as measured by NRS in the bupivacaine subgroup was 3.5 ​h (SD 8.7, 95% CI 0.6-6.5) versus mean duration of 16.4 ​h (SD 19.6, 95% CI 5.4-27.4) in the lidocaine subgroup. Mean duration of ≥80% pain relief as measured by PPR in the bupivacaine subgroup was 19.2 ​h (SD 19.2, 95% CI 13.3-25.1) versus mean duration of 12.2 ​h (SD 15.9, 95% CI 5.6-18.8) in the lidocaine subgroup.

Conclusions

This study demonstrates that there is no discernable or statistically significant difference in the duration of effect when comparing lidocaine to bupivacaine in patients that experience 80% or more relief following a medial branch block. This data suggests any emphasis on concordant duration of relief from specific anesthetics utilized for diagnostic medial branch blocks should be reconsidered.

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.

Third-degree full-thickness burns as a complication of cervical radiofrequency ablation

A 46-year-old woman underwent a cervical radiofrequency ablation (RFA) for chronic neck pain. Following the procedure, two areas surrounding the grounding pad in the lumbar region developed full thickness third-degree burns. Burn injuries following cervical RFA are rarely reported and are most often associated with cardiac and solid tumour RFA. Only one other case has been reported in literature with a similar outcome following a thoracic facet RFA. In our case, the lesion was directly from the ground pad and not from the radiofrequency electrode, which is more often the culprit. This is the first case reported in the literature of a full-thickness skin burn from a cervical RFA. Physicians should be aware of the potential for severe burns around the RF probe and ground pad as sequelae of RFA, and we caution the use of sedation during the procedure, as patients will unlikely be able to report any unusual sensation.

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.

Image-guided spinal injection for pain management

Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.

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.

Efficacy and Long-term Effect of Radiofrequency Denervation in Patients with Clinically Diagnosed Cervical Facet Joint Pain: A Double-blind Randomized Controlled Trial

STUDY DESIGN

Multicenter double-blind randomized sham-controlled trial.

OBJECTIVE

To assess the efficacy of radiofrequency (RF) denervation of the cervical facet joints in chronic cervical facet joint pain.

SUMMARY OF BACKGROUND DATA

One randomized controlled trial showed efficacy of RF denervation in whiplash-associated disease. There are no randomized controlled trials on RF denervation in patients with chronic cervical facet joint pain.

METHODS

Patients were randomized to receive RF denervation combined with bupivacaine (intervention group) or bupivacaine alone (control group). In the intervention group, an RF thermal lesion was made at the cervical medial branches after the injection of bupivacaine. The primary outcome was measured at 6 months and consisted of pain intensity, self-reported treatment effect, improvement on the Neck Disability Index, and the use of pain medication. Duration of effect was determined using telephone interviews.

RESULTS

We included 76 patients. In the intervention group, 55.6% showed > 30% pain decrease versus 51.3% in the control group (P = 0.711); 50.0% reported success on the Patients' Global Impression of Change in the intervention group versus 41.0% (P = 0.435); the Neck Disability Index was 15.0 ± 8.7 in the intervention group compared with 16.5 ± 7.2 (P = 0.432), the need for pain medication did not differ significantly between groups (P = 0.461). The median time to end of treatment success for patients in the RF group was 42 months, compared with 12 months in the bupivacaine group (P = 0.014).

CONCLUSIONS

We did not observe significant differences between RF denervation combined with injection of local anesthesia compared with local anesthesia only at 6 months follow-up. We found a difference in the long-term effect after 6 months follow-up in favor of the RF treatment.Level of Evidence: 2.

Tolerability and Feasibility of X-ray Guided Non-Invasive Ablation of the Medial Branch Nerve with Focused Ultrasound: Preliminary Proof of Concept in a Pre-clinical Model

Four to six million patients a year in the United States suffer from chronic pain caused by facet joint degeneration. Thermal ablation of the affected facet joint's sensory nerve using radiofrequency electrodes is the therapeutic standard of care. High-intensity focused ultrasound (HIFU) is a novel technology enabling image-guided non-invasive thermal ablation of tissue. Six pigs underwent fluoroscopy-guided HIFU of the medial branch nerve and were followed up for 1 wk (two pigs), 1 mo (two pigs) and 3 mo (two pigs). At the end of each follow-up period, the animals were sacrificed, and targeted tissue was excised and evaluated with computed tomography scans as well as by macro- and micropathology. No significant adverse events were recorded during the procedure or follow-up period. All targets were successfully ablated. X-Ray-guided HIFU is a feasible and promising alternative to radiofrequency ablation of the lumbar facet joint sensory nerve.

Pain Management in Neurosurgery: Back and Lower Extremity Pain, Trigeminal Neuralgia

Interventional anesthetic techniques are an integral component of a biopsychosocial approach and multidisciplinary treatment. Injection techniques are often used to diagnose disorders, decrease the need for surgery, or increase the time to surgery. The role of neural blockade techniques using local anesthetics and steroids in the assessment and treatment of pain continues to be refined. With the current opioid crisis and an aging population with increasing medical comorbidities, there is an emphasis on the use of nonopioid, nonsurgical, and multimodal therapies to treat chronic pain. This article reviews indications, goals, and methods of common injection techniques.

[Interdisciplinary position paper: the value of radiofrequency denervation in the treatment of chronic pain]

Radiofrequency denervation has been established for many years as an important minimally invasive procedure for the treatment of chronic pain conditions. Positive experiences of many users for various indications are contrasted by a nonuniform evidence. With meticulous patient selection and correct assessment of the indications a longer term reduction of pain, a reduced need for analgesics and an improvement in the quality of life can be achieved. The aim of this interdisciplinary position paper is to present the value of radiofrequency denervation in the treatment of chronic pain. The summarized recommendations of the expert group are based on the available evidence and on the clinical experiences of Austrian centers that frequently implement the procedure. The position paper contains recommendations on patient selection and proven indications. We discribe safety aspects, complications, side effects and contraindications.

Therapeutic Facet Joint Interventions in the Lumbar Spine: An Economic Value Perspective

OBJECTIVE

In this narrative review, the current literature on therapeutic interventions for low back pain of facet joint etiology is assessed from an economic value perspective.

SUMMARY OF BACKGROUND DATA

The efficacy and economics of facet joint interventions in the treatment of lumbar back pain is a controversial topic. Trends show that facet joint interventions are becoming increasingly used, perhaps as physicians become more averse to treating chronic low back pain with opioids. With the emphasis on value-based spine care and changing reimbursement models, the perspective of rigorously evaluating the outcomes these interventions provide and the costs they incur is particularly relevant.

DISCUSSION

Although the evidence is noted to be limited, most systematic reviews fail to demonstrate the therapeutic utility of intra-articular facet joint injections in low back pain because of high study heterogeneity. A few good quality studies and systematic reviews describe moderate evidence for the utilization of therapeutic medial branch blocks and radiofrequency neurotomies in alleviating facet joint pain.

CONCLUSION

Consequently, there is a need for high-quality cost-effectiveness studies for facet joint interventions so that evidence-based and economically viable solutions can be used to optimize patient care at a societally affordable price.

Does Thoracic Manipulation Cause Extravasation at Joint Following Facet Injections?

Facet injections and other pain management interventions are commonly performed in combination with conservative therapy to address spinal pain. Joint mobilizations are a highly utilized intervention for manual practitioners to treat patients with spinal pain. Clinical reasoning and decision making models have not been well described in the literature assessing if and when joint mobilizations are appropriate interventions immediately or shortly following facet injection procedures. It has not been well studied if joint mobilizations immediately following facet injections negatively impact the injected solution at the respective joint and thus influence therapeutic effect. More specifically, there is a paucity of evidence assessing this at the thoracic spine. The purpose of this study was to assess if thoracic joint high-velocity low amplitude thrust manipulations caused extravasation of injected radiolucent material at respective thoracic facet joints on a cadaver. This study included an expert physician performing ultrasound-guided facet injections, an experienced manual physical therapist performing joint mobilization techniques, and fluoroscopic assessment of radiolucent material pre- and post-manipulation by a board-certified radiologist with experience in this field of study. Imaging interpretation confirmed that extravasation at respective joints did not occur following manipulation. This basic research can help guide clinical reasoning for practitioners considering implementing manual therapy techniques following facet injections and help guide further research. 

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.

An incoherent HIFU transducer for treatment of the medial branch nerve: Numerical study and in vivo validation

BACKGROUND

Chronic back pain due to facet related degenerative changes affects 4-6 million patients a year in the United States. Patients refractory to conservative therapy may warrant targeted injections of steroids into the joint or percutaneous medial branch nerve denervation with radiofrequency ablation. We numerically tested a novel noninvasive high intensity focused ultrasound transducer to optimize nerve ablation near a bone-soft tissue interface.

METHODS

A transducer with 4 elements operating in an incoherent mode was modeled numerically and tested pre-clinically under fluoroscopic guidance. After 6 lumbar medial branch nerve ablations were performed in 2 pigs, they were followed clinically for 1 week and then sacrificed for pathological evaluation.

RESULTS

Simulations show that the acoustic spot size in water at 6 dB was 14mm axial x 1.6mm lateral and 52mm axial x 1.6mm lateral for coherent and incoherent modes, respectively. We measured the size of N = 6 lesions induced in vivo in a pig model and compared them to the size of the simulated thermal dose. The best match between the simulated and measured lesion size was found with a maximum absorption coefficient in the cortical bone adjusted to 30 dB/cm/MHz. This absorption was used to simulate clinical scenarios in humans to generate lesions with no potential side effects at 1000 and 1500 J.

CONCLUSION

The elongated spot obtained with the incoherent mode facilitates the targeting during fluoroscopic-guided medial branch nerve ablation.

In vivo measurements of medial branch nerve depth and adjacent osseous structures for ablation of facet-related back pain: Predictors for patient candidacy

•

The average distance from skin-to-MB at a 15 angle to the skin and the average thickness of the pedicles both increased as the lumbar level increased.

•

The linear regression model returned BMI, vertebral level, and gender as significant predictors of MB depth.

•

The MB resides 107 mm or less in depth when measured at a 15° angulation from the skin in > 95% of patients.

Background

Methods

Results

Conclusions

Use of Single-Photon Emission Computed Tomography Imaging for Hypermetabolic Facet Identification in Diagnosis of Cervical and Axial Back Pain

BACKGROUND

Few studies have used hybrid single-photon emission computed tomography (SPECT)/computed tomography (CT) scan to identify degenerative facet disease. We aimed to determine the incidence of hypermetabolic facets on SPECT/CT imaging in patients with axial neck or back pain to elucidate the value of SPECT/CT scan in identifying pain generators.

METHODS

A retrospective review of adult patients with axial neck or back pain was conducted. A total of 190 patients underwent high-resolution SPECT/CT imaging using a standardized protocol from January 2010 to April 2018. Facet joints with increased radionuclide uptake on SPECT imaging were characterized as hypermetabolic. Number, level, and laterality of hypermetabolic facets were recorded based on review of imaging and radiologist impressions.

RESULTS

The average age of the patients was 58 ± 13 years, and 51% of patients were men. A total of 85 patients (48%) demonstrated zygapophyseal joint hypermetabolism (ZJH) on SPECT imaging. A total of 202 hypermetabolic facets were identified, indicating the average number of facets with ZJH was 2.38 ± 1.91. Of patients with a positive scan, lumbar facets were most commonly affected (69% of ZJH) followed by cervical (24%) and thoracic regions (6%). C1-2 and C2-3 (22% each of cervical ZJH) and L4-5 (32% of lumbar ZJH) were most commonly affected in the cervical and lumbar regions, respectively.

CONCLUSIONS

Nearly half of all patients with axial neck or back pain demonstrated ZJH on SPECT/CT imaging, supporting ZJH sites as potential pain generators and targets for treatment. Our results support the role for SPECT/CT imaging in the workup of patients with axial neck or back pain, which may reduce invasive diagnostic procedures and aid in treatment planning.

Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique

Objective

To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques.

Design

Comprehensive systematic review.

Methods

A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.

Outcome Measures

The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes.

Results

Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months.

Conclusions

This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

Evaluation of Cost-Utility of Thoracic Interlaminar Epidural Injections

PURPOSE OF REVIEW

Chronic thoracic pain, even though not as prevalent as low back and neck pain, appears in approximately 30% of the general population. The severity of thoracic pain and degree of disability seems to be similar to other painful conditions. Despite this severity, interventions in managing chronic thoracic pain are less frequent, and there is a paucity of literature regarding epidural injections and facet joint interventions.

RECENT FINDINGS

As with lumbar and cervical spine, a multitude of interventions are offered in managing chronic thoracic pain, including interventional techniques with epidural injections and facet joint interventions. A single randomized controlled trial (RCT) has been published with a 2-year follow-up of clinical effectiveness of the results. However, there have not been any cost-utility analysis studies pertaining to either epidural injections or facet joint interventions in thoracic pain. Based on the results of the RCT, a cost-utility analysis of thoracic interlaminar epidural injections was undertaken. Evaluation of the cost-utility analysis of thoracic interlaminar epidural injections with or without steroids in managing thoracic disc herniation, thoracic spinal stenosis, and thoracic discogenic or axial pain was assessed in 110 patients with a 2-year follow-up. Direct payment data from 2018 was utilized for procedural costs and indirect costs. Costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 or addition of 40% of cost to accommodate for indirect payments and arrive at overall costs. Cost-utility analysis showed direct procedural cost of USD $1943.19, whereas total estimated costs year per QALY were USD $3245.12.

Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials

Objective

To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine.

Design

Narrative review.

Method

We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers.

Results

Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data.

Conclusions

Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

BACKGROUND

Neck pain is one of the most common causes of chronic pain and the fourth leading cause of disability worldwide; it is estimated that between 36% and 67% of this pain is due to facet arthropathy. For patients who have pain refractory to conservative treatments literature supports management with diagnostic cervical medial branch blocks (MBBs) to identify the associated facet innervation as the source of pain followed by therapeutic radiofrequency ablation (RFA) of the identified nerves. Cervical RFA has good published outcomes; however, the procedure is dependent upon the specificity of the diagnostic block to achieve maximal success. Currently, this prerequisite test has false positive rates between 27% and 63% and recent studies have shown that this may, in part, be a consequence of currently accepted injection volumes of 0.50 mL or more, which may decrease the sensitivity of MBBs.

OBJECTIVE

To evaluate the possible differences in volume dispersion between 0.25 and 0.50 mL of injectate during cervical MBBs.

STUDY DESIGN

Cadaveric study.

SETTING

An academic medical center in the United States.

PATIENTS

Not applicable.

METHODS

This was a cadaveric study in which six subjects were chosen with intact cervical spines. Cervical MBB were performed bilaterally at the midcervical spine, using a posterior approach under fluoroscopic guidance. 0.25 or 0.50 mL of a 9:1 solution of Omnipaque 180 mg iodine/mL and 1% medical grade methylene blue were administered on the left and right sides, respectively. Postinjection computed tomography (CT) imaging and gross dissection were performed to assess injectate spread.

MAIN OUTCOME MEASURES

Outcome measures after using commonly injected volumes for cervical MBB, included visualized and measured spread (by CT and gross dissection) of cervical medial branch blocks, coating adjacent structures not targeted by RFA.

RESULTS

Postinjection CT imaging and cadaveric dissection demonstrated that, although both volumes adequately coated the medial branches, the 0.50 mL cohort reliably spread dorsally to superficial muscles (splenius) and nerves distant from the targeted nerves (dorsal motor branches to splenius), whereas the 0.25 mL injectate cohort was contained in the deep and intermediate muscular cervical layers directly juxtaposed to the targeted cMBBs.

CONCLUSION

Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without extensive extravasation. This indicates that there would potentially be fewer local anesthetic effects on distant tissues, increasing the specificity of cervical MBBs and likely improving RFA planning.

Facet joint syndrome: from diagnosis to interventional management

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.

Clinical diagnosis scale for pain lumbar of facet origin: systematic review of literature and pilot study

INTRODUCTION

Lumbar pain affects between 60-90% of people. It is a frequent cause of disability in adults. Pain may be generated by different anatomical structures such as the facet joint. However, nowadays pain produced by the facet joint has no clinical diagnosis. Therefore, the purpose of this article is to propose a clinical diagnostic scale for lumbar facet syndrome.

MATERIALS AND METHODS

The study was conducted by means of 6 phases as follows, Phase 1, a systematic review of the literature was performed regarding the clinical diagnosis of facet-based lumbar pain based on the PRISMA checklist; Phase 2, a list of signs and symptoms proposed for diagnosis lumbar pain of facet origin was made. Phase 3, the list of signs and symptoms found was submitted to a committee of experts to discriminate the most significant signs and symptoms, these were linked to general sociodemographic variables to develop an evaluation questionnaire; Phase 4, the evaluation questionnaire was applied, including those selected signs and symptoms to a group of patients with clinical diagnosis of facet disease lumbar pain and who underwent a selective facet block. Phase 5, under standard technique selective facet block and subsequent postoperative clinical control at 1 month. Phase 6, given pre and postsurgical results associated with signs present in the patients we propose a clinical scale of diagnosis scale. Descriptive statistics and Stata 12.0 were used as statistical software.

RESULTS

A total of 36 signs and symptoms were found for the diagnosis of lumbar facet syndrome that were submitted to the group of experts, where a total of 12 (8 symptoms and 4 signs) were included for the final survey. 31 patients underwent selective lumbar facet blockade, mostly women, with an average of 60±11.5 years, analogous visual scale of preoperative pain of 8/10, postoperative of 1.7/10, the signs and symptoms most frequently found included in a diagnostic scale were: 3 symptoms 1) axial or bilateral axial lumbar pain, 2) improvement with rest, 3) absence of root pattern, may have pseudoradicular pattern, however, the pain is greater lumbar than pain in the leg and 3 clinical signs 1) Kemp sign, 2) pain induced in joint or transverse process, 3) facet stress sign or Acevedo sign.

CONCLUSION

The clinical diagnosis of lumbar facet pain is still debated. Few diagnostic scales have been postulated, with little or no external validity, so the present study proposes a diagnostic scale consisting of 3 symptoms and 3 clinical signs.

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

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

Effect of Pulsed Radiofrequency Treatment on the Thoracic Medial Branch for Managing Chronic Thoracic Facet Joint Pain Refractory to Medial Branch Block with Local Anesthetics

OBJECTIVE

To evaluate the effect of pulsed radiofrequency (PRF) stimulation of the thoracic medial branch of the dorsal ramus in patients with chronic thoracic facet joint (TFJ) pain who were refractory to medial branch block (MBB).

METHODS

This was a prospective, observational study. The author retrospectively reviewed data from 72 patients who had received therapeutic MBB with 0.5 mL of 2% lidocaine mixed with 0.5 mL of 0.25% bupivacaine to treat TFJ-origin upper or midback pain. Of these patients, 20 were included to evaluate the effects of PRF on the thoracic medical branch to manage TFJ pain refractory to therapeutic MBB. PRF stimulation was administered at 5 Hz and a 5-millisecond pulsed width for 360 seconds at 45 V. The pain-reducing effect of the PRF procedure was evaluated via the numeric rating scale (NRS) at 1, 2, and 3 months after treatment. Successful pain relief was defined as ≥50% reduction in the NRS score compared with the score before treatment.

RESULTS

The NRS scores changed significantly over time (pretreatment, 6.0 ± 1.0; 1 month, 3.3 ± 2.2; 2 months, 3.9 ± 2.1; and 3 months, 4.0 ± 2.2). At 1, 2, and 3 months after the PRF procedure, the NRS scores were significantly reduced compared with the scores before the treatment. Eleven (55%) of 20 patients reported successful pain relief at 3 months after PRF.

CONCLUSIONS

The author suggests that PRF on the thoracic medial branch is an effective and safe interventional technique for the control of chronic TFJ pain.

Comparison of Intra-articular Thoracic Facet Joint Steroid Injection and Thoracic Medial Branch Block for the Management of Thoracic Facet Joint Pain

STUDY DESIGN

A prospective observational study.

OBJECTIVE

The aim of this study was to show the effect of intra-articular (IA) thoracic facet joint (TFJ) steroid injection for the management of TFJ pain, and to compare it with the effect of therapeutic thoracic medial branch block (MBB) with a local anesthetic and steroid.

SUMMARY OF BACKGROUND DATA

Several studies have shown the effects of thoracic MBB with local anesthetics with or without steroids and radiofrequency neurotomy in managing TFJ pain, but thus far, the effectiveness of IA TFJ steroid injection has not been studied.

METHODS

Forty patients with TFJ pain were recruited and randomly assigned to one of two groups, the IA steroid injection and the MBB group, each with 20 patients. For IA TFJ steroid injection and therapeutic MBB, we injected 0.5 mL of 0.5% bupivacaine, mixed with 10 mg (0.25 mL) of dexamethasone. We assessed the severity of TFJ pain using a numeric rating scale (NRS) before treatment and at 1, 3, and 6 months after treatment.

RESULTS

Compared to the pretreatment NRS scores, the NRS scores at 1, 3, and 6 months after each treatment showed a significant decrease in patients in both the groups. Intergroup changes in the NRS scores were not significantly different over time. Six months after the treatment, 65% of the patients in the IA steroid injection group reported successful pain relief (pain relief ≥50%), and 40% of the patients in the MBB group showed successful pain relief.

CONCLUSION

In the present study, both IA TFJ steroid injection and therapeutic MBB significantly relieved TFJ pain. Their effects persisted for at least 6 months after the procedure. Thus, we think that both IA TFJ steroid injection and therapeutic thoracic MBB are useful treatment options for managing TFJ pain.

LEVEL OF EVIDENCE

2.

Drivers and Risk Factors of Unplanned 30-Day Readmission Following Spinal Cord Stimulator Implantation

OBJECTIVES

Unplanned 30-day readmission rates contribute significantly to growing national healthcare expenditures. Drivers of unplanned 30-day readmission after spinal cord stimulator (SCS) implantation are relatively unknown. The aim of this study was to determine drivers of 30-day unplanned readmission following SCS implantation.

METHODS

The National Readmission Database was queried to identify all patients who underwent SCS implantation for the 2013 calendar year. Patients were grouped by readmission status, "No Readmission" and "Unplanned 30-day Readmission." Patient demographics and comorbidities were collected for each patient. The primary outcome of interest was the rate of unplanned 30-day readmissions and associated driving factors. A multivariate analysis was used to determine independent predictors of unplanned 30-day readmission after SCS implantation.

RESULTS

We identified 1521 patients who underwent SCS implantation, with 113 (7.4%) experiencing an unplanned readmission within 30 days. Baseline patient demographics, comorbidities, and hospital characteristics were similar between both cohorts. The three main drivers for 30-day readmission after SCS implantation include: 1) infection (not related to SCS device), 2) infection due to device (limited to only hardware infection), and 3) mechanical complication of SCS device. Furthermore, obesity was found to be an independent predictor of 30-day readmission (OR: 1.86, p = 0.008).

CONCLUSION

Our study suggests that infectious and mechanical complications are the primary drivers of unplanned 30-day readmission after SCS implantation, with obesity as an independent predictor of unplanned readmission. Given the technological advancements in SCS, repeated studies are necessary to identify factors associated with unplanned 30-day readmission rates after SCS implantation to improve patient outcomes and reduce associated costs.

Predictability of the effects of facet joint infiltration in the degenerate lumbar spine when assessing MRI scans

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.

Segmental variations in facet joint translations during in vivo lumbar extension

The lumbar facet joint (FJ) is often associated with pathogenesis in the spine, but quantification of normal FJ motion remains limited to in vitro studies or static imaging of non-functional poses. The purpose of this study was to quantify lumbar FJ kinematics in healthy individuals during functional activity with dynamic stereo radiography (DSX) imaging. Ten asymptomatic participants lifted three known weights starting from a trunk-flexed (∼75°) position to an upright position while being imaged within the DSX system. High resolution computed tomography (CT) scan-derived 3D models of their lumbar vertebrae (L2-S1) were registered to the biplane 2D radiographs using a markerless model-based tracking technique providing instantaneous 3D vertebral kinematics throughout the lifting tasks. Effects of segment level and weight lifted were assessed using mixed-effect repeated measures ANOVA. Superior-inferior (SI) translation dominated FJ translation, with L5S1 showing significantly less translation magnitudes (Median (Md) = 3.5 mm, p < 0.0001) than L2L3, L3L4, and L4L5 segments (Md = 5.9 mm, 6.3 mm and 6.6 mm respectively). Linear regression-based slopes of continuous facet translations revealed strong linearity for SI translation (r² > 0.94), reasonably high linearity for sideways sliding (Z-) (r² > 0.8), but much less linearity for facet gap change (X-) (r² ∼ 0.5). Caudal segments (L4-S1), particularly L5S1, displayed greater coupling compared to cranial (L2-L4) segments, revealing distinct differences overall in FJ translation trends at L5S1. No significant effect of weight lifted on FJ translations was detected. The study presents a hitherto unavailable and highly precise baseline dataset of facet translations measured during a functional, dynamic lifting task.

Hybrid Bone SPECT/CT Imaging in Evaluation of Chronic Low Back Pain: Correlation with Facet Joint Arthropathy

BACKGROUND

Evidence to support the use of bone hydroxydiphosphonate (HDP) single photon emission computed tomography (SPECT/CT) in patients with facetogenic low back pain (LBP) is still limited. In this study we compared the scintigraphic patterns on bone SPECT/CT with the degree of structural facet joint (FJ) degeneration on CT in patients with LBP.

METHODS

Ninety-nine consecutive patients with LBP were prospectively evaluated. Patients with known or suspected malignancy, trauma, infectious processes, chronic inflammatory diseases, and previous surgery were excluded. The effect of LBP on the daily quality of life was assessed with the Oswestry disability index (ODI). The Pathria grading system was used to score FJ degeneration on CT scans. The correlation between the degree of FJ degeneration and osteoblastic activity on SPECT/CT was analyzed with Kappa statistics.

RESULTS

Ninety-nine patients were included (59 female, mean age 56.2 years). The mean ODI score was 38.5% (range, 8% to 72%). In all, 792 FJ (L2-3 to L5-S1) were examined. Of the FJs, 49.6% were Pathria grade 0-1 (normal to mild degeneration) on CT, 35% were grade 2 (moderate degeneration), and 16% were grade 3 (severe degeneration). Sixty-seven percent of the patients had scintigraphically active FJs on SPECT/CT. Sixty-nine percent of Pathria grade 3 FJs were scintigraphically active; 5.5% and 16.8% of Pathria grade 0-1 and Pathria grade 2, respectively, were active. Of the metabolically active FJs, 71.4% were at the L4-5/L5-S1 levels.

CONCLUSIONS

The ability of SPECT/CT to precisely localize scintigraphically active FJs may provide significant improvement in the diagnosis and treatment of patients with LBP. In this study we demonstrate that in >40% of FJs, the scintigraphic patterns on SPECT/CT did not correlate with the degree of degeneration on CT.

Outcomes and prognostic variables of radiofrequency zygapophyseal joint neurotomy in Utah workers' compensation patients

Purpose

The prevalence of radiofrequency zygapophyseal joint neurotomy (RFN) has increased substantially across the past decade. Limited research exists that has examined pre-procedure predictors of RFN outcomes, particularly within workers’ compensation populations. The purpose of this study was to determine if pre-procedure biopsychosocial variables are predictive of outcomes in a cohort of compensated Utah patients who have undergone RFN.

Patients and methods

This was a retrospective cohort study consisting of a review of pre-procedure medical records and a telephone outcome survey. The sample consisted of 101 compensated workers from Utah who had undergone RFN. Fifty-six patients (55%) responded to the outcome survey. Patients were an average of 46 months post-neurotomy at the time of follow-up. Outcome measures included patient satisfaction, disability status, Roland–Morris Disability Questionnaire, Stauffer–Coventry Index, and Short-Form Health Survey-36 (v.2). Statistical techniques utilized included frequencies, mean comparisons, and logistic and multiple regressions.

Results

Forty percent of patients were totally disabled at the time of follow-up. Lawyer involvement, older age, and a positive history of depression were predictors of poor outcomes in logistic and multiple regression equations.

Conclusion

Presurgical biopsychosocial variables were predictive of multidimensional patient outcomes, and a high rate of total disability was observed. Additional research on the effectiveness of RFN for workers’ compensation patients is recommended.

Value of 18 F-FDG PET/MRI for the outcome of CT-guided facet block therapy in cervical facet syndrome: initial results

INTRODUCTION

The aim of this study was to evaluate the ability of ¹⁸ F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (¹⁸ F-FDG PET/MRI) to detect PET-positive cervical facet arthropathy and identify patients who benefit from facet block therapy.

METHODS

Ten patients with cervical facet syndrome (mean age: 65 ± 12 years) underwent ¹⁸ F-FDG PET/MRI of the neck. Focal ¹⁸ F-FDG uptake in PET-positive facet joints served as target for computed tomography (CT)-guided facet blocks. In PET-negative patients, the target joint for facet block therapy was selected by current clinical standards considering the level of maximum facet arthrosis and pain. Neck pain was measured on visual analogue scale (VAS) before and after therapy. Bone marrow signal intensity (SI) ratio on turbo inversion recovery magnitude (TIRM) images and maximum standard uptake values (SUVmax) was calculated for each facet joint. Pearson's correlation coefficient (r) was calculated between bone marrow SI ratios on TIRM and SUVmax.

RESULTS

¹⁸ F-FDG PET/MRI detected PET-positive facet arthropathy in six patients. Patients with PET-positive facet arthropathy had significantly less pain compared with the pretreatment pain 3 h (P = 0.002), 4 weeks (P = 0.002) and 3 months (P = 0.026) after facet block therapy. Pain did not change significantly in patients with PET-negative facet arthropathy. TIRM SI ratio was higher in PET-positive facet arthropathy than in PET-negative facet arthropathy (P < 0.001). Correlation was strong between bone marrow SI ratio on TIRM images and SUVmax (r = 0.7; P < 0.001).

CONCLUSIONS

¹⁸ F-FDG PET/MRI can detect PET-positive cervical facet arthropathy and help to identify patients benefitting from facet block therapy. Bone marrow TIRM SI ratio might be a surrogate for PET-positive facet arthropathy.

Effects of Cervical Extension on Deformation of Intervertebral Disk and Migration of Nucleus Pulposus

BACKGROUND

We theorized that active cervical extension should influence the position of the nucleus pulposus (NP) within the intervertebral disk (IVD) in the sagittal plane. Although several studies on the lumbar IVD have been conducted, there are no quantitative data for in vivo positional changes of the NP in the cervical IVD.

OBJECTIVE

To evaluate the influence and mechanism of cervical extension on the deformation and migration of IVD and NP in the sagittal plane and understand underlying mechanisms of the extension maneuver.

DESIGN

Asymptomatic subjects underwent magnetic resonance imaging while supine with their cervical spines in neutral and extended positions.

SETTING

Academic medical center.

PARTICIPANTS

Ten young, healthy male participants (age range 19-30 years; mean 22.4 ± 1.64 years).

METHODS

T2-weighted sagittal images from C3-C4 to C6-C7 of subjects in both neutral and extension positions were analyzed.

MAIN OUTCOME MEASUREMENTS

Deformation of IVD and positional change of NP were quantified and compared between neutral and extension positions. Intersegmental angles between vertebrae, horizontal positions of anterior and posterior IVD and NP margins, IVD outer and inner heights, and sagittal morphology of NP were quantified and compared between the neutral and extension positions. Correlations between the measured parameters and segmental extension angle were also investigated.

RESULTS

Anterior and posterior IVD margins moved posteriorly with respect to the vertebral body in extension. Both NP margins remained unchanged relative to the vertebral body but moved anteriorly with respect to the IVD. IVD outer and inner heights in the anterior region increased in extension, and morphological changes of the NP were less noticeable when compared with its relative migration within the IVD. Most of the intradiskal changes were linearly correlated with the segmental extension angle.

CONCLUSIONS

Cervical extension induces anterior migration of the NP away from the posterior disk margin and may have a clinical effect on diskogenic neck pain resulting from internal disk disruption.

LEVEL OF EVIDENCE

Not applicable.