Facet Injections Research Articles

Lumbar segmental rigidity: Can its identification with facet injections and stretching exercises be useful?

Mayer TG, Robinson R, Pegues P, Kohles S, Gatchel RJ. Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful? Arch Phys Med Rehabil 2000;81:1143-50. Objectives: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. Design: Preliminary 2-part study: (1) presentation of a technique for identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. Setting: An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. Patients: Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. Interventions: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1–4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. Main Outcome Measures: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. Results: Patients' mobility improved significantly (p <.01–.0001) across all 4 motions. A large majority (71%–97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings. Conclusions: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

The pain-procedure-insurance triad: bonds to help may hurt.

In Ethics Forum , we will present clinical cases selected on the basis of diagnostic dilemmas and/or difficult therapeutic decisions that occur in the practice of pain medicine. We will ask several pain specialists to help identify the ethical issues raised in these cases and to give their opinions based on their perceptions and experience. Please send or e-mail (ch53@drexel.edu) your comments or remarks to Colleen Healy, Editorial Assistant, Pain Medicine , Pain Center, Graduate Hospital, 1800 Lombard Street, Philadelphia, PA 19146. Also, if you believe you have witnessed a case that presents an interesting ethical dilemma for examination, send it for possible inclusion in the Forum. The patient is a 69-year-old widowed white female with a 10-year history of chronic low back and leg pain. She has had two back surgeries in the past for presumed spinal stenosis. These did not produce significant pain relief. They were followed by multiple interventions to address her pain, including selective nerve root blocks, lumbar epidural steroid injections, facet injections, and rhizotomies. The patient did not experience any lasting pain relief from any of these procedures. The patient's overall functional status has deteriorated steadily since the beginning of treatment. Before her first surgery she played tennis regularly. Now she is essentially bedridden. Insurance coverage of her care is becoming more difficult, leaving more and more out-of-pocket expenses, which the patient can barely meet. The patient has been reading information on the Internet and now requests implantation of an intrathecal pump for opioids. The insurance company is balking at this expense, given her lack of response to other therapies. The patient wonders how they can deny her this last chance at relief. ### Comment no. 1: Mark Sullivan, MD, PhD This case raises a number of ethical issues. One concerns the insurance company's perspective on the case. Another concerns the nature and …

Facet blocks and denervations

The lumbar facet (zygapophyseal) joint has been considered to be a significant source of low back pain for almost a century. Ghormley was the first individual to describe “facet syndrome” which he defined as a lumbosacral pain with or without radiculopathy, occurring most often after a sudden twisting or rotary strain of the lumbosacral region [1]. Hirsch et al. [2] injected hypertonic saline in the region of the facet joints and produced low back pain in the sacroiliac and gluteal regions with radiation to the greater trochanter. This was confirmed by Mooney and Robertson [3], who performed intra-articular saline facet injections, producing a similar pain referral pattern, which was relieved by intra articular local anesthetic injection. Also, neck pain and headache were produced by cervical facet injection with hypertonic saline by Pawl [4].

MRI-controlled facet block--technique and initial results

In a clinical study, 5 patients with chronic low back pain were treated by MR-guided facet injection of the motion segments L4/L5 and L5/S1. For the infiltration, special nonmagnetic needles were used. The investigations were carried out in an MR unit having a field strength of 1.0 tesla. In all patients, MR visualisation of the facet joints and measurement of the distance to the reference point was readily accomplished. Placement of the special MR needle, however, proved difficult in situations in which the needle had to be advanced through dense fibrous tissue. Nevertheless, the needle was successfully placed at the first attempt in two patients; in all other patients a second attempt was necessary. The entire procedure took about 30 to 40 minutes per patient. The needles were identified without any artefacts. All the patients were pain-free for at least 3 weeks after injection.

Percutaneous Aspiration of Lumbar Facet Synovial Cyst

Percutaneous Aspiration of Lumbar Facet Synovial Cyst

The value of facet joint blocks in patient selection for lumbar fusion.

The purpose of this study was to ascertain the correlation between diagnostic facet blocks and treatment outcome, both surgical and nonsurgical. One hundred twenty-six patients who had previously undergone diagnostic facet injections were reviewed. Eighty-two had subsequently undergone lumbar arthrodesis. The rest were treated with a variety of nonoperative modalities. Statistical analysis of accumulated data failed to show any significant correlation between the results of facet blocks and outcome of operative arthrodesis. In addition, statistical analysis failed to show any significant correlation between the facet block results and the outcome of nonoperative treatment. The authors concluded that lumbar facet joint injections cannot be used to determine appropriate patient treatment because they are not predictive of either surgical of nonsurgical success.

Ear Pain Due to Cervical Spine Arthritis: Treatment With Cervical Facet Injection

Two patients with cervical spine arthritis and ear pain were recently evaluated at our clinic. Injection of the C1-2 facet joints with local anesthetic plus corticosteroid resulted in relief of the pain. Therapeutic cervical facet injections may be indicated in cases of recalcitrant head and neck pain due to cervical spine arthritis.

1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study.

From January 1980 through December 1984, 454 patients were evaluated with facet joint injections. All had the chief complaint of low-back pain, normal neurologic examinations and no root tension signs. Three hundred and ninety completed the protocol, which included a lumbar motion pain assessment before and after facet injection. A total of 127 variables were studied. There were 229 males and 161 females with a median age of 38. Facet joint arthrograms were performed prior to intra-articular injection of local anesthetic and cortisone. Initial mean pain relief was only 29%. Variables correlating significantly (P less than 0.05) with more postinjection pain relief were older age, prior history of low-back pain, normal gait, maximum pain on extension following forward flexion in the standing position, and the absence of leg pain, muscle spasm and aggravation of pain on Valsalva. Greatest pain relief immediately after injection was seen with lumbar extension and rotation, motions reported to stress the facet joints or aggravate pain of facet joint origin. Patients with more pain on lumbar extension and rotation as a group, however, did not get more pain relief. From this study we were not able to identify clinical facet joint syndromes or predict patients responding better to this procedure. The facet joints were not commonly the single or primary source for low-back pain in the great majority (greater than 90%) of patients studied.

Failed Lumbar Disc Surgery

The challenge of failed back surgery is in the decision of when to operate and how to do it competently. Specific neuroanatomic indications as a basis for surgical treatment should reduce surgical failures. One source of failure is a "battered root" and the arachnoiditis which may follow limited or inadequate interlaminar exposure. Even with adequate interlaminar exposure, hemostasis may be difficult if preoperative positioning of the patient to diminish intra-abdominal pressure has not been performed. Bleeding can obscure the operative field and the surgeon's ability to visualize and deal with the problem at hand. A less common cause of failure is segmental instability. This may be pre-existing and related to facet tropism. It may also be a consequence of surgical removal of posterior vertebral elements, thus creating a loss of stability with or without a discernable change in vertebral alignment. The surgeon should try to: avoid becoming enmeshed in the psychodynamic problems of patients. He should use specific diagnostic tests, e.g., nerve blocks or facet injections, in an effort to localize specific sources of pain; recognize that prognosis is adversely affected by additional surgery; and avoid "exploratory" operations. Furthermore, neurolysis without spatial decompression, bony or otherwise, is eventually futile. All patients with failed back surgery have a psychodynamic component to their pain. This article will have achieved its purpose if it promotes recognition that a small percentage of patients with failed back surgery can be helped. These are individuals in whom specific diagnostic tests or clinical acumen uncover a surgically correctable lesion, be it compressive or radiculopathy or segmental instability. In such instances an adverse psychologic profile need not necessarily be a deterrent to surgical treatment.

A More Precise Diagnosis for Low-Back Pain

Five common syndromes productive of low-back and leg pain are presented as the basis for clinical investigation to arrive at an early and definite diagnosis in low-back pain problems. The five are posterior facet syndromes, sacroiliac-piriformis syndrome, herniated nucleus pulposus, central spinal stenosis, and nerve entrapment in the lateral recess. All may present with a common symptom complex of low-back, buttock, trochanteric, and posterior thigh pain. Specific details from history, physical, and radiographic examination may allow separation of these entities, but proof of diagnosis requires data from response to treatment, facet and nerve injection, myelography, discography, and computerized tomography (CT) scan.