Facet Joint Disease Research Articles

The Role of Intra-Articular Injection of Autologous Platelet Rich Plasma versus Corticosteroids in Treatment of Synovitis in Lumbar Facet Joint Disease

Abstract Background Low back pain (LBP) is an extremely common health problem and lumbar facet joint (FJ) disease is one of its main causes. Intra-articular injection of FJ is one of the vital therapeutic methods for FJ disease. Corticosteroids (CS) are the most commonly used injected drugs; however, previous studies have indicated that it has limited ability in long-term relief of LBP. Aim of the Work to compare the efficacy of intra-articular injection of platelet rich plasma (PRP) versus CS in improving MRI detected synovitis in correlation to clinical complaints of the patients with lumbar FJ syndrome. Patients and Methods Thirty patients with lumbar FJ syndrome divided into two equal groups: Group ‘I’ injected with PRP and Group ‘II’ with CS. The patients were comparatively assessed pre and post the intervention according to; number of tender lumbar FJs on palpation, maximum active lumbar extension range of motion, LBP visual analogue score (VAS), functional disability questionnaires - Roland Morris disability questionnaire (RMQ) and Oswestry disability index (ODI) - and MRI lumbar FJ detected synovitis and their grading. Results Both study groups showed statistical significant improvement in all mentioned parameters at 3 month follow up, there was no statistically significant difference between the results of both groups, however, PRP injected joints showed better performance regarding MRI synovitis grade in all lumbar FJ levels as compared to those injected with CS. Conclusion Both PRP and CS injections were determined to be effective in improvement of MRI detected FJ synovitis concurrently with improving clinical parameters, pain and functional activities of the patients at 3 months follow-up. However, PRP showed superior effect in improving MRI detected synovitis grade, therefore may be a better treatment option for longer duration efficacy and fewer side effects. TRN NCT04860531- 1/3/2021

End-on versus parallel radiofrequency lesioning for neurotomy of the cervical medial branch nerves: a study protocol of a prospective, randomized, double-blind clinical trial: the “EndPaRL” study

BackgroundCervical facet joint disease is a common source of neck pain and its prevalence increases with aging. Conservative multimodal management options (e.g., strengthening of neck muscles, non-steroidal anti-inflammatory medications, massage, and thermal modalities) often fail to relieve pain. Cervical medial branch nerve (CMBN) radiofrequency neurotomy (RFN) is an effective minimally invasive technique for treating chronic neck pain secondary to facet joint disease. An end-on approach for this procedure has been proposed that may be technically easier and require less time while reducing post-procedural discomfort. The protocol presented here is for a study that aims to compare the efficacy of a new end-on approach using multi-tined cannulae, against the conventional parallel technique that employs straight cannulae for RFN of the CMBN in patients with chronic neck pain due to cervical facet joint disease.MethodsA multicentre randomized, non-inferior, active comparator-controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessor. The study will include 72 adults with chronic neck pain secondary to facet joint disease who are candidates for RFA of the CMBN. Participants will be randomized to either the conventional parallel or the end-on approach in a 1:1 ratio. The intensity of pain and pain-related domains (function, quality of life, sleep, adverse effects of the interventions, analgesic intake) will be measured at 1, 3, 6, and 12 months after the procedure.DiscussionNeck pain secondary to cervical facet joint disease is prevalent and RFA of the CMBN is a validated treatment for relieving it. The conventional parallel technique can be technically challenging, and it can be associated with adverse effects while the newer end-on approach has the potential of being a simpler technique with less adverse effects. This trial will be the first non-inferiority study to compare the clinical efficacy of the end-on approach against the conventional parallel approach for RFN of CMBN in patients with chronic neck pain due to cervical facet joint disease.Trial registrationClinicalTrials.gov NCT05818774. Registered on April 20, 2023.

Anterior lumbar interbody fusion (ALIF): a review of the procedure and associated complications

Degenerative disc disease and facet joint disease involving the lumbar spine are common in the aging population and are the most frequent causes of disability. Surgical interbody fusion of degenerative levels is the most common management technique. This is an effective treatment option to stabilize the spine and reduce mechanical pain and provides indirect decompression of the neural elements while restoring lordosis and correcting the deformity. Depending on the direction of the approach to the vertebral column, various techniques have been described. Anterior lumbar interbody fusion (ALIF) offers clear and wide visualization of the disc allowing the use of large interbody grafts, which provide a significant biomechanical advantage over other types of fusion. The transperitoneal approach is a much older technique and it is not commonly performed unless in isolated cases with extensive retroperitoneal scaring following multiple abdominal surgeries. The transperitoneal approach has been associated with higher rates of bowel injury, ileus, and retrograde ejaculation, and is limited at the L5–S1 segment, hence many spine surgeons favor a retroperitoneal approach. The major setback of ALIF is the need for great vessel mobilization. This manipulation of the vessels may lead to deep vein thrombosis and a direct vascular injury. This makes vascular anatomy studies in the preoperative stage invaluable in avoiding vascular injury. Other complications include possible injury to intraperitoneal and retroperitoneal organs, especially in patients with previous surgery and adhesions. Manipulation of the intestines causes postoperative ileus which lasts a few days. Sexual dysfunction in form of retrograde ejaculation is another complication seen in patients following ALIF and this has been attributed to injury to the superior hypogastric sympathetic nerves in the lower lumbar region.This article reviews the ALIF procedure i. e., transperitoneal and retroperitoneal approaches, and the associated intraoperative, early, and late complications.

Intervertebral vacuum phenomenon - prevalence and severity CT-scan analysis in patients older than 50 years: a retrospective cohort study.

Chronic low back pain secondary to degenerative changes in the spine is a common cause of disability, and disc degeneration is one of the most frequent imaging findings. Intervertebral vacuum phenomenon (IVP) is usually observed in advanced degeneration. Recently, this phenomenon has gained interest due to a relatively new surgical technique called percutaneous discoplasty, aimed at treating low back pain secondary to degenerative disc disease in elderly patients. To analyze the prevalence and related factors of the vacuum phenomenon in adult patients. A retrospective cohort study was performed of patients who underwent abdominal computed tomography (CT) for non-spine-related reasons. Age, body mass index, smoking, and CT-based characteristics as presence of IVP, subchondral sclerosis, and facet joint degeneration at the lumbar spine from L1 to the sacrum were included in order to determine the prevalence of the vacuum phenomenon in this population and establish a relationship between this condition and patient demographics and other signs of spine degeneration, such as sclerosis and facet joint disease. A total of 238 patients were included in the study (114 men, 124 women; mean age = 75.6 ± 12.3 years. In total, 91 (38%) patients had at least one level of IVP; 59 (25%) patients exhibited subchondral sclerosis, and 235 (98%) facet joint degeneration. Among risk factors, age, smoking, and subchondral sclerosis were significantly associated with the presence of vacuum. IVP was present in 38% of participants. Risk factors associated with vacuum were age, smoking, and subchondral sclerosis.

Facets of facet joint interventions.

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

Facet joint disease in patients with axial spondyloarthritis: A retrospective computed tomography study

BackgroundFacet joints’ (FJ) ankylosis was reported in patients with radiographic axial spondyloarthritis (r-AxSpA). However, a detailed FJ evaluation over the whole spectrum of AxSpA was not performed. We aimed to analyze structural lesions in the FJ of patients with different forms of AxSpA, using computed tomography (CT). MethodsCT studies of the cervical/thoracic/lumbar spine, or of the chest/abdomen of patients with r-AxSpA or non-radiographic AxSpA (nr-AxSpA) (age ≤ 50 years) were analyzed for the presence of erosions, ankylosis, joint-space narrowing, osteophytes, subchondral sclerosis, subchondral cysts and vacuum phenomenon. Age- and gender-matched subjects without known rheumatic disease who performed spinal CT, formed the control group. Findings were compared between groups, separately for each spinal segment. Further, FJ findings between three subgroups of the axSpA subjects, including r-AxSpA with or without syndesmophytes, and nr-AxSpA, were compared. Results959/666 FJs (49/44 patients) were assessed in the AxSpA/control group patients, respectively. The study group consisted of 16 r-AxSpA patients with syndesmophytes and 22 r-AxSpA patients without syndesmophytes, and 11 nr-AxSpA patients. FJ ankylosis was significantly more prevalent in all spinal segments of the r-AxSpA patients with syndesmophytes. Erosions were seen almost exclusively in patients with r-AxSpA. Joint-space narrowing and osteophytes were noted in all segments and all subgroups of AxSpA patients, including those with nrAxSpA. ConclusionsDisease-specific FJ changes present almost exclusively in patients with r-AxSpA, while degenerative FJ changes are prevalent in all spinal segments and all AxSpA subgroups, suggesting that FJs can be affected early in the disease course.

Therapeutic effect of transcatheter arterial microembolization on lumbar facet joint disease in 6 cases

Therapeutic effect of transcatheter arterial microembolization on lumbar facet joint disease in 6 cases

Response to a letter by M. Slouma et al

A letter by Slouma et al highlights several important matters regarding the recently reported association of serum levels of interleukin (IL)-22 with the clinical diagnosis of axial spondyloarthritis (AxSpA).1 While the full spectrum of action and pathological significance of IL-22 has not been fully elaborated, the involvement of this cytokine in the pathogenesis of various systemic disorders has been demonstrated or suggested. Thus, the potential diagnostic utility of this test should be limited to the differentiation of AxSpA from non-inflammatory conditions, such as osteitis condensans ilii, fibromyalgia and myofascial pain, enthesopathy, facet joint disease, and diffuse idiopathic systemic hyperostosis, which were diagnosed in this study in the group of patients with an alternative to AxSpA diagnosis. We completely agree with Slouma et al that the presence of some chronic systemic disorders can cause a bias in the interpretation of the test. Thus, it is important to mention that none of the enrolled patients was diagnosed with any malignant or chronic disease with possible inflammatory pathogenesis, excluding 3 smokers with mild chronic obstructive pulmonary disease; serum levels of IL-22 were at the low end in these patients. The IL-22 levels did not depend on the presence of peripheral arthritis, uveitis, psoriasis, or inflammatory bowel disease in our study; however, the numbers of patients with the extra-spinal manifestations were too low to make statistical calculations. The total sample size of the study was also judged to be insufficient for making final recommendations on the practical utilization of IL-22 test for AxSpA diagnosis, and as it was advocated by Slouma et al, and also acknowledged in the manuscript, further prospective studies examining the diagnostic utility of IL-22 testing in patients with suspected AxSpA are warranted. The authors declare no conflict of interest.

“Not just herniated disc” back pain: Outcome of oxygen-ozone treatment in selected applications.

Low back pain and sciatica are highly debilitating conditions affecting all socioeconomic groups at an increasingly early age. They are caused by different often concomitant spinal disorders: disc or facet joint disease, spondylolisthesis (with or without listhesis), vertebral body and interapophyseal arthrosis, spinal stenosis, radicular and synovial cysts and, more rarely, infections and primary or metastatic cancer.Treatment of low back pain and/or sciatica requires an accurate diagnosis based on thorough history-taking and physical examination followed by appropriate imaging tests, namely computed tomography and/or magnetic resonance scans in addition to standard X-rays of the spine.In recent years, several reports have demonstrated the utility of oxygen-ozone therapy in reducing the size of herniated discs. The present study reports on the outcome of oxygen-ozone treatment in 416 patients with non-discogenic low back pain caused by degenerative disease of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Optimal Cut-Off Points of Sagittal Spinopelvic Parameters as a Morphological Parameter to Predict Efficiency in Nerve Block and Pulsed Radiofrequency for Lumbar Facet Joint Pain: A Retrospective Study.

BackgroundAfter proper patient selection, anatomically correct pulsed radiofrequency of the lumbar facet joints provide long-term pain relief in a routine clinical setting. In the study, we performed an analysis of clinical and radiological predictive factors and provide the scientific basis for this promising modality.MethodsThe study included 198 patients with lower back pain due to lumbar facet joint disease who underwent medial branch block and pulsed radiofrequency during the period 2015–2019. According to the improvement in pain score, the patients were divided into good and poor outcome groups. Clinical and radiological data were collected and analyzed.ResultsThe multivariable analysis revealed the predictive factors, including lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and post lumbar fusion procedures.ConclusionWith the results of this study, we demonstrated that the improved outcome after the surgery was related to lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and the lumbar fusion procedures. Old compression fractures and lumbar fusion would change the radiological factors and cause refractory lumbar facet joint pain.

Differential Diagnosis of Facet Joint Disorders.

Spinal pain due to facet joint disease is difficult to diagnose since the clinical history and physical examination findings are usually nonspecific. Facet joint disorders have a wide range of causes and, because of the potential for chronic back pain and disability, an accurate diagnosis is essential. The most frequent cause of pain in facet joints is osteoarthritis, which can be assessed at radiography, CT, or MRI. Ganglion and synovial cysts of the facet joints can cause compressive symptoms of adjacent structures, especially radiculopathy, lower back pain, and sensory or motor deficits. In ankylosing spondylitis, imaging findings of the facet joints are useful not only for diagnosis but also for monitoring structural changes. In septic arthritis of the facet joints, an early diagnosis at MRI is essential. Gout and metabolic diseases are best evaluated at dual-energy CT, which allows the depiction of crystals. Traumatic dislocations of facet joints are usually unstable injuries that require internal reduction, fixation, and fusion and can be well assessed at CT with three-dimensional reconstructions. Facet joint neoplasms like osteoid osteoma, plasmacytoma, tenosynovial giant cell tumor, and osteochondroma are best evaluated at CT or MRI. The authors provide an overview of key imaging features of the most common facet joint disorders along with anatomic tips and illustrative cases. Acknowledging key imaging findings for the differential diagnosis of facet joint disorders plays a crucial role in the diagnostic accuracy and proper treatment approach for such entities. Online supplemental material is available for this article. ©RSNA, 2021.

Application of CT Image Based on Three-Dimensional Image Segmentation Algorithm in Diagnosis of Osteoarthritis

Objective: To investigate the application of multi-slice spiral CT in degenerative changes of lumbar facet joints using the LOG algorithm. Methods: The CT findings of 100 cases of degenerative vertebral facet joint disease were reviewed and analyzed in this paper. Results: The main CT manifestations of facet disease are osteophyte formation, articular hyperplasia and hypertrophy, osteosclerosis, narrowing of joint space, articular surface destruction, joint capsule calcification, joint gas accumulation, joint subluxation, and lateral recesses and vertebrae. Signs such as narrow mesopores. Conclusion: The multi-slice spiral CT (MSCT) and multi-planar reconstruction (MPR) techniques are analyzed by the LOG operator algorithm. It is found that the two techniques can fully display the anatomical structure and pathological changes of the vertebral facet joints, and are useful for the diagnosis of facet joint disease. Provide enough imaging evidence.

External and internal responses of cervical disc arthroplasty and anterior cervical discectomy and fusion: A finite element modeling study

Surgical treatment for spinal disorders, such as cervical disc herniation and spondylosis, includes the removal of the intervertebral disc and replacement of biological or artificial materials. In the former case, bone graft is used to fill the space, and this conventional procedure is termed anterior cervical discectomy and fusion (ACDF). The latter surgery is termed as artificial disc replacement ADR) or cervical disc arthroplasty (CDA). Surgeries are most commonly performed at one or two levels. The present study was designed to determine the external (range of motion, ROM) and internal (anterior and posterior load sharing) responses of the spines with one-level and two-level surgeries in both models (ACDF and CDA) using a previously validated finite element model (FEM) of the subaxial cervical spinal column. The FEM simulated the vertebra (cancellous core and cortical shell of the body, posterior elements – laminae, pedicles and spinous processes), discs (anulus fibers, ground substance, and nucleus pulposus), anterior and posterior ligaments of the disc and facet joints, and interspinous and supraspinous ligaments. Appropriate material properties were assigned to the spinal components. The United States Food Drug Administration-approved Mobi-C was used for the CDA option. The FEM was exercised under pure flexion and extension moment loading of 2 Nm in the intact state. The overall ROM of the column was obtained. The hybrid loading protocol applied moments that matched the ROM in the intact spine for both one-level (C5–C6) and two-level (C5–C7) ACDF and CDA surgeries. ROM at the level(s) of surgery, termed the index level was obtained. These data along with anterior column load (ACL) and posterior column load (PCL) sharing were obtained for all surgical options at superior and inferior segments (termed adjacent segment outputs). Results for both one-level and two-level surgeries showed that ACDFs decreases ROM at the index level, while CDAs increase motions compared to the intact normal spine. The ROM, ACL, and PCL increased at both adjacent levels for the ACDF while CDA showed a decrease. Although two-level surgeries resulted in increased these biomechanical variables, greater changes to adjacent segment biomechanics in ACDF may accelerate adjacent segment disease. Decreased ROM and lower load sharing in CDAs may limit adjacent segment effects such as accelerated degeneration. Their increased posterior load sharing, however, may need additional attention for patients with suspected facet joint disease.

Prevalence of facet joint arthritis and its association with spinal pain in mountain population - A cross-sectional study.

Introduction:People living in the mountains are subject to tough terrain and climbing biomechanics which lead to degeneration of the spine and Facet joint arthritis (FJA).Aims:The goal of present study was (1) to know the prevalence of facet joint arthritis on CT scans in mountain population in regard to (a) different levels in spine (b) age (c) sex (2) to know if there is any significant association between FJA and spinal pain at that corresponding level.Materials and Methods:Bilateral Facet joints of 210 participants (age range, 18 to 97 years) who underwent MDCT imaging for reasons other than spinal pain, were graded and statistically analysed with SPSS software in this study. FJA was defined as at least one joint affected by facet joint disease (grade 2).Results:In our study, Seventy two men (68.5%) and eighty four women (80%) had Facet Joint arthritis. The difference between men and women in the prevalence of FJA was not statistically significant (P = 0.058). The increasing age demonstrated a higher prevalence of facet joint arthritis with statistical significance (P = 0.000). In dorsal and lumbar spine region, there was a statistically significant difference in prevalence of FJA according to spinal level. The prevalence of FJA grade 2 in cervical and dorsal spine region was associated with spinal pain in both men (P = 0.000) and women (P = 0.000). However, no statistically significant association was found between FJA grade 2 and spinal pain in lumbar spine region in both males (P = 0.680) and females (P = 0.680) as well as in total population (P = 0.513).Conclusions:People residing and actually ambulating in the mountain regions and exposed to the terrain have higher prevalence of Facet joint arthritis as compared to general population and this may be an independent risk factor for development of facet joint arthritis. However, a statistically significant relation between FJA and spinal pain exists only in cervical and dorsal spine.

Lumbar facet joint disease : Classification, clinical diagnostics, and minimally invasive treatment

The degeneration of the lumbar facet joint is amulti-factorial process that is closely linked to degeneration of the intervertebral discs and has been implicated as one of the causes of low-back pain of elderly patients in about 15 up to 40% of cases. Moreover, emerging data suggest that increased inflammatory features play an important role in the progression of lumbar facet joint disease and may serve as alink to the afferent pain nerve fibers. Since the first description in 1975 of minimally invasive treatment of lumbar facet joint disease, different techniques have been developed and used with varying results. Today, the major techniques are thermorhizotomy, cryorhizotomy, and endoscopic or percutaneous facet debridement with different anatomical targets, such as the medial branch of the dorsal ramus or facet joint capsule.

Evaluation of the Short- and Long-Term Effectiveness of Pulsed Radiofrequency and Conventional Radiofrequency Performed for Medial Branch Block in Patients with Lumbar Facet Joint Pain.

Background Diagnosis of lumbar facet joint disease is the sum of the combinations consisting of history, physical activity, and diagnostic imaging frequently including computed tomography and magnetic resonance imaging scans. Prevalence of facet-based chronic low back pain is 15–45%. Intra-articular injections with corticosteroid or medial branch block are traditionally used prevalently in the management of chronic low back pain due to lumbar facet joints. However, the evidence levels of these procedures are at either a low or a medium level. Radiofrequency neurolysis of the lumbar medial branch can be used as an alternative in the management of lumbar facet joint pain. There are two types of radiofrequency applications for radiofrequency neurolysis as pulsed radiofrequency and conventional radiofrequency. Materials and Methods Patients with lumbar facet pain were separated into 2 groups. Group 1 (n=75): patients were given pulsed radiofrequency under fluoroscopy. Group 2 (n=43): patients were given conventional radiofrequency under fluoroscopy. Pre-op and post-op 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values of all patients were asked, recorded, and statistically compared. Visual Analogue Scale values of the groups in the same months were compared as well. At the end of the second year, Odom criteria of both groups were recorded and statistically compared. Results Preoperation Visual Analogue Scale values and postoperation 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values were compared in Group 1 and Group 2, and there was a statistically significant difference between preoperation Visual Analogue Scale values and postoperation 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values in both groups. However, the number of repetitions of the operation was higher in Group 1. In the comparison of Odom criteria for both groups at the end of the second year, it was observed that the patients in Group 2 were more satisfied with the treatment. Conclusion Conventional radiofrequency in patients with lumbar facet joint pain for medial branch neurolysis effectively decreases Visual Analogue Scale values in both short and long term. The quality of life and daily activities of patients were better at conventional radiofrequency.

Real-time fusion-imaging in low back pain: a new navigation system for facet joint injections.

The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance. Sixty-five consecutive patients (34 females; mean age 68.3 ± 12.8years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1 ± 2.0months. A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively. EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.

Paravertebral injections: techniques and indications

The paravertebral injections were first referred in 1989 by Dr. Cesare Verga [1], an italian orthopedist. He used them to treat disc herniation. We call them “classical paravertebral injections”. Later on, one colleague of him, Dr. Scuccimarra [2], used longer needles to inject ozone close to the foramen, under the hypothesis of improving the results, and he succeeded. They are known as “deep paravertebral injections”. Other techniques have been developed in order to improve the results, reduce the risks and shorten the treatment.[3-9]
 
 The classical paravertebral approach is done locating the upper part of the spinous process of the superior vertebrae involved in the disco-radicular conflict and injecting 2,5 cm to the left and right of the spinous process with a 0,8 x 40 mm needle an amount of 5-10 mL per point depending on the size of the patient. Some authors(63) have proved that using lower ozone concentration (10 µg/mL) can be as useful as standard concentration (20 µg/mL). Our advice is to use a 0,4 x 40 mm needle or thinner if available. Local, topic anesthesia or cryotherapy can be used to reduce the pain of the needle. Injection should be done slowly. Using local anesthesia in the muscle can reduce the effect of ozone injection. The “deep paravertebral injection” uses a similar procedure, but the distance from the middle line is narrower (1,5 cm for cervical and dorsal injection and 2 cm for lumbar injection) and it is necessary using longer needles (0,4 or 0,5 x 90 mm spinal needle) to be able to locate the posterior joints with the tip of the needle an inject periarticularly. The amount of ozone used is the same.
 
 It is also possible to inject over the laminae, close to the foramen, instead of around the facet joints, but risk of accidental dura or radicular puncture is greater (although without permanent side effects); this can be done for nerve root de-inflammation. Dr Verga modified his technique for cervical and dorsal disc herniation, narrowing the distance from the spinous process to 1,5 cm left and right, using shorter needles (25 or 30 mm) and decreasing the ozone volume per point to 3-7 mL. Dorsal approach uses the same technique as for cervical paravertebral injections.
 
 The classical paravertebral injection produce a relaxation in the muscle spam of the lumbar spine in low back pain. The deep paravertebral injection produce an anti-inflammatory effect that can reduce inflammation on the facet joint or nerve root, depending on the point of injection.
 
 Based on this empirical approach, and the publications that have already used them , the indications of these injections are:
 
 -Disc herniation [1-2]
 -Spondylolysis [10]
 -Spondylosis [11-14]
 -Lumbar spinal stenosis [7, 15]
 -Symptomatic treatment of facet joint disease [7]
 -Mechanical low back pain
 
 These injections may have side effects due to the technique itself, not the ozone, but we have few reports on anecdotal cases, most of them without aftermath.

Cervical facet force analysis after disc replacement versus fusion

BackgroundCervical total disc replacement was developed to preserve motion and reduce adjacent-level degeneration relative to fusion, yet concerns remain that total disc replacement will lead to altered facet joint loading and long-term facet joint arthrosis. This study is intended to evaluate changes in facet contact force, pressure and surface area at the treated and superior adjacent levels before and after discectomy, disc replacement, and fusion. MethodsTen fresh-frozen human cadaveric cervical spines were potted from C2 to C7 with pressure sensors placed into the facet joints of C3–C4 and C4–C5 via slits in the facet capsules. Moments were applied to the specimens to produce axial rotation, lateral bending and extension. Facet contact force and pressure were measured at both levels for intact, discectomy at C4–C5, disc replacement with ProDisc-C (Synthes Spine, West Chester, Pennsylvania, USA) at C4–C5, and anterior discectomy and fusion with Cervical Spine Locking Plate (Synthes Spine, West Chester, Pennsylvania, USA) at C4–C5. Facet contact area was calculated from the force and pressure measurements. An analysis of variance was used to determine significant differences with P-values <0.05 indicating significance. FindingsFacet contact force was elevated at the treated level under extension following both discectomy and disc replacement, while facet contact pressure and area were relatively unchanged. Facet contact force and area were decreased at the treated level following fusion for all three loading conditions. InterpretationTotal disc replacement preserved facet contact force for all scenarios except extension at the treated level, highlighting the importance of the anterior disco-ligamentous complex. This could promote treated-level facet joint disease.

In vivo feasibility of real-time MR-US fusion imaging lumbar facet joint injections.

Traditionally, facet joint injections (FJI) are performed under fluoroscopic or computed tomography (CT) guidance, mainly due to the deep anatomical location and the presence of bony landmarks. Fusion imaging technology, which couples the ultrasound scan with the corresponding CT or magnetic resonance (MR) image obtained from the diagnostic examination and reformatted in real time according to the ultrasound scanning plane, allows to combine the panoramic view and the elevated anatomical detail of MR or CT with the ease of use of ultrasound without patient exposure to ionizing radiation. Thirty eight patients (24 females; mean age±SD: 64±9years) received MR fusion-assisted ultrasound-guided FJI of 1ml of a mixture of local anaesthetic and corticosteroid using a ultrasound machine (Logiq E9, GE Healthcare) equipped with a GPS-enhanced fusion imaging technology which couples real-time B-mode images with those of the previous recent diagnostic MR examination. Low-dose CT needle positioning confirmation was performed in the first 28 patients. Patients' pain was recorded using a visual analogue scale (VAS), at baseline and at 2, 4 and 8weeks. All fusion imaging-guided injections were performed successfully. Out of 112, 96 FJI had optimal intra-articular needle positioning (accuracy: 85.7%). Patients VAS significantly decreases after the procedure with no differences among who received CT needle positioning control and who did not receive it. No major complications were observed. Ultrasound needle guidance with MR fusion assistance allows for safe and effective injection of degenerative facet joint disease.