Article

The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents.

Pain Management Center, 2831 Lone Oak Road, Paducah, KY 42003, USA.
Current Review of Pain 02/2000; 4(5):337-44.
Source: PubMed

ABSTRACT Facet joints have been described as an important source of low back pain. The value of medial branch blocks in the diagnosis of facet joint mediated pain is considered important. However, the therapeutic value of medial branch blocks has not been determined. This study was designed to evaluate the duration of relief obtained and therapeutic value following controlled medial branch blocks with or without adjuvant agents Sarapin (High Chemical Company, Levittown, PA) and Depo-medrol (Pharmacia and Upjohn Company, Kalamazoo, MI). The study population consisted of 180 consecutive patients seen in a single pain management practice, divided into three groups with 60 patients in each group. Group I was treated with local anesthetic only, Group II with the addition of Sarapin, and Group III with the addition of Depo-medrol along with Sarapin. The prevalence of facet joint pain in chronic low back pain was determined as 36%, with a false-positive rate of 25%. Comparison of duration of relief in days with each block in the three groups showed that the relief was significantly superior in Group III compared with Group I and Group II, whereas Group II was superior to Group I.

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    • "Additionally , in patients undergoing one diagnostic injection, there is a 22% to 32% false positive rate [28] [29] [30]. Of those positive diagnostic injections, 41% to 69% of them are falsely positive [28] [29] [30]. Therefore, at least two diagnostic injections should be performed to decrease the false positive rate to an acceptable level. "
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    ABSTRACT: The prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective. This article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials. Review article. Extensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature. Fluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective. Intraarticular sacroiliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections. The prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.
    The spine journal: official journal of the North American Spine Society 10/2008; 9(8):690-703. DOI:10.1016/j.spinee.2008.06.447 · 2.80 Impact Factor
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    • "One method advocated to screen out placebo (or false-positive) responders is to exclude patients who obtain prolonged, discordant pain relief after their diagnostic block. Whereas some patients may experience prolonged relief after MBB with local anesthetic secondary to a resetting of pain thresholds, most should not [24] [40] [41]. A second possible reason no difference was found in outcomes is because once a certain analgesic threshold is exceeded, a host of different confounding factors diminish the relationship between the degree of pain relief experienced after blocks and the extent l-z joint arthropathy Table 2 Patient characteristics by response to diagnostic block "
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    ABSTRACT: The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate. To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB). Multicenter, retrospective clinical data analysis. Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics. Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement. Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables. One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE. Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.
    The Spine Journal 05/2008; 8(3):498-504. DOI:10.1016/j.spinee.2007.04.022 · 2.80 Impact Factor
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    • "One method advocated to screen out placebo (or false-positive) responders is to exclude patients who obtain prolonged, discordant pain relief after their diagnostic block. Whereas some patients may experience prolonged relief after MBB with local anesthetic secondary to a resetting of pain thresholds, most should not [24] [40] [41]. A second possible reason no difference was found in outcomes is because once a certain analgesic threshold is exceeded, a host of different confounding factors diminish the relationship between the degree of pain relief experienced after blocks and the extent l-z joint arthropathy Table 2 Patient characteristics by response to diagnostic block "
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    ABSTRACT: Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis Abstract BACKGROUND CONTEXT: The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate. PURPOSE: To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB). STUDY DESIGN/SETTING: Multicenter, retrospective clinical data analysis. PATIENT SAMPLE: Two hundred and sixty-two patients with chronic low back pain who under-went l-z RF denervation at three pain clinics. OUTCOME MEASURES: Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months post-procedure, and global perceived effect (GPE), which considered pain relief, satisfaction and func-tional improvement. METHODS: Data were garnered at three centers on 262 patients who underwent l-z RF denerva-tion after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables. RESULTS: One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the
    The Spine Journal 01/2008; · 2.80 Impact Factor
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