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Review of chronic low back pain of facet joint origin
Abstract
Chronic low back pain secondary to involvement of the facet joints is a common problem. Facet joints have been recognized as potential sources of back pain since 1911. Multiple authors have described distributions of pain patterns of facet joint pain. The facet joints are paired diarthrodial articulations between the posterior elements of the adjacent vertebrae. Lumbar facet joints are innervated by medial branches of the dorsal rami of the spinal nerves from the L1 to L4 levels. At L5, the dorsal ramus travels between the ala of the sacrum and its superior articular process and divides into medial and lateral branches at the caudal edge of the process. Each segmental medial branch of the dorsal ramus supplies at least two facet joints. The existence of lumbar facet joint pain claims has a preponderance of evidence, even though there are a few detractors. Multiple studies utilizing controlled diagnostic blocks have established the prevalence of lumbar facet joint involvement in patients with chronic low back pain, as ranging from 15% to 52%, based on type of population and setting studied. Long-term therapeutic benefit has been reported from three types of interventions in managing lumbar facet joint pain, including intraarticular injections, medial branch blocks and neurolysis of medial branches. This review will discuss chronic low back of facet joint origin and covers anatomy, pathophysiology, diagnosis, and various aspects related to treatment, including clinical effectiveness, cost effectiveness, technical aspects and complications.
... Mooney, Robertson and McCall reproduced those findings during the seventies using fluoroscopic guidance to inject hypertonic solutions into the facet joints. 6 Other authors have demonstrated the pathological changes that these joints are subjected to over time, [7][8][9] and the inflammatory changes associated with them. [10][11][12] Taking all this information into account, we believe that facet syndrome is a separate nosological entity with characteristic symptoms, methods of diagnosis and treatment. ...
... Patients will manifest increased pain when changing from the seating to the standing positions. 6 One of the characteristics of LFPS is the lack of consistent information regarding its true incidence and prevalence. 15 Reported rates of prevalence vary between 5% and 95%. ...
Objective:
Facet joints are true synovial joints, which derive their nerve supply from the sinuvertebral or recurrent nerve of Luschka as well as the posterior primary division of the corresponding spinal nerve. Diagnosis of low-back pain originating in the facet joints is difficult, and has traditionally relied upon invasive tests. To aid in the clinical diagnosis of this condition, the senior author described a new clinical sign. The following research project was designed to test the utility of this sign in the diagnosis of lumbar facet joint pain.
Methods:
We conducted a prospective evaluation of patients suspected of having low back pain secondary to facet joint involvement (Lumbar Facet joint Pain Syndrome – LFPS) during a twelve month observation period; candidate patients were evaluated clinically using the new diagnostic sign, which was then compared to findings on radionuclide bone scans and diagnostic medial branch blocks. Contingency table analysis was performed to calculate the sensitivity, specificity, positive and negative predictive values and accuracy of the new clinical sign.
Results:
Contingency table analysis showed the following operating characteristics for the new diagnostic sign: Sensitivity: 70.37%, Specificity: 50%, Positive predictive value: 90.47%, Negative predictive value: 20% and accuracy 67.7%.
Conclusions:
Although the new clinical sign failed to show the same operating characteristics as the ones originally described, it has high sensitivity coupled with a good positive predictive value. We consider that although the sign by itself is not diagnostic of lumbar facet joint pain, its presence should alert the clinician to the diagnosis and the possibility of requiring additional testing. Level of Evidence III; Case control studyg.
... 8,12,13 Even in specific case of spinal disease, such as herniated disc and spondylolisthesis, effective treatment of LBP is complicated by multifactorial conditions, such as sagittal balance or back muscle problems. [14][15][16][17] Accordingly, in addition to conventional treatment, including pharmacologic therapy, intervention, or surgery, a multidisciplinary conservative approach should be considered for effective treatment of LBP, which can include back muscle exercises, posture correction, and lifestyle modifications. 10 Among various conservative treatments, lumbar core exercises have been extensively used clinically to strengthen the lumbar back muscles and improve pain. ...
Objective
This study aimed to implement a digital therapeutics-based approach based on motion detection technology and analyze the clinical results for patients with chronic low back pain (LBP).
Methods
A prospective, single-arm clinical trial was conducted with 22 patients who performed mobile app-based sitting core twist exercise for 12 weeks. Clinical outcomes were assessed using the visual analog scale (VAS) for LBP, Oswestry Disability Index-Korean version (K-ODI), and EuroQol-5 dimension 5-level version (EQ-5D-5L) every 4 weeks after the initiation of treatment. Laboratory tests for factors associated with muscle metabolism, plain X-ray for evaluating sagittal balance, and magnetic resonance imaging for calculating cross-sectional area (CSA) of back muscles were performed at pretreatment and 12 weeks post-treatment.
Results
The study population included 20 female patients with an average age of 45.77 ± 15.45 years. The clinical outcomes gradually improved throughout the study period in the VAS for LBP (from 6.05 ± 2.27 to 2.86 ± 1.86), K-ODI (from 16.18 ± 6.19 to 8.64 ± 5.58), and EQ-5D-5L (from 11.09 ± 3.24 to 7.23 ± 3.89) (p < 0.001, respectively). The laboratory test results did not show significant changes. Pelvic incidence (from 53.99 ± 9.70° to 50.80 ± 9.20°, p = 0.002) and the mismatch between pelvic incidence and lumbar lordosis (from 8.97± .67° to 5.28 ± 8.57°, p = 0.027) decreased significantly. Additionally, CSA of erector spinae and total back muscles increased by 5.20% (p < 0.001) and 3.08% (p = 0.013), respectively.
Conclusions
The results of this study suggest that the efficacy of digital therapy-based lumbar core exercise for LBP is favorable. However, further large-scale randomized controlled studies are necessary.
... Low back pain is acknowledged as the primary cause of disability worldwide (Hoy et al., 2012;Vos et al., 2016;Wu et al., 2020) and has significant economic consequences in many countries (Dagenais et al., 2008;Fatoye et al., 2023). Several works have indicated that low back pain could be caused by intervertebral disc degeneration (Cheung et al., 2009;Simon et al., 2014) and facet joint degeneration (Manchikanti, 2002;Kalichman et al., 2008;Bashkuev et al., 2020). Also, it has been highlighted that the mechanical environment is linked to the pathogenesis of low back pain (Iatridis et al., 2013;Iorio et al., 2016). ...
Introduction: Lumbar disc arthroplasty is a surgical procedure designed to treat degenerative disc disease by replacing the affected disc with a mobile prosthesis. Several types of implants fall under the term total disc replacement, such as ball-and-socket, mobile core or elastic prostheses. Some studies have shown that facet arthritis can develop after arthroplasty, without much precision on the mechanical impact of the different implant technologies on the facet joints. This study aims to create validated patient-specific finite element models of the intact and post-arthroplasty lumbar spine in order to compare the mechanical response of ball-and-socket and elastic prostheses.
Methods: Intact models were developed from CT-scans of human lumbar spine specimens (L4-S1), and arthroplasty models were obtained by replacing the L4-L5 disc with total disc replacement implants. Pure moments were applied to reproduce physiological loadings of flexion/extension, lateral bending and axial rotation.
Results: Models with ball-and-socket prosthesis showed increased values in both range of motion and pressure at the index level and lower values at the adjacent level. The mechanical behaviour of the elastic prosthesis and intact models were comparable. The dissipated friction energy in the facet joints followed a similar trend.
Conclusion: Although both implants responded to the total disc replacement designation, the mechanical effects in terms of range of motion and facet joint loads varied significantly not only between prostheses but also between specimens. This confirms the interest that patient-specific surgical planning using finite element analysis could have in helping surgeons to choose the appropriate implant for each patient.
... 4 ). Although LBP is often termed non-specific, intervertebral disc (IVD) degeneration (IDD) and facet joint OA are the most common specific disorders associated with LBP [5][6][7][8][9] . Despite the intimate biomechanical interdependence of the IVD and the facet joint, the distinctions between IDD and facet joint OA have been emphasized historically, with little crosstalk between the two research areas. ...
Intervertebral disc degeneration (IDD) and osteoarthritis (OA) affecting the facet joint of the spine are biomechanically interdependent, typically occur in tandem, and have considerable epidemiological and pathophysiological overlap. Historically, the distinctions between these degenerative diseases have been emphasized. Therefore, research in the two fields often occurs independently without adequate consideration of the co-dependence of the two sites, which reside within the same functional spinal unit. Emerging evidence from animal models of spine degeneration highlight the interdependence of IDD and facet joint OA, warranting a review of the parallels between these two degenerative phenomena for the benefit of both clinicians and research scientists. This Review discusses the pathophysiological aspects of IDD and OA, with an emphasis on tissue, cellular and molecular pathways of degeneration. Although the intervertebral disc and synovial facet joint are biologically distinct structures that are amenable to reductive scientific consideration, substantial overlap exists between the molecular pathways and processes of degeneration (including cartilage destruction, extracellular matrix degeneration and osteophyte formation) that occur at these sites. Thus, researchers, clinicians, advocates and policy-makers should consider viewing the burden and management of spinal degeneration holistically as part of the OA disease continuum.
... Societal lifestyle and occupational trends combined with natural disc degeneration due to aging results in low back pain affecting over 80% of Americans at some point in their lives [1]. The facet joints have been recognized as a potential source of back pain since 1911 [2]. While this incidence rate may be relatively high, perhaps a more pertinent observation involves those individuals who are exposed to elevated frequency loading due to occupation. ...
... This causes lumbar facet joint osteoarthritis and Lumbar facet joint arthropathy are also believed to be the primary etiology in 15%-20% of patients with chronic low back pain[8, 10,17]. Some other researches established that lifting contributes the most to the risk of low back pain [5]. ...
Background: Lumbar facet joints (LFJ) are usually related to the pathogenesis of the spine, but the quantification of normal FJ motion is still limited to in vitro studies, animal models, and imaging analysis. Few people report the in vivo kinematics of facet joints. There has always been a debate about whether it can induce biomechanical changes in the motion pattern of the facet joints after weight-bearing, resulting in the degeneration of the facet joints and osteoarthritis.
Methods: A total of 10 healthy volunteers, 5 males , and 5 females, aged 21≤39 years, with an average age of 32±5 years, were recruited. Using the combination of DFIS and CT, the sagittal images of L3-S1 segments scanned by CT were transformed into three-dimensional reconstruction models and then matched to the instantaneous images of lumbar spine motion taken by a double fluorescent X-ray system under different loads. To reproduce the instantaneous motion state of lumbar vertebrae in different positions (supine position, standing position, flexion-extension position, left-right bending, left-right rotation) under different loads(0kg,10kg), assisted by computer-related software, in vivo human LFJ 6-DOF kinematics were obtained.
Result: In flexion and extension exercises: there is no statistical difference in the horizontal rotation angle (α, β, r) of each segment after weight-bearing. The coupling translations are significantly reduced in the left and right direction of the L34 segment (P<0.05). In the L45 segment, the articular process was significantly reduced in the anteroposterior direction (left P<0.05). In lateral bending: the main rotation axis rotation range was different after weight-bearing, L45 decreased (P=0.023), and L5S1 decreased significantly (P=0.021), there is no difference in the coupling rotation range, the coupling translations only decreases in the left and right direction of the L34 segment (P<0.05); in the rotation movement: the horizontal rotation angle of each segment after the load (α, β, r) There was no statistical difference. The coupling translation was only in the L5/S1 segment and decreased in the craniocaudal direction (P<0.05). In the three movements, the asymmetric movement of the left and right articular processes occurred in the L34 segment (P<0.05), and the maximum translations after weight-bearing were found at L5/S1.
Conclusion: Increased weight-bearing will affect the motion pattern of lumbar facet joints. The asymmetric movement of the left and right sides of the L34 segment is related to the asymmetry of the facet. The increase in translation of L5/S1 after weight-bearing compared with other segments may be related to the anatomical structure of the facet joint morphology deviated to the coronal position and frontal plane. Through the analysis of the body motion data of the lumbar facet joints before and after the weight-bearing, the relationship with the lumbar spine-related diseases is obtained. And it can provide a reference for guiding healthy lifestyles, clinical surgical procedures, and new spinal implants.
... Other symptoms are cervical spine stiffness, headache, shoulder and back pain, numbness, dizziness, sleeping difficulty, fatigue, and memory and cognitive deficits. In chronic whiplash injury, multiple structures may be involved including intervertebral disc, facet joints, ligaments, and other soft tissues (68,71,75,85,92,95,(98)(99)(100)(101)(102)(103)(104)(105)(106)(107)(113)(114)(115)(116)213). ...
Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, “pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur.” In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist’s clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/EvidenceBased Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions. Key words: Chronic pain, chronic spinal pain, chronic low back pain, chronic neck pain, chronic thoracic pain, prevalence, health care utilization, loss of productivity, interventional techniques, surgery, comorbid factors, socioeconomic effects, health care impact
... Pain lasts for more than 3 months with a distribution between the segments L1-S1 [8] and a typical irradiation to the gluteal or intertrochanteric regions [9,10]. ...
IntroductionLow back pain (LBP) is a common problem, and facet joint pain is responsible for 15–45% of cases. Treatment is multidisciplinary, and when conservative measures are not sufficient, radiofrequency (RF) is often used. It allows the interruption of nociceptive input, producing a heat lesion in a continuous or pulsed mode.Methods
Medical records of 60 patients who underwent pulsed RF denervation were examined. The standard procedure provided follow-up of pain intensity. Numerical rating scale (NRS) and Douleur Neuropathique en 4 Questions (DN4) were recorded before treatment, and 15 and 40 days, and 6 months after treatment. Oswestry Disability Index (ODI) and patient satisfaction were also recorded. Successful treatment was defined as more than a 50% reduction in the NRS scores at 6 months compared with pretreatment scores.ResultsScores on the NRS and DN4 were statistically different over time (p < 0.05). Scores at 6 months were significantly decreased when compared with pretreatment scores (p < 0.05). ODI scores decreased during the follow-up period. No adverse effect was recorded and 57 patients (97%) reported successful pain relief.Conclusions
Continuous RF is the gold standard in the management of lumbar facet joint pain. Pulsed RF is a promising technique: patients with chronic LBP who had not responded to conservative care tended to improve after pulsed RF. The procedure was well tolerated in the absence of contraindications, and reliable if the nerve endings regrew.
... rádiofrekveNčNá deNervácia fazetových kĺbov v liečbe low back paiN pri lumbálNom fazetovom syNdróme Senzitívna inervácia lumbálnych fazetových kĺbov je cestou mediálnych ramienok (medial branch) zadných vetiev miechových koreňov L1-L5. Každé mediálne ramienko inervuje kĺby nad svojím priebehom a pod ním s výnimkou koreňa L5, ktorý má mediálne ramienko len pre L5-S1 fazetový kĺb (Suseki, 1997 (Manchikanti, 2002). ...
... Although in the majority of cases LBP is non-specific, benign, and self-limiting, previous research identified a number of specific causes of LBP. Among many factors, intervertebral disc (IVD) degeneration (Buckwalter, 1995;Cheung et al., 2009;Luoma et al., 2000;Simon et al., 2014) and facet joint (FJ) degeneration Lewinnek and Warfield, 1986;Manchikanti et al., 1999;Manchikanti and Singh, 2002) are the most common specific disorders associated with LBP. While genetic factors are considered the most important contributors to the onset of degeneration (Battié et al., 2009;Feng et al., 2016;Matsui et al., 1998), the mechanical environment also plays an important role in its pathogenesis (Iatridis et al., 2013;Iorio et al., 2016;Stokes and Iatridis, 2004). ...
Both intervertebral disc (IVD) and facet joint (FJ) degeneration are frequently associated with chronic low back pain. While genetic factors are considered the most relevant in the onset of degeneration, the mechanics play an important role in its progression. Degenerative changes in one of these two structures are believed to induce degeneration in the other. However, despite decades of research, there is no consensus on the mechanical interplay between the two structures. On the basis of a parametric finite element model of a human L4-L5 spinal motion segment, one thousand individual segments were probabilistically generated covering all grades of degeneration in both structures. The segments were subjected to combined compression and flexion/extension loads. Correlation matrices were created to identify the effect of individual degeneration parameters of each structure on the mechanical stresses in the corresponding counterpart. In the non-degenerated group, a strong positive and a moderate negative correlation was found between the strain of the capsular ligament and the disc height and the nucleus compressibility, respectively. With increasing degeneration, the correlation between IVD morphologies and the FJ loads gradually decreased, whereas the correlation between FJ morphologies and disc load gradually increased. The results suggest that early mechanical changes associated with IVD degeneration have the greatest effect on the FJ loading. With progression of degeneration, this effect is diminished, whereas the appearance of FJ degeneration increasingly influences the disc loading, which might indicate an increasing support of the disc degeneration.
... In contrast, axial back pain is multifactorial without a clear source of pain, which can arise from the IVDs and associated structures of the motion segment, such as facet joints, ligaments, and spinal muscles. (9)(10)(11)(12)(13)(14) Axial LBP that is thought to originate from disc degeneration (discogenic pain) therefore remains hard to define, diagnose, and treat. It commonly requires prolonged treatment, has mixed-to-poor surgical outcomes, and opioids are often prescribed. ...
Discogenic back pain is multifactorial and physicians often struggle to identify the underlying source of the pain. As a result, discogenic back pain is often hard to treat with clinical treatment strategies of questionable efficacy. The aim of this review paper is to define discogenic back pain into a series of more specific and often interacting pathologies, and to highlight the need to develop novel approaches and treatment strategies for this challenging and unmet clinical need based on a broad literature review. Discogenic pain involves degenerative changes of the intervertebral disc including structural defects that result in biomechanical instability and inflammation. These degenerative changes in intervertebral discs closely intersect with the peripheral and central nervous system at early and late time points to cause nerve sensitization and ingrowth and eventually central sensitization to result in chronic pain conditions. Existing imaging modalities are non‐specific to pain symptoms, whereas discography methods which are more specific have known co‐morbidities due to the intervertebral disc puncture and injection. As a result, alternative non‐invasive and specific diagnostic methods require development in order to better diagnose and identify specific conditions and sources of pain that can be more directly treated. Currently, there are a wide variety of treatments/intervention for discogenic back pain. Many surgical approaches for discogenic pain have limited efficacy thus, accentuating a need to develop novel treatments. Regenerative therapy such as biologics, cell‐based therapy, intervertebral disc repair, and gene‐based therapy offer the most promise and have many advantages over current therapies. This article is protected by copyright. All rights reserved
... Chronic low back pain (CLBP) is defined as pain in the lumbar region for >3 months, which corresponds to 10%e15% of cases of low back pain, 1 and may be secondary to alterations in intervertebral disc, lumbar facet joints, and sacroiliac joint. 2 Facet joint pain is characterized by a diffuse pattern, with distribution between the segments L1-S1. 3 Regions where pain is most frequently located are central or lateral, associated with a band pattern, and can be manifested with irradiation to the gluteal or intertrochanteric regions. 4,5 It represents 10%e40% of cases of CLBP as a result of mechanical damage by compression or extensive stretching and degenerative changes owing to osteoarthritis and inflammation, as in rheumatoid arthritis. ...
Objective:
To compare pulsed radiofrequency (PRF) treatment with continuous radiofrequency (CRF) to improve pain, functionality, and safety profile in patients with facet joint chronic low back pain.
Methods:
A systematic, critical review of recent literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, Cochrane, Clinical Trials, and LILACS databases were searched. Medical Subject Heading terms were "low back pain," "zygapophyseal joint," and "pulsed radiofrequency treatment." Original research articles in peer-reviewed journals were included in the review. The articles were thoroughly examined and compared on the basis of study design and outcomes. Only studies that met the eligibility criteria were included.
Results:
Three randomized clinical trials comprising 103 patients (39 in PRF group, 44 in CRF group, and 20 in control group) were included in the final analysis. Two trials compared PRF with CRF, and 1 trial compared 3 groups: PRF, CRF, and control with intervention as conventional treatment. The studies reported greater pain control and better functionality with CRF compared with PRF. PRF showed a decrease in visual analog scale and Oswestry Disability Index in 2 studies, and 1 study reported increased pain and disability after the intervention. No side effects were reported.
Conclusions:
PRF treatment is less effective than CRF regarding pain control and return of functionality in patients with facet joint chronic low back pain. We recommend CRF with a large safety profile after conventional treatment.
... This predisposes the disc to further degeneration and can lead to degeneration of neighboring structures. For example, facet-joint degeneration, which was reported as the source of chronic back pain in up to 52% of cases [10,11], has been shown to occur following disc degeneration [12,13]. ...
Background context:
Intervertebral disc degeneration has been subject to numerous in vivo and in vitro investigations and numerical studies during recent decades, reporting partially contradictory findings. However, most of the previous studies were limited in the number of specimens investigated and, therefore, could not consider the vast variety of the specimen geometries, which are likely to strongly influence the mechanical behavior of the spine.
Purpose:
To complement the understanding of the mechanical consequences of disc degeneration, while considering natural variations in the major spinal geometrical parameters.
Study design/setting:
A probabilistic finite element study.
Methods:
A parametric finite element model of a human L4-L5 motion segment considering forty geometrical parameters was developed. One thousand individual geometries comprising four degeneration grades were generated in a probabilistic manner, and the influence of the severity of disc degeneration on the mechanical response of the motion segment to different loading conditions was statistically evaluated.
Results:
Variations in the individual structural parameters resulted in marked variations in all evaluated parameters within each degeneration grade. Nevertheless, the effect of degeneration in almost all evaluated response values was statistically significant. With degeneration, the intradiscal pressure progressively decreased. At the same time, the facet loads increased and the ligament tension was reduced. The initially non-linear load-deformation relationships became linear while the segment stiffness increased.
Conclusions:
Results indicate significant stiffening of the motion segment with progressing degeneration and gradually increasing loading of the facets from non-degenerated to moderately degenerated conditions along with a significant reduction of the ligament tension in flexion.
... Degenerative spondylolisthesis is common and may become more important with aging populations [8]. The proportion of patients with low back pain in whom facet joints are causative has been estimated to be 5-15% [9] has been shown to increase with age [10] and may amount up to 50% in chronic pain cohorts [11]. ...
... [2][3][4] Low back pain in 15% to 52% of the patients is closely correlated with lesion of facet joints in the lumbar spine. [5] At present, we can use X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) to diagnose degeneration of facet joints in the lumbar spine in imaging, especially CT. However, besides the study on examining facet joints of lumbar spine by ultrasound in normal population, [6] there has not been any related report about examining abnormal facet joints of lumbar spine by ultrasound so far. ...
Besides the study on examining facet joints of lumbar spine by ultrasound in normal population, there has not been any related report about examining normal facet joints of lumbar spine by ultrasound so far. This study was aimed to explore the feasibility of ultrasound assessment of lumber spine facet joints by comparing ultrasound measure values of normal and degenerative lumber spine facet joints, and by comparing measure values of ultrasound and computed tomography (CT) of degenerative lumber spine facet joints.
This study included 15 patients who had chronic low back pain because of degenerative change in lumbar vertebrae, and 19 volunteers who did not have low back pain or pain in the lower limb. The ultrasound measure values (height [H] and width [W]) of normal and degenerative lumber spine facet joints were compared. And the differentiation between measure values (H and W) of ultrasound and CT of degenerative lumber spine facet joints was also analyzed.
The ultrasound clearly showed abnormal facet joints lesion, which was characterized by hyperostosis on the edge of joints, bone destruction under joints, and thinner or thicker articular cartilage. There were significant differences between the ultrasound measure values of the normal (H: 1.26 ± 0.03 cm, W: 0.18 ± 0.01 cm) and abnormal facet joints (H: 1.43 ± 0.05 cm, W: 0.15 ± 0.02 cm) (all P < .05). However, there were no significant differences between the measure values of the ultrasound (H: 1.43 ± 0.17 cm, W: 0.15 ± 0.03 cm) and CT (H: 1.42 ± 0.16, W: 0.14 ± 0.03) of the degenerative lumber spine facet joints (all P > .05).
Ultrasound can clearly show the structure of facet joints of lumbar spine. It is precise and feasible to assess facet joints of lumbar spine by ultrasound. This study has important significance for the diagnosis of lumbar facet joint degeneration.
... A physician with fellowship training and extensive experience performed the MBB (NS) using standard C hronic persistent low back and neck pain occurs in 25% to 60% of patients, one year or longer after the initial episode (1,2). It is estimated that 33% to 65% of patients with chronic neck pain and 17% to 44% of patients with chronic low back pain have facet joint pain (3)(4)(5)(6)(7)(8)(9)(10). Facet joints are a common cause of chronic neck and back pain (7)(8)(9)(10)(11). ...
Background:
Facet joint pain is a common cause of low back pain. There are no physical exam findings that provide a reliable diagnosis. Diagnosis is made by medial branch block injections (MBB). Once the source of pain has been determined, radiofrequency neurotomy (RFN) can be performed. Previous studies have shown that RFN reduces level of pain and improves function. No study has tried to correlate MBB results with outcomes after RFN.
Objectives:
(1) Estimate percentage decrease in pain, decrease in analgesic use, and increase in activity tolerance after facet joint radiofrequency neurotomy (2) Determine correlation between percentage pain relief or duration of pain relief after MBB and RFN outcomes.
Study design:
Retrospective review of patients undergoing RFN, who had = 70% pain relief on 2 sets of MBB with 0.5 - 1 mL of 2% lidocaine (MBB 1) and 0.75% bupivacaine (MBB 2). IRB approval was obtained before data collection began.
Setting:
All patients undergoing RFN between 12/06-1/10 at University Spine and Pain clinics.
Methods:
Subgroup analysis was performed based on response to MBB, a)100% pain relief and <100% pain relief after MBB 1 and 2 and a) those with > 8 hours and = 8 hours pain relief after MBB 1 and 2. Correlational analysis was conducted to determine the correlation between a) percent pain relief after MBB1 and 2 and percent change in pain after RFN and b) duration of pain relief after MBB 1 and 2 and percent change in pain relief after RFN.
Outcome measures:
Pain intensity, disability index, analgesic use, and patient perception of benefit.
Results:
Mean improvement of Disability scores at 3 months was 12.63 (P = 0.001), percent pain relief was 47.68% (P = 0.001). Patients with 100% pain relief after MBB 1 had greater improvement of disability scores (P = 0.008). Those with > 8 hours pain relief after MBB 1 had greater reduction in pain (P = 0.014). Pearson correlation analysis showed no correlation between percent pain relief or duration of pain relief after MBB and percent pain relief after RFN.
Limitations:
This was a small observational study with short-term follow up.
Conclusion:
Patients had improved disability scores and decreased pain after RFN. No correlation was seen between results on MBB and pain relief after RFN. It is still unclear how many medial branch blocks are needed and the criteria for MBB results before proceeding to RFN.
... Most of those affected have non-specific low back pain [3]. Low back pain can arise from the synovial facet joints [4] . Facet joint injury can occur from mechanical damage due to compressive forces or extensive stretching; degenerative changes such as osteoarthritis and inflammatory processes including rheumatoid arthritis [5, 6]. ...
Purpose
Evidence supporting the use of therapeutic intra-articular facet joint injections for patients with suspected facet joint pain is sparse. A systematic review including a narrative synthesis was carried out to determine if intra-articular facet joint injections with active drug are more effective in reducing back pain and back pain-related disability than a sham procedure or a placebo/inactive injection. Secondly, to determine if intra-articular facet joint injections with active drug or placebo/inactive injection are more effective in reducing back pain and back pain-related disability than conservative treatment.
Methods
Medline, EMBASE, CINAHL, CENTRAL, Index to Chiropractic Literature and the Cochrane Central Register of Controlled Trials were searched from inception through April 2015. Data were screened and single extraction with independent verification and risk of bias assessment was performed.
Results
A total of 391 records were screened, and six trials were included. The trials included were small (range 18–109 participants) and overall in terms of pain and disability outcomes most were inconclusive. Only two of the trials report any significant between-group differences in pain (mean difference −1.0, 95 % CI −2.0 to −0.1) and (p = 0.032) or disability (mean difference −3.0, 95 % CI −6.2 to 0.2) and (p = 0.013) outcomes.
Conclusions
The studies found here were clinically diverse and precluded any meta-analysis. A number of methodological issues were identified. The positive results, whilst interpreted with caution, do suggest that there is a need for further high-quality work in this area.
... Although the leading cause of chronic low back pain is degenerative disc disease, the facet joints are responsible for approximately 30% of chronic lumbar pain [1,2]. Unfortunately, limited treatment options and difficulties in differential diagnoses leave many patients with only temporary palliative management such as medial branch blocks or rhizotomy [3]. ...
Background context:
Although approximately 30% of chronic lumbar pain can be attributed to the facets, limited surgical options exist for patients. Interpositional facet arthroplasty (IFA) is a novel treatment for lumbar facetogenic pain designed to provide patients who gain insufficient relief from medical interventional treatment options with long-term relief, filling a void in the facet pain treatment continuum.
Purpose:
This study aimed to quantify the effect of IFA on segmental range of motion (ROM) compared with the intact state, and to observe device position and condition after 10,000 cycles of worst-case loading.
Study design/setting:
In situ biomechanical analysis of the lumbar spine following implantation of a novel IFA device was carried out.
Methods:
Twelve cadaveric functional spinal units (L2-L3 and L5-S1) were tested in 7.5 Nm flexion-extension, lateral bending, and torsion while intact and following device implantation. Additionally, specimens underwent 10,000 cycles of worst-case complex loading and were testing in ROM again. Load-displacement and fluoroscopic data were analyzed to determine ROM and to evaluate device position during cyclic testing. Devices and facets were evaluated post testing. Institutional support for implant evaluation was received by Zyga Technology.
Results:
Range of motion post implantation decreased versus intact, and then was restored post cyclic-testing. Of the tested devices, 6.5% displayed slight movement (0.5-2 mm), all from tight L2-L3 facet joints with misplaced devices or insufficient cartilage. No damage was observed on the devices, and wear patterns were primarily linear.
Conclusions:
The results from this in situ cadaveric biomechanics and cyclic fatigue study demonstrate that a low-profile, conformable IFA device can maintain position and facet functionality post implantation and through 10,000 complex loading cycles. In vivo conditions were not accounted for in this model, which may affect implant behavior not predictable via a biomechanical study. However, these data along with published 1-year clinical results suggest that IFA may be a valid treatment option in patients with chronic lumbar zygapophysial pain who have exhausted medical interventional options.
... One variable yet to be examined for its relationship to RF treatment outcome is the pain relief cutoff for designating a diagnostic block as ''positive.'' Several authors have claimed that the identification of z-joints as pain generators is best accomplished only after complete or near-total relief of back pain after low-volume diagnostic injections [12][13][14][15]. In addition to the logic behind this assertion, this claim seems to be borne out by an examination of prospective studies evaluating medial branch RF denervation. ...
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
... Patients with facet arthropathy and/or refereed sciatica were assessed clinically (Table 1) and radiologically using CT/MRI [20][21][22][23]. The therapeutic procedure was decided using the European guidelines and the evidence-based practice guidelines in the management of chronic spinal pain as follows; intraarticular and medial branch block for facet arthropathy; sacroiliac block for sacroiliac pain; caudal epidural injection for epidural scar, residual disc post surgery, and multilevel stenosis; and transforaminal epidural injection for lumbar disc or single-or double-level stenosis [5,24]. ...
... With a yearly prevalence of up to 70% in Germany alone (Schmidt et al. 2007;Wenig et al. 2009) back pain is responsible for annual treatment costs of up 8.4 billion (Lange and Ziese, 2006). Facet joints, as one of the most important parts of a spinal segment, are increasingly recognised as a source of back pain (Schwarzer et al. 1994(Schwarzer et al. , 1995Manchikanti and Singh, 2002;Manchikanti et al. 2004;Manchikanti et al. 2008;DePalma et al. 2011). They form the posterior column of the spinal segment and serve as a motion delimiter and guide the movement of the spinal segment. ...
Back pain constitutes a major problem in modern societies. Facet joints are increasingly recognised as a source of such pain. Knowledge about the internal morphology and its changes with age may make it possible to include the facets more in therapeutic strategies, for instance joint replacements or immobilisation. In total, 168 facets from C6/7 and L4/5 segments were scanned in a micro-computed tomography. Image analysis was used to investigate the internal morphology with regard to donor age and gender. Additional data from trabecular bone of the vertebral core allowed a semi-quantitative comparison of the morphology of the vertebral core and the facets. Porosity and pore spacing of the cortical sub-chondral bone does not appear to change with age for either males or females. In contrast, bone volume fraction decreases in females from approximately 0.4 to 0.2 , whereas it is constant in males. Trabecular thickness decreases during the ageing process in females and stays constant in males , whereas trabecular separation increases during the ageing process in both genders. The results of this study may help to improve the understanding of pathophysiological changes in the facet joints. Such results could be of value for understanding back pain and its treatment.
Background With significant advancement and demand for digital transformation, the digital twin has been gaining increasing attention as it is capable of establishing real-time mapping between physical space and virtual space. In this work, a digital twin solution is presented to predict the real-time biomechanics of the lumbar spine during human movement. Methods A finite element model (FEM) of the lumbar spine was firstly developed using computed tomography (CT) and constrained by the body movement which calculated by the inverse kinematics algorithm. The Gaussian process regression was utilized to train the predicted results and create the digital twin of the lumbar spine in real-time. Finally, a three-dimensional virtual reality system was developed using Unity3D to display and record the real-time biomechanics performance of the lumbar spine during body movement. Results The evaluation results presented an agreement ( R ² >0.8) between the real-time prediction from digital twin and offline FEM prediction. Conclusions This approach provides an effective method of real-time planning and warning in spine rehabilitation.
Radiofrequency ablation of the medial branch is commonly used to treat chronic low back pain involving facet joints, which accounts for 12% to 37% of the total cases of chronic low back pain. An adverse effect of this procedure is the denervation of the multifidus muscle, which may lead to its atrophy which can affect the spine and possibly disc degeneration. This study aims to quantify changes in joint angles and loading caused by multifidus denervation after radiofrequency ablation. AnyBody model of the torso was used to evaluate intervertebral joints in flexion, lateral bending, and torsion. Force-dependent kinematics was used to calculate joint angles and forces. These dependent variables were investigated in intact multifidus, unilateral, and bilateral ablations of L3L4, L4L5, and L5S1 joints. The results showed pronounced angular joint changes, especially in bilateral ablations in flexion, when compared with other cases. The same changes’ trend from intact to unilaterally then bilaterally ablated multifidus occurred in joint angles of lateral bending. Meanwhile, joint forces were not adversely affected. These results suggest that multifidus denervation after radiofrequency ablation affects spinal mechanics. Such changes may be associated with abnormal tissue deformations and stresses that can potentially alter their mechanobiology and homeostasis, thereby possibly affecting the health of the spine.
Objective
Investigate the ability of Patient Reported Outcomes Measurement Information System (PROMIS) to capture the therapeutic effect of first-time medial branch radiofrequency ablation (RFA).
Design
Before-after trial
Setting
Single academic spine center
Participants
Patients who underwent first-time medial branch RFA for lumbar facet joint pain identified by dual comparative medial branch block (MBB) with 80% or greater pain relief between January 1st, 2015 and September 1st, 2019 were identified utilizing procedural billing codes. Charts were reviewed manually to confirm accuracy and strict adherence to the 80% pain relief threshold for each MBB. Thirty-nine patients met the criteria and were included in this study.
Intervention
Medial branch RFA.
Main Outcome Measures
PROMIS score domains of Depression, Pain Interference, and Physical Function collected pre and post RFA were compared. Pre-treatment scores were within 6 weeks prior to the first MBB. Post-treatment scores were between 5 weeks and 6 months after RFA. Paired-sample t-test analyses were used to calculate responsiveness to treatment, with significance assigned as p<0.05 prior to acquiring data. Effect size was calculated using Cohen's d.
Results
PROMIS domains of Pain Interference and Physical Function demonstrated a statistically significant improvement (p=0.004 and p=0.017, respectively). The PROMIS domain of Depression did not demonstrate a statistically significant change (p=0.12). The effect size was medium (d=-0.43) for Pain Interference, small/medium (d=0.31) for Physical Function, and small (d=-0.12) for Depression.
Conclusions
Medial branch RFA as a treatment for lumbar facet syndrome is associated with a statistical improvement in PROMIS domains of Physical Function and Pain Interference.
Background: With significant advancement and demand for digital transformation, the digital twin has been gaining increasing attention as it is capable of establishing real-time mapping between physical space and virtual space. In this work, a shape-performance integrated digital twin solution is presented to predict the real-time biomechanics of the lumbar spine during human movement.
Methods: A finite element model (FEM) of the lumbar spine was firstly developed using computed tomography (CT) and constrained by the body movement which was calculated by the inverse kinematics algorithm. The Gaussian process regression was utilized to train the predicted results and create the digital twin of the lumbar spine in real-time. Finally, a three-dimensional virtual reality system was developed using Unity3D to display and record the real-time biomechanics performance of the lumbar spine during body movement.
Results: The evaluation results presented an agreement (R-squared > 0.8) between the real-time prediction from digital twin and offline FEM prediction.
Conclusions: This approach provides an effective method of real-time planning and warning in spine rehabilitation.
Background Context
The diagnosis of discogenic low back pain (LBP) from disc degeneration of the lumbar spine is often evaluated with discography. Non-invasive, simple screening methods other than invasive discography are useful, as evidence supporting clinical findings and magnetic resonance imaging (MRI) have come to the forefront.
Purpose
To investigate disc height (DH) discrepancy between supine and standing positions on simple radiography to clarify its clinical screening value in individuals with discogenic LBP.
Study Design/Settings
Retrospective matched cohort design.
Patient Sample
Ninety-two patients with early to middle stage disc degeneration (Pfirrmann grade II, III, IV).
Outcome measures
Each subject underwent simple radiographs and MRI. Baseline characteristics, including demographic data and MRI findings, and radiological findings, including DH discrepancy, segmental angle, and sagittal balance, were analyzed. DH discrepancy ratio was calculated as (1 - [calibrated DH on standing radiography/calibrated DH on supine radiography]) × 100%.
Methods
We matched LBP group of 46 patients with intractable discogenic pain (≥7 of visual analog scale scores) confirmed by discography with control group of 46 patients with similar stage disc degeneration with mild LBP (≤4 of visual analog scale scores). Binary regression analysis, receiver operating characteristic (ROC) curve analysis, and cut-off value for diagnosis were used to evaluate and clarify diagnostic value of various factors.
Results
There was no significant difference between the two groups in terms of baseline characteristics, including age, sex, body mass index, pathological level, and magnetic resonance findings such as disc degeneration, high intensity zone, and para-spinal muscle volume.
Among the various radiological findings, the calibrated mean DH in the standing position (20.87±5.65 [LBP group] versus 26.95±3.02 [control group], p<0.001) and the DH discrepancy ratio (14.55±6.13% [LBP group] versus 1.47±0.75% [control group], p=0.007) were significantly different between the two groups. The cut-off value for DH discrepancy ratio to screen discogenic LBP was ≥6.04%.
Additionally, as a compensation for pain, sagittal vertical axis (3.43±2.03 cm [LBP group] versus -0.54±3.05cm [control group], p=0.002) and pelvic incidence (54.74±6.76° [LBP group] versus 43.98±8.67° [control group]; p=0.006) were different between the two groups.
Conclusions
The results suggest that DH discrepancy between the supine and standing positions could be a screening metric for discogenic LBP in early to middle stage disc degeneration of the lumbar spine.
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.
In this article, we present the latest knowledge of the anatomy and functional anatomy of dorso-lumbar posterior joints (DLPJ) and their pathologies. After a reminder of embryology we specify the morphology of the DLPJ with the help of the work of Masharawi and Louis highlighting among others a constant asymmetry and different characteristics at each level. The morphological peculiarities of DLPJ allow to understand their participation in the vertical and horizontal stability and dynamics of the DL spine. The innervation of DLPJ is described. We end with a reminder of the most common pathologies of lumbar PJ.
Introduction
Lumbar pain affects between 60 and 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.
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.
In dit hoofdstuk wordt, aan de hand van een casus, het klinisch redeneerproces van de fysiotherapeut geschetst vanaf het moment dat de patiënt binnenkomt en de fysiotherapeut nog niet weet wat er aan de hand is. Het hoofdstuk start met algemene informatie over de epidemiologie van lage rugpijn, de risicofactoren en de prognose. Vervolgens wordt besproken wat er wetenschappelijk bekend is over de validiteit van de anamnese, het lichamelijk onderzoek, eventuele provocatietesten en beeldvormende diagnostiek in het valide diagnosticeren van subgroepen van patiënten met lage rugpijn. Aangezien dit het eerste van de acht hoofdstukken is, zijn een aantal begrippen iets uitgebreider beschreven in vergelijking met de volgende hoofdstukken.
Joint pain is a common problem among elderly patients. Joint injection with various injectates such as analgesics and corticosteroids can be an alternative form of treatment for joint pain that is unresponsive to conventional treatment. The spinal facet joints and other joints, such as the sacroiliac, hip, shoulder, and knee, can be safely and efficaciously treated percutaneously under imaging guidance. This chapter aims to review the relevant anatomy, indications and contraindications, complications, and expected results of various imaging-guided joint injections.
Objective: To assess the therapeutic effect of imaging-guided pulsed-radiofrequency stimulation of medial branch of lumbar spinal nerve in treating lumbar facet joint syndrome. Methods: A total of 48 patients with clinically-diagnosed lumbar facet syndrome were randomly divided into group A (antiinflammatory and analgesic group, n=26) and group B (pulsed-radiofrequency group, n=22). The patients of group A received oral meloxicam dispersible tablets, while the patients of group B were treated with DSA-guided pulsed-radiofrequency stimulation of dorsal medial branch of lumbar spinal nerve corresponding to the diseased lumbar facet. Using visual analogue scale (VSA) the severity of pain at the time of admission, discharge and 6 month after discharge was separately evaluated, and the therapeutic effect was assessed based on the improvement of VSA score. Results: The VAS scores of group A and group B at the time of discharge and 6 months after discharge were significantly lower than those determined at the time of admission (P<0.01). At the time of discharge, the VSA score of group B was significantly lower than that of group A (P<0.05). Six months after discharge, the VAS score of group B was significantly lower than that of group A (P<0.05). The total effective rates at 6 months after di scharge of group A and group B were 46.5% and 87.6% respectively; the excellent effect rates of group A and group B were 26.4% and 76.2% respectively. Both the total effective rate and excellent effect rate of group B were significantly higher than those of group A (P<0.01). Conclusion: Imaging - guided pulsed - radiofrequency stimulation of dorsal medial branch of lumbar spinal nerve can effectively relieve chronic lower back pain caused by lumbar facet joint syndrome, and its therapeutic effect is superior to oral anti-inflammatory and analgesic medication.
The spine is the most common cause of chronic back pain. It can cause significant loss of function or disruption in activity of daily living and is extremely common in the elderly. Of the various causes of spinal pain, facet joint syndrome is often a diagnosis of exclusion, as it is difficult to differentiate the latter from pain secondary to degenerative disk disease or spinal stenosis because of overlapping clinical features and poor correlation between the clinical presentation and the imaging abnormalities. Further, localizing the source of pain is challenging as facet joint disease may not be limited to only 1 joint. Pain arising from the facet joints can be attributed to segmental instability, synovitis, synovial entrapment, trauma, meniscoid impingement, chondromalacia, and osteoarthritis. Facet joint injection is performed under fluoroscopy or computed tomography guidance, which facilitates accurate needle placement while reducing potential injury to the surrounding vital structures. Indications of facet joint injection include clinical suspicion of facet joint syndrome, chronic pain not relieved by trial of nonsteroidal anti-inflammatory drugs and physiotherapy, patients with confirmed facet joint syndrome, presence of adjacent segment deterioration after spinal fusion or persistent low back pain after a stable posterolateral fusion, and patients in whom oral or systemic drug therapy have to be withdrawn because of adverse effect or have exceeded the maximum tolerable dose. Given the high success rate and low complications, image-guided facet injection is deemed safer and more effective compared with conventional “blind” injections.
Lumbar zygapophysial joints are a common source of chronic lower back pain and radiofrequency thermocoagulation (RF) of the medial branches (MB) has been shown to be effective at providing substantial pain relief for chronic low back pain. Therefore, we carried out this study to determine the short term outcomes and prognostic factors of RF on the MB of patients with lumbar facet syndrome.
Interventional pain management practice policies are state- ments developed to assist physician and patient decisions about appropriate health care related to chronic pain. These policies are professionally derived recommendations for practices in the diagnosis and treatment of chronic or per- sistent pain. They were developed utilizing a combination of evidence- and consensus-based techniques to increase patient access to treatment, improve outcomes and appro- priateness of care, and optimize cost effectiveness. These practice policies do not constitute inflexible treat- ment recommendations. It is recommended that a provider establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, and the physician's experience. Based on an individual patient's needs, treatment different from that outlined here may be warranted.
Goldthwait (1911) is often attributed as being the first to mention the zygoapophysial joints as a cause of low back pain. Examination of the original publication is made to determine the accuracy of this claim. While Goldthwait does describe the lumbosacral zygoapophysial joint, it was more related to a displacement or dislocation. Ghormley (1933) clearly describes the zygoapophysial joints as a potential cause of low back pain and deserves acknowledgement for this. © The Society of Orthopaedic Medicine and the British Institute of Musculoskeletal Medicine 2012.
Objectives:
Diagnostic medial branch blocks (MBB) are considered the reference standard for diagnosing facetogenic pain and selecting patients for radiofrequency (RF) denervation. Great controversy exists regarding the ideal cutoff for designating a block as positive. The purpose of this study is to determine the optimal pain relief threshold for selecting patients for RF denervation after diagnostic MBB.
Methods:
In this multicenter, prospective correlational study, 61 consecutive patients undergoing lumbar facet RF denervation after experiencing significant pain relief after MBB were enrolled. A positive outcome was defined as a ≥50% reduction in back pain at rest or with activity coupled with a positive satisfaction score lasting longer than 3 months. The relationship between pain relief after the blocks and denervation outcomes was evaluated by pairwise correlation matrix, receiver's operating characteristic curve, and stratifying outcomes based on 10- and 17-percentage point intervals for MBB.
Results:
There were no significant differences in RF outcomes based on any MBB pain relief cutoff over 50%. A trend was noted whereby those patients who obtained <50% pain relief reported poorer outcomes. No optimal threshold for designating a diagnostic block as positive, above 50% pain relief, could be calculated.
Conclusion:
Employing more stringent selection criteria for lumbar facet RF is likely to result in withholding a beneficial procedure from a substantial number of patients, without improving success rates.
Although this textbook will not specifically address the details of lumbosacral region spinal injection procedures, the important
issue of when to refer a patient for a possible lumbosacral spinal injection will be discussed. This is an important topic
to physicians involved with musculoskeletal medicine given the frequency with which patients report low back pain and the
morbidity associated with it.
Cadaver dissection.
To examine the potential points of spinal nerve entrapment and the articular branches in the thoracic spine.
Despite many cadaver studies focused on the cervical and lumbar spinal nerves, detailed anatomy of the thoracic nerve branches is missing from the viewpoint of painful neuropathy on the thoracic region.
A total of 120 pairs of thoracic spinal nerves out of 10 donated cadavers were dissected. Detailed anatomy of the posterior ramus and medial/lateral branches and their fine branches in the entire thoracic region was investigated by both macroscopic and stereomicroscopic dissections.
The posterior ramus of the thoracic nerve passed through the narrow space between the bony structures and adjacent fibrous tissue. It is sent to the first branch, which is called "the descending branch," before bifurcating into medial and lateral branches. The medial branch runs posterolaterally, then turns medially along the edge of multifidus, and passes between that and semispinalis, whereas the lateral branch runs underneath the intertransverse ligament. Both medial and lateral cutaneous branches penetrated the thoracolumbar fascia, and the medial cutaneous branch penetrated the tendinous portion of back muscles.
Several points might be listed as potential sites of entrapment along the course of the posterior ramus of the thoracic nerve and its branches, leading to the cause of thoracic back pain. In addition, the articular branch entering the facet (zygapophyseal) joint originated from the descending branch, which was the first branch of the posterior ramus.
Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated.
To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients.
Retrospective chart review.
Community based interventional spine practice.
378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed.
Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified.
Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP.
The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age.
Retrospective study design.
The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain.
Chronic spine pain poses a peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features and nonspecific radiological findings. Facet joint injection is an interventional pain management tool for facet-related spinal pain that can be effectively administered by a radiologist. This technique is the gold standard for identifying facet joints as the source of spinal pain. The major indications for facet injections include strong clinical suspicion of the facet syndrome, focal tenderness over the facet joints, low back pain with normal radiological findings, post-laminectomy syndrome with no evidence of arachnoiditis or recurrent disc disease, and persistent low back pain after spinal fusion. The contraindications are more ancillary, with none being absolute. Like any synovial joint degeneration, inflammation and injury can lead to pain on motion, initiating a vicious cycle of physical deconditioning, irritation of facet innervations and muscle spasm. Image-guided injection of local anesthetic and steroid into or around the facet joint aims to break this vicious cycle and thereby provide pain relief. This outpatient procedure has high diagnostic accuracy, safety and reproducibility but the therapeutic outcome is variable.
Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, "pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur." In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.
Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians.
To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain.
Systematic assessment of the literature.
Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.
Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term.
The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2.
The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations.
The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include 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. Further, these guidelines also do not represent "standard of care."
The prevalence of back and joint impairments was studied in a representative subsample of 77 women and 57 men aged 79. Forty-six per cent of the subjects had no history of back or joint complaints. Thirty-two per cent reported current back pains while 50% stated they never experienced such pains. Back pains (past or present) were localized in the lumbar region predominantly (40%), and were almost constantly present in 8% of the subjects. The spinal mobility remained acceptable for function of the activities of daily living (ADL) in the majority of the subjects. Thirty-six per cent of the subjects had past or present complaints from the joints of the extremities, predominantly of the knee, shoulder or hip joints. Physical signs of joint disorders as deformities, swelling or tenderness were rare except for enlargement of distal interphalangeal joints (right hand: females 38%, males 14%). Restricted range of motion (ROM) in one or several joints was found in one fifth (i.e., knee joints) to two thirds (i.e., hip joints). No significant gender differences were observed with the exception of the thoracolumbar ROM that was more frequently restricted in males. Severe restriction of separate movements (to less than 50% of ROM) was, generally, infrequent (0-8% of the subjects) although advanced impairment of hip inward rotation was found in 14% of the subjects. Restricted ROM associated with joint complaints was found in 2-11% of the subjects (i.e., knee joints 2%, shoulder joints 9%, hip joints 11%). A considerable proportion of 79-year-olds, thus, had some--though usually limited--restriction of joint ROM.
This study based on the examination of 200 joints points out the great interindividual variability concerning the innervation of the posterior or zygapophyseal articulations of the lumbar spine. Furthermore, their innervation varies in a given individual according to the level and the side of the spine under consideration. The nerves supplying these joints are of multiple origins. The zygapophyseal articulations receive their innervation by the anterior, lateral or posterior aspect. Rather than following a strictly metameric pattern, such nerve supply involves at least three spinal levels.
The first part of this study deals with the descriptive anatomy of the best known neural structure innervating these articulations, i.e. the dorsal ramus of the spinal nerve, as well as the other nerves supplying the posterior joints. These anatomical data are then followed by a tentative synthesis of the different modes of innervation. This part of the paper treats both the origins of the nerves and the features of their distribution to the joints. Finally, the results of this study are discussed with respect to the metameric arrangement of nerve supply.
In a study of 47 cases of lumbar disc protrusion, the hypothesis that asymmetry of the facet joints is correlated with the presence of a disc protrusion, was tested. Seventeen cases of protrusion of the L4-L5 disc and 30 cases of protrusion of the L5-S1 disc were measured on coronal computed tomography (CT) scans. The nonprotruded discs of each level were used as controls of the protruded discs of the same level. The transverse interfacet angle, the inclination and curvature of the facet joints, and the frequency of asymmetric facet joints showed no significant differences, whether there was a disc protrusion or not. The magnitude of the asymmetry was significantly greater only at the L4-L5 interspace in cases of disc protrusion. However, taking into consideration the error of measurement, the difference becomes highly questionable. These results do not indicate any relation between facet joint asymmetry and protrusion of the intervertebral disc.
The reliability of assessing facet joint obliquity from standard CT scans in the lumbar spine was studied. There was no significant difference in repeated measurements by one single examiner, nor in measurements made by different examiners. Measurement of facet joint obliquity from CT scans made on different occasions was not significantly different either. This reproducibility occurred despite the fact that adjacent CT scans from one joint extremity to the other showed variation in obliquity of about 11%.
Facet joint arthrography was performed in 11 patients with lumbar spondylolysis. An abnormal communication between the two facet joints bordering the separated par interarticularis was observed in nine of these patients. This communication occurred through a channel in the area of the defect. In one patient with bilateral spondylolysis of the L5 vertebra, both left adjacent apophyseal joints were observed to communicate not only with one another, but also with the contralateral facet joints, through a transverse channel joining the isthmic areas of L5. Significant pain relief following intra-articular administration of anesthetics and corticosteroids was recorded in 5 patients, for periods lasting from 2 to 10 months. Spondylolysis considerably alters the soft tissues of the adjacent facet joints. Irritation of these structures might explain certain complaints of patients with spondylolysis.
The synovium-lined apophysial joint is an important cause of back pain through facet arthrosis and nerve root pressure. The short-term results of two relatively noninvasive treatments--facet block and facet rhizotomy--have been better than their long-term results. The authors propose treatment with fusion of the posterior facet joints in the lumbar spine by means of a simple percutaneous procedure performed under local anesthetic with use of radiologic guidance.
In the first phase of this study the technical feasibility of the concept was established in human cadaver spine. In the second phase a canine model was tested in which bone grafts were surgically inserted into lumbar facet joints. Five male and two female mongrel dogs, weighing 18-25 kg (mean, 20.3 kg), were operated on. Each procedure was done in three steps: First, preoperative computed tomographic (CT) scans were obtained to measure facet depth. Second, surgery was performed under fluoroscopic guidance with use of a threaded guide wire, a small cannulated coaxial drilling system, and hydroxyapatite cancellous bone plugs. Third, early postoperative CT scans were obtained to verify bone plug location. CT was repeated at 4 and 6 months after surgery to check for fusion. The dogs were killed at 6 months, and histologic examination was performed.
Successful insertion of the bone plug was achieved in 12 of the 14 facets (86%). One dog died as a complication of the procedure. Fusion occurred in five of the 12 surgically treated facets (42%).
Drilling and surgical insertion of bone plugs into facet joints of dogs were feasible. The fusion results are promising and may improve with future modifications of the technique.
The curvature of the lower lumbar facet joints in the transverse plane was measured using an innovative computed tomographic approach, and its relationship with the orientation of the joints was evaluated. Two hundred three vertebral levels were examined in 116 patients with low back pain. Reference circles were used to quantify joint curvature. The mean curvature (+/- SD) at the levels L3-L4, L4-L5, and L5-S1 conformed to circles of 27.3 mm +/- 11.5; 35.1 mm +/- 14.6; and 51.0 mm +/- 34.5 in diameter respectively. The ratio between the curvature of the facets and their orientation was 62.6% +/- 19.0; 57.8% +/- 21.6; and 64.9% +/- 48.9. From L3-L4 down to L5-S1 the curvature of the facet joints decreases. The differences between L3-L4 and L4-L5 is smaller than between L4-L5 and L5-S1. The curvatures of the joints conform to circles that are in mean approximately 40% in diameter smaller than those to which their orientations conform.