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

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

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

Beyond Pedicle Screw Placement: Future Minimally Invasive Applications of Robotics in Spine Surgery

Advancements in spine surgery have dramatically enhanced minimally invasive techniques, prominently through integrating robotic systems. Although pedicle screw placement remains the most widespread application of this technology, new developments are emerging to create innovative future avenues for these tools. This review explores the promising applications of robotic technology in minimally invasive spinal procedures, ranging from assistance with laminectomies and vertebroplasty to pain management and treatment of spinal tumors. We also discuss the potential for integrating artificial intelligence and augmented reality with robotic systems. If the current trajectory of research and innovation continues, there is promise in creating fully autonomous robotic systems that can revolutionize spine surgery by processing, planning, and performing procedures without heavy reliance on the surgeon.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Glucocorticoid facet joint injection for chronic back or neck pain

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The primary objective is to assess the benefits and harms of glucocorticoid facet joint injections in adults with chronic back or neck pain that is presumed to be facet joint-mediated. The secondary objective is to assess whether the effects differ by diagnostic method for facet joint-mediated pain.

CellKine clinical trial: first report from a phase 1 trial of allogeneic bone marrow-derived mesenchymal stem cells in subjects with painful lumbar facet joint arthropathy

Background

Lumbar facet joint arthropathy (LFJA) is a major cause of low back pain (LBP), with current treatments offering limited long-term benefits. Bone marrow-derived mesenchymal stem cells (BM-MSCs) show promise due to their immunomodulatory and trophic effects, potentially addressing underlying degenerative processes in LFJA.

Objectives

This initial report describes the outcomes of the first treated patient in an ongoing mutidisciplinary phase 1 clinical trial evaluating the safety and feasibility of intra-articular allogeneic BM-MSCs for painful LFJA.

Methods

Following enrollment in our IRB-approved protocol, symptomatic LFJA was confirmed through double blocks on L4 and L5 medial branches. Two 1-mL syringes, each containing 10 million BM-MSCs, were prepared in the cGMP facility and administered bilaterally to the patient's L4-L5 lumbar facet joints. The patient underwent standardized follow-ups, including clinical examinations and functional and imaging assessments for 2 years, utilizing patient-reported outcomes measurement information system-computer adaptive tests (PROMIS CATs), visual analogue scale, Oswestry disability index, work functional status and opioid pain medication use, and MR imaging Fenton-Czervionke score.

Results

The patient tolerated the procedure well, with no drug-related adverse events during the study period. Pain, spine function, and work functional status improved at multiple follow-ups. This patient also reported improvements in mental and social health, along with a notable improvement in the grade of facet synovitis observed at the one-year follow-up MRI evaluation.

Conclusions

This case report suggests the safety and feasibility of administering intra-articular allogeneic BM-MSCs, offering therapeutic benefits for pain management and functional activities.

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

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

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

Purpose

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

Patients and methods

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

Results

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

Conclusion

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

Preliminary evaluation of a novel method for computed tomography quantification of lumbosacral articular process displacement in dogs with and without degenerative lumbosacral stenosis

Objective

This study aimed to describe the diagnostic discrimination and reliability of a novel technique for quantifying lumbosacral articular process displacement (LSAPD) on dorsal plane computed tomography (DPCT) imaging in dogs with and without degenerative lumbosacral stenosis (DLSS).

Study design

DPCT surveys of the lumbosacral vertebral column were performed with dogs positioned in extension and flexion. LSAPD is defined as the distance between the cranial aspects of the L7 and S1 articular processes. The LSAPD ratio is identified by dividing the LSAPD by the length of the L7 articular process. Intraclass correlation coefficients (ICCs) for intra- and inter-observer reliability were calculated, and logistic regressions were used to test for the association of LSAPD and LSAPD ratio with odds of DLSS. Significance was set at 0.05. Receiver operator characteristic (ROC) curves were calculated to determine diagnostic discrimination and optimal cutoff for LSAPD and LSAPD ratio in the diagnosis of DLSS.

Results

Intra- and inter-observer reliabilities were excellent for most measurements. In the current cohort, excluding covariates, the area under the curve (AUC) (95%CI) for LSAPD and LSAPD ratio measured in a flexed position were both 0.89 (0.82-0.96), suggesting potentially excellent discrimination for using this measurement as a marker for diagnosing DLSS, pending further studies. The cutoffs for flexed LSAPD and LSAPD ratio that maximizes Youden's index were ≥ 1.2 mm and ≥ 9%, respectively. When age and weight were subsequently included as covariates in a multivariable analysis, a significant relationship between LSAPD or LSAPD ratio and odds of diagnosis of DLSS was not demonstrated, suggesting the need for a larger sample size.

Conclusion

The results of this study suggest that measurements of LSAPD and LSAPD ratio on DPCT are feasible and reliable, although their diagnostic discrimination in DLSS should be evaluated further in future prospective studies.

Anatomy of mamillo-accessory foramen and prevalence of ossified mamillo-accessory ligament in lumbar vertebrae related to age

PURPOSE

Ossification of the mamillo-accessory ligament (MAL) results in the formation of a mamillo-accessory foramen (MAF), which is associated with aging. The MAL tethers the medial branches of the lumbar dorsal rami to the lumbar vertebrae. A MAL ossified at the lumbar vertebrae can cause low back pain by compressing the medial branch of a dorsal ramus. Age ranges related to ossification of the MAL have not been reported in previous studies. The objective of the present study was to determine the prevalence of ossification of the MAL in the lumbar column and its relationship to aging, and to measure the newly formed MAF at each level of the lumbar vertebrae.

METHODS

This study examined 935 dried lumbar vertebrae from 187 donors at Khon Kaen University, Thailand, consisting of 93 females and 94 males. The research focused on ossification patterns of the MAL, categorizing them into three patterns.

RESULTS

We found that over 50% of ossified MAL occurred in the 30-45-year-old range and the frequency increased with age. The prevalence of ossified lumbar MAL was 72.73%, especially in L5 on the left side in females (76.92%). The width of the MAF did not differ significantly between the sexes, but it was greater on the left side (2.46 ± 1.08; n = 76) than the right (2.05 ± 0.95; n = 72) (p = 0.016).

CONCLUSION

Ossification of the MAL into the MAF progresses with age, leading to low back pain from nerve compression. Physicians should be aware of the MAF during anesthesia block to treat low back pain.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Facet joint disorders: from diagnosis to treatment

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

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

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

An Unexpected Complication Resulting from Radiofrequency Ablation for Treating Facet Joint Syndrome: A Case Report

Lumbar facet joints have been identified as a potential source of chronic low back pain (LBP) in 15% to 45% of patients, with the prevalence of such pain varying based on specific populations and settings examined. Lumbar facet joint interventions are useful in the diagnosis as well as the therapeutic management of chronic LBP. Radiofrequency ablation (RFA) of medial branch nerves is recognized as a safe and effective therapy for chronic facet joint pain in the lumbosacral spine, and its efficacy has already been established. The use of RFA is currently widespread in the management of spinal pain, but it is noteworthy that there have been works in the literature reporting complications, albeit at a very low frequency. We present a case of third-degree skin burns following radiofrequency ablation (RFA) for the management of facet joint syndrome. Postoperatively, the patient's skin encircling the needle displayed a pallor and exhibited deterioration in conjunction with the anatomical anomaly. The affected area required approximately 5 months to heal completely. During RFA, heat can induce burns not only at the point of contact with the RF electrode but also along the length of the needle. Vigilant attention is necessary to ensure patient safety and to address any potential complications that may arise during the procedure, including the possibility of minor technical errors.

Paraplegia Following Ultrasound-Guided Caudal Epidural Block in Chronic Lumbosciatica: What Can Be Learned From This Complication?

Caudal epidural block is a procedure that involves the injection of anesthetic agents through the sacral hiatus, commonly used for regional anesthesia. It is also valuable for chronic pain management in lumbosacral conditions, trauma, and palliative care. Ultrasound-guided caudal epidural blocks can be an alternative to fluoroscopy-guided techniques and have demonstrated a notably high success rate. However, despite both techniques being generally regarded as safe, they can lead to severe complications, such as abscesses, epidural hematomas, and subdural punctures. Furthermore, documented instances of lumbosacral region anomalies, stemming from either anatomical variations or underlying pathology, have been associated with an elevated risk of some of these complications. The authors report a rare case of paraplegia following an ultrasound-guided caudal block in a patient with refractory chronic lumbosciatica. This case underscores the need for vigilance in risk assessment and detailed procedural planning. It also highlights the importance of transparent communication, particularly during informed consent, to convey risks and benefits to the patient and their family.

Low Back Pain and Radiofrequency Denervation of Facet Joint: Beyond Pain Control-A Video Recording

Chronic low back pain is often due to L5S1 instability resulting in facet joint syndrome. Patients suffering from low back pain may also have a gait pattern characterized by a reduced speed and a shorter, asymmetrical step in order to reduce pain. This case is of a patient with L5S1 instability that occurred after L1 to L5 lumbar stabilization who was treated with radiofrequency (RF) denervation of the medial branch of L5S1 bilaterally. RF ablation outcome was tested by comparing its impact on pain, function, quality of life, and on gait pattern, before and 1 month after the procedure. To objectify the impact of a good pain control on gait, a video recording was performed (see Video 1).

Comparison of the effectiveness of ultrasound-guided versus fluoroscopy-guided medial lumbar bundle branch block on pain related to lumbar facet joints: a multicenter randomized controlled non-inferiority study

BACKGROUND

The aim of this multicenter randomized interventional prospective study was to compare the ultrasound (US)-guided lumbar medial branch block (LMBB) with the fluoroscopy (FS)-guided LMBB in terms of analgesic efficacy and disability in the setting of the treatment of pain arising from the lumbar facet joints (LFJ).

METHODS

Fifty adults with a "LFJ" syndrome were randomized into two groups: in group FS, fluoroscopic-guidance was used to block the medial branch at three lumbar levels (L3-L4, L4-L5 and L5-S1); in group US, same blocks were performed under ultrasound. Needle transverse approach was used with both techniques. Effects of these procedures were assessed with a Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Duke's Activity Status Index (DASI) scale, before the treatment, 1 week and 1 month after. Hospital Anxiety and Depression Scale (HADS) score was also collected before the procedure. Analysis of variance, one (for non-inferiority) and two-sided Mann-Whitney tests and Chi-square tests were performed.

RESULTS

LMBB under US-guidance was not inferior to FS-guidance (P = 0.047) in terms of VAPS, ODI and DASI at 1 week and 1 month. Duration of techniques and HADS were similar between groups (=0.34; p = 0.59).

CONCLUSIONS

The medial lumbar bundle branch block under ultrasound-guidance is not inferior to the fluoroscopy-guidance procedure in effectively alleviating pain arising from the facet joints. Considering that this ultrasound technique has the benefit of an irradiation-free, real-time procedure, it can be considered as an effective alternative to the fluoroscopy-guided technique.

Mixed reality technology enhances teaching of spinal blockade procedures

To investigate the efficacy of utilizing mixed reality technology-assisted teaching of a spinal medial branch nerve block. Twenty undergraduate students from a 5-year clinical medicine program in Fujian Medical University were selected. They were divided into group A and group B using a random number generator, with 10 students in each group. Group A used the traditional teaching method and Group B used the mixed reality technology-assisted teaching method. At the end of the teaching period, both groups were assessed on the blocking operation, number of punctures required, puncture time, and final error value (distance between the final position and the reference position). A questionnaire was administered to both groups to assess teaching satisfaction. The number of punctures required was 7.40 ± 1.26 and 2.10 ± 0.74 for groups A and B, respectively. The puncture time in group A was 297.80 ± 50.95 s and 65.60 ± 22.02 s in group B. All differences were significant p < 0.01. The final error of the puncture in group A was 2.24 ± 0.35 mm and 1.96 ± 0.26 mm in group B-not significant. Group B had (p < 0.01) higher evaluation scores than group A for teaching effectiveness, learning interest, initiative, and teaching satisfaction. The application of mixed reality technology in the teaching of posterior medial branch blocks of the spinal nerve is superior to previous methods. This method should be adopted wherever possible to enhance learning of this difficult technique.

Case report: Use of peripheral nerve stimulation for treatment of pain from vertebral plana fracture

Vertebral plana fractures are a severe form of compression fractures that can cause significant morbidity due to incapacitating pain. Due to the flattening of the vertebrae in a plana fracture, accessing the vertebral body transpedicularly can be difficult, making traditional vertebral augmentation treatment dangerous. These injuries also typically occur in elderly patients with contraindications to invasive procedures. Peripheral nerve stimulation is a relatively new and minimally invasive treatment that uses electrical stimulation to inhibit pain signals from reaching the somatosensory cortex. Our case describes an 80 Year old female with multiple comorbidities and refractory pain due to a vertebral planar fracture successfully treated with a 60 day course of peripheral nerve stimulation as evidenced by over 50% reduction in symptoms and discontinuation of opioid pain medication use.

Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment

Facet joint osteoarthritis (OA) is the most frequent form of facet joint syndrome. Medical history, referred pain patterns, physical examination, and diagnostic imaging studies (standard radiographs, magnetic resonance imaging, computed tomography and single-photon emission computed tomography) may suggest but not confirm lumbar facet joint (LFJ) syndrome as a source of low back pain (LBP). However, the diagnosis and treatment of facet joint syndrome is still controversial and needs further study. It is widely acknowledged that block with local anesthetic is perhaps the most effective method to establish a diagnosis of pain from LFJ. Particularly, there are different rates of success among different populations selected for diagnostic block with various positive criteria. Currently, in addition to conservative treatments for pain such as painkillers, functional exercises, and massage, there are many other methods, including block, denervation of the nerves that innervate the joints by radiofrequency, freezing or endoscopy, and injections. Due to the limited duration of pain relief from neurolysis of medial branch, many scholars have recently turned their targets to dorsal roots and LFJ capsules. Therefore, we reviewed the latest research progress of facet joint syndrome from diagnosis to treatment.

Medial Branch Radiofrequency Treatment for Low-Back Pain in Cancer Patients: A Case Series

Cancer patients are increasing in number, with an increased lifespan and advances in cancer treatment. Palliative care physicians often encounter difficulties in caring for patients with pain. In addition to cancer-related pain, patients with cancer may suffer from various musculoskeletal diseases, resulting in significant functional limitations of physical activities of daily living. We present three cases illustrating methods to deal with nonspecific mechanical low-back pain in patients with advanced cancer. We provide our therapeutic experiences, focusing on the usefulness of radiofrequency treatment in palliative care in patients with cancer.

The role of intra-articular injection of autologous platelet-rich plasma versus corticosteroids in the treatment of synovitis in lumbar facet joint disease

OBJECTIVES

To compare the efficacy between platelet-rich plasma (PRP) and corticosteroids (CS) in improving magnetic resonance imaging (MRI)-detected synovitis in correlation with clinical complaints among patients with lumbar facet joint (FJ) disease.

METHODS

This study was carried out at Eldemerdash Hospital, Cairo, Egypt between September 2019 and January 2021. A prospective, randomized, comparative, single blinded study included 30 patients with lumbar FJ disease, divided into 2 equal groups, received PRP and CS injections. Patients were comparatively assessed before and after the intervention according to number of tender lumbar FJs, maximum active lumbar extension range of motion, LBP visual analogue score, LBP functional disability questionnaires and MRI lumbar FJ detected synovitis and their grading.

RESULTS

Both groups showed a significant improvement in all mentioned parameters at follow-up after 3 months. However, PRP injections promoted better performance in terms of MRI synovitis grade in all lumbar FJ levels compared to CS injections.

CONCLUSION

Both PRP and CS injections were effective in improving MRI-detected FJ synovitis while concurrently improving all examined parameters at follow-up after 3 months. However, PRP promoted better improvement in MRI-detected synovitis grade, suggesting that it may be a better treatment option for longer duration efficacy.TRN: NCT04860531- 1/3/2021.

RADIOFREQUENCY DENERVATION OF THE FACET JOINTS AND LOCAL PERIARTICULAR ADMINISTRATION OF ANAESTHETICS IN FACET SYNDROME TREATMENT

OBJECTIVE

The aim: To determine the effectiveness of radiofrequency denervation of the facet joints in combination with periarticular administration of local anaesthetics in patients with facet syndrome.

PATIENTS AND METHODS

Materials and methods: The early and long-term results of treatment patients with facet syndrome were analysed. The Visual Analogue Scale of pain and the Oswestry Disability Index were used. The 47 patients underwent radiofrequency denervation of the facet joints in combination with periarticular administration of local anaesthetics (the main group). The 136 patients underwent only radiofrequency denervation of the facet joints (control group).

RESULTS

Results: Immediately after the treatment as well as in 3 months and in 1 year after it, a reliable results of treatment of facet syndrome in both the main and the control groups was attained. At the same time, there were significant differences between the main group and the control group immediately after treatment. But in 3 months and in 1 year after it there were no such differences that proved a significantly higher efficiency of high radiofrequency denervation of facet joints in combination with periarticular administration of local anaesthetics in the early postoperative period.

CONCLUSION

Conclusions: The radiofrequency denervation of the facet joints has proved to be an effective method of treatment of patients with spondyloarthritis both in the short and long term outcomes. Periarticular administration of local anaesthetics enhances the effectiveness of radiofrequency denervation of the facet joints only for the short term outcomes.

Agents Used for Nerve Blocks and Neurolysis

The recognition of pain and the treatments used for it are vital for all practitioners. Many types of pain can be treated in a locoregional fashion, which has significant implications not just for any individual patient but for society as a whole. These treatments are most effective when performed in a minimally invasive, image-guided fashion. Interventional radiologists should play a central role in providing these lifestyle-limiting treatments. This article describes the medications most typically used for spinal and extra-axial treatments in the management of patients in pain.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study

BACKGROUND

A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS).

METHODS

We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated.

RESULTS

The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success.

CONCLUSION

The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

[Therapeutic injections and manual medicine in low-back pain : Bimodal synergies between evidence and empiricism]

Hintergrund

Angelehnt an die zielorientierte Therapieplanung und -führung in der Versorgung chronisch Rheumakranker, plädiert der Autor bei Patienten mit (chronischem) degenerativem tiefem Rückenschmerz (TRS), orientiert an den differenzialtherapeutischen Grundsätzen der Manuellen Medizin (MM), und unter Kenntnis von Techniken und Evidenzen therapeutischer Lokalinfiltrationen (TLI), für die Etablierung eines strukturierten mechanismenbasierten Therapiekonzeptes im Sinne des „treat to target“ (T2T) im ambulanten schmerztherapeutischen Versorgungsbereich.

Diagnostik

Dies setzt eine konsequente (Primär‑)Diagnostik mit Schmerzanalyse unter der Prämisse, dass TRS, wenn strukturell-funktionell bedingt, immer spezifisch ist, voraus. Eine breite biopsychosoziale Anamnese und strukturbezogene klinisch-bildgebende (Ausschluss‑)Diagnostik mit funktioneller Differenzierung nach MM-Grundsätzen und ggf. interventionelle Blocks, sollten am Ende zur Formulierung einer 3‑Ebenen-Diagnose als Voraussetzung zu einer mechanismenbasiert-zielorientiert-hierarchischen Stufentherapie bei TRS führen. Diese wird in diesem Artikel pragmatisch fallorientiert, unter Implementierung von Techniken und Evidenzen der TLI und MM, vorgestellt.

Medical ozone therapy in facet joint syndrome: an overview of sonoanatomy, ultrasound-guided injection techniques and potential mechanism of action

Facet joint osteoarthritis is the most prevalent source of facet joint pain and represents a significant cause of low back pain. Oxygen-ozone therapy has been shown to have positive results in acute and chronic spinal degeneration diseases and it could be a safe and efficacious alternative to traditional facet joint conservative treatments. This review article explains the interventional facet joint management with ultrasound-guided oxygen-ozone therapy, providing an anatomy/sonoanatomy overview of lumbar facet joints and summarizing the potential mechanism of action of oxygen-ozone in the treatment of facet joint osteoarthritis, not yet fully understood.