Radiofrequency facet denervation procedures are widely used for the treatment of chronic low-back pain. Currently, both temperature-controlled and voltage-controlled techniques are used. In this combined in vivo and in vitro study, the electrophysiologic consequences and the effects on lesion size of these techniques were determined.
Thirty-three patients were randomly assigned to receive a lumbar radiofrequency facet denervation by using either temperature-controlled (80 degrees C, 60 seconds) or voltage-controlled (20 V, 60 s) mode. Electrophysiologic parameters in both groups during radiofrequency lesioning were registered. Observed differences between electrodes were quantified and interpreted, using lesion-size data from egg-white experiments.
Seventeen patients in the temperature group were treated with a total of 55 radiofrequency lesions, all considered technically adequate. In the voltage-controlled group, 16 patients received 63 lesions. Of these, 44 (69.8%) procedures were found to be technically inadequate. Voltage-controlled radiofrequency lesioning resulted in uncontrollable fluctuations of temperature, with resultant uncontrollable variations in lesion size. Temperature-controlled mode created reproducible lesion sizes.
There is no consistent relation between voltage and the temperature obtained during radiofrequency lumbar facet denervation. Temperature-controlled radiofrequency lesioning is preferred to create reproducible lesion sizes.
"A 50% or greater improvement in pain as criteria for a successful diagnostic medial branch block has also been used by other investigators [93–98]. Studies that employed diagnostic intra-articular blocks as apposed to medial branch blocks have also used similar criteria of 50% or greater improvement of pain [99, 100, 107]. However, others have suggested that a more strict definition of a confirmatory block is necessary to avoid performing radiofrequency denervation on patients who may have low back pain of other etiologies. "
[Show abstract][Hide abstract] ABSTRACT: Abstract
Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.
Current Reviews in Musculoskeletal Medicine 04/2009; 2(1):15-24. DOI:10.1007/s12178-008-9039-y
[Show abstract][Hide abstract] ABSTRACT: The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management.
To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices.
A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventions and outcomes.
The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Methodologic quality evaluation criteria utilized included AHRQ criteria, QUADAS criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate).
The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thoracic facet joint pain. The evidence was strong for lumbar discography, whereas, the evidence was limited for cervical and thoracic discography. The evidence was moderate for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anesthetics and steroids was moderate for short-term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections was strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis was strong. For spinal endoscopic adhesiolysis, the evidence was strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain was indeterminate. The evidence for intradiscal electrothermal therapy was strong for short-term relief and moderate for long-term relief in managing chronic discogenic low back pain, whereas, for nucleoplasty, the evidence was limited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems was moderate to strong.
These guidelines included the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines do not represent "a standard of care".
[Show abstract][Hide abstract] ABSTRACT: Lumbar zygapophysial joint arthropathy is a challenging condition affecting up to 15% of patients with chronic low back pain. The onset of lumbar facet joint pain is usually insidious, with predisposing factors including spondylolisthesis, degenerative disc pathology, and old age. Despite previous reports of a "facet syndrome," the existing literature does not support the use of historic or physical examination findings to diagnose lumbar zygapophysial joint pain. The most accepted method for diagnosing pain arising from the lumbar facet joints is with low-volume intraarticular or medial branch blocks, both of which are associated with high false-positive rates. Standard treatment modalities for lumbar zygapophysial joint pain include intraarticular steroid injections and radiofrequency denervation of the medial branches innervating the joints, but the evidence supporting both of these is conflicting. In this article, the authors provide a comprehensive review of the anatomy, biomechanics, and function of the lumbar zygapophysial joints, along with a systematic analysis of the diagnosis and treatment of facet joint pain.
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