Facet Joint Pain Research Articles

Ultrasound-guided cervical facet joint injections

Cervical facet joints are a common cause of chronic neck pain. Radiofrequency neurotomy is a validated treatment technique for cervical facet joint pain, but the role of intra-articular injections is less clear. Ultrasound guidance can be used to inject the cervical facet joints. Given that the accuracy of any injection technique is likely to affect treatment outcomes, it would be useful to know the accuracy of ultrasound-guided cervical facet joint injections. The primary purpose of this study was to determine the accuracy of ultrasound-guided cervical facet joint injections using a lateral technique. The secondary purpose was to describe the technique. Cohort study of ultrasound-guided cervical facet joint injections performed by an experienced spine and ultrasound interventionist, as assessed by contrast dye arthrography at a community interventional spine practice. Sixty joints in 36 patients with facet mediated pain. Accuracy of ultrasound-guided injections as determined by the percent of fluoroscopic contrast dye patterns interpreted to be intra-articular by the operator and an independent imaging specialist. Confidence intervals were determined using binomial "exact" and normal approximation to the binomial calculations. Ultrasound using a long-axis or in-plane approach was used to guide a needle into a facet joint, followed by injection of contrast dye and a lateral fluoroscopic image. The dye pattern was interpreted by the operator. Depending on the pattern, local anesthetic and corticosteroid were injected. The patient was asked whether their neck pain had resolved. If not resolved, another joint was selected and the process was repeated. At the end of the study, all of the contrast patterns were interpreted independently by the imaging specialist. Funding was through a 501(c)(3) foundation without any commercial or sponsorship interests. The accuracy of ultrasound-guided cervical facet joint injections using the lateral technique ranged from 92% to 98% depending on the criteria used to confirm an intra-articular contrast pattern (95% CI: 0.82-0.97 to 0.91-1.0, and 0.85-0.99 to 0.95-1.00). The distribution of injections was C2-3 (22%), C3-4 (40%), C4-5 (33%) and C5-6 (5%). Cervical facet joint injections can be performed with a high degree of accuracy using a lateral ultrasound-guided technique. As with fluoroscopy-guided cervical facet joint injections, the technique requires a careful approach and a high degree of skill.

How I do it? Full endoscopic lumbar rhizotomy for chronic facet joint pain due to failed back surgery syndrome

Failed back surgery syndrome (FBSS) is a general term for persistent postoperative back pain with or without accompanying radicular pain. FBSS may present as chronic facet joint pain. We introduced full endoscopic lumbar rhizotomy for patients suffering from facet joint pain due to FBSS. Facet joint block was introduced into the facet joint to determine whether pain improved after the injection. With full endoscopic lumbar rhizotomy, the surgeon can identify the regions involved more clearly and directly. Although it is an invasive procedure, it provides a more effective and safe treatment for patients with FBSS-related facet joint pain.

Comparison of two different treatment methods in the approach to facet (Zygapophyseal) joint pain

Low back pain has been recorded as the second most common pathology in adults. Irregularities in the zygapophyseal joints constitute one of the most well-known pathologies in this type of pain. Medial branch blocks and intra-articular injections have been used for the treatment. Local corticosteroid injections are also reliable for the treatment of low back pain. This study aims to compare the efficiency, in terms of low back pain palliation, of “intra-articular injection of local anesthetic and steroid drug combination” and “oral pain reliever and muscle relaxant combination” in the treatment of diagnosed non-discogenic low back pain. After Ethics Committee aproval 96 patients who had applied to outpatient clinic with low back pain complaints and were then treated for the diagnosis of facet joint pain between 2016 June -2019 June were examined. This retrospective study included 80 patients whose records were properly recorded and followed up in the scope of this one-center. Patients were classified into two groups; those given oral pain killers and muscle relaxants (n=40) and those who injected steroids and local anesthetics into the lumbar facet joint (n=40). Pain scores significantly decreased in both groups. When the low back pain is not discogenic, the patient should be subjected to further examination, and pain treatment should be started since this painful condition results in severe labor loss in society. We suggest that oral treatment or combined injections of steroids and local anesthetics for the cases, whose low back pain is determined to originate from the lumbar facet joint, will be very effective in therapeutic pain relief.

The effect of consecutive facet medial branch radiofrequency denervation and dorsal root ganglion pulse radiofrequency therapy on lumbar facet joint pain.

The aim of this study was to evaluate the efficacy of consecutive facet medial branch (FMB) radiofrequency denervation (RFD) and dorsal root ganglion pulse radiofrequency (DRG PRF) therapy in patients with chronic lumbar facet joint pain. The study included 27 patients with chronic lumbar pain who had ≥50% pain reduction after FMB block for suspected lumbar facet syndrome and subsequently underwent FMB RFD together with PRF to the adjacent DRG. The patients were retrospectively analyzed in terms of age, gender, pre-procedure symptom duration, history of previous back surgery, FMB RFD and DRG PRF level and side, and numerical rating scale scores immediately before and at 1, 3, and 6 months after the procedure, and subjective pain reduction at 6 months post-treatment. Treatment success was defined as ≥50% subjective pain reduction at 6 months. A total of 19 women and 8 men with a mean age of 57.7±12.4 years were analyzed. Twenty patients (74.1%) had no prior history of low back surgery. The success rate of the procedure in terms of subjective pain reduction at 6 months was 82.5% (n=25). The subjective percentage of pain reduction at post-procedure 6 months was significantly lower in patients with a pre-procedure symptom duration of 12 months or longer compared to those whose pre-procedure symptom duration was <12 months (p=0.04). Our study results show that the analgesic efficiency of DRG PRF added to FMD RFD treatment can be increased in patients with short symptom durations.

Results of Fluoroscopy-guided Medial Branch Block for the Treatment of Lower Lumbar Facet Joint Pain: 2-year Follow-up

Results of Fluoroscopy-guided Medial Branch Block for the Treatment of Lower Lumbar Facet Joint Pain: 2-year Follow-up

Cooled-radiofrequency neurotomy for the treatment of chronic lumbar facet (zygapophyseal) joint pain: A retrospective study.

Cooled-radiofrequency (CRFA) is a newer technique and may have some theoretical advantages over traditional radiofrequency ablation (TRFA). In this study, we aimed to investigate the efficacy and safety of CRFA for the treatment of lumbar facet joint-mediated pain. In this retrospective study, we evaluated 185 CRFA performed on 105 patients. All patients with axial lower back who received the preliminary diagnosis of lumbar facet joint-mediated pain and refractory to conservative therapy underwent diagnostic medial branch blocks. CRFA was recommended to those patients who responded favorably to two sets of diagnostic medial branch blocks. Pain scores in numeric rating scale (NRS) were recorded pre-treatment and post-treatment at different time-points. The primary outcome measure was to report descriptive NRS score and average % improvement from baseline at each time point. A significant pain relief was determined by a decrease of ≥50% of mean NRS. Secondary outcome measure was the time to repeat treatment with subsequent CRFA. Adverse events were also recorded.Primary outcome measure determined as the improvement in NRS, for at least 50% or more, was achieved in both 1st (4–8 weeks) and 2nd (>2–6 months) follow-up (FU) with 60.5% and 53.6% reduction in NRS respectively. Our subgroup analysis comparing the younger (<50) and older (≥50) age groups showed superior pain relief with CRFA in the older (≥50) age group, both in the 1st (4–8 weeks) and 2nd (>2–6 months) FU time points (63.4% and 58.4% reduction in NRS, respectively). Cooled-radiofrequency ablation is an effective and safe procedure for the treatment of chronic lumbar facet joint related pain. The duration of pain relief was comparable to traditional radiofrequency ablation as reported in the literature.

Single Entry Posterior Parasagittal Approach Radiofrequency Neurotomy of Cervical Medial Branch: A Feasible Alternative to Conventional Approaches in the Treatment of Cervical Facet Pain.

Cervical facet joint pain is an important cause of chronic neck pain. The recommended treatment for this condition is radiofrequency (RF) neurotomy of the medial branch of dorsal rami. There have been attempts to find safe and effective ways to perform this procedure. The objective of this study is to describe the single entry posterior parasagittal approach and to evaluate the efficacy and safety of this approach compared to the conventional posterolateral approach of RF neurotomy of cervical medial branch. The record of all patients with cervical facet pain who were treated with RF neurotomy medial branch of dorsal rami between January 2016 and December 2019 were reviewed retrospectively. Comparisons were made between patients who underwent RF neurotomy with multiple skin entry posterolateral approach and those who underwent RF neurotomy with single entry posterior parasagittal approach. The primary outcome was measured as the mean changes in numerical rating scale (NRS), and the secondary outcomes were duration and complications related to both approaches. Thirty-one patients who underwent RF neurotomy via posterolateral approach were compared with 40 patients who underwent the procedure via posterior parasagittal approach. Both approaches showed a significant decrease in the NRS from baseline values. However, the differences in the NRS lowering effect at 3 and 12 months between these 2 approaches were not statistically significant. The duration of the procedure was significantly shorter with posterior parasagittal approach (44.13 ± 4.72 minutes vs 54.68 ± 7.39 minutes; P < 0.001). There were no serious complications encountered in both approaches. With comparable efficacy and safety profile between the posterior parasagittal and the conventional posterolateral approaches, the former single skin entry approach offers the added advantage of being less time-consuming. Further randomized prospective studies are necessary to validate these findings.

A History of the Development of Radiofrequency Neurotomy.

The technique of lumbar medial branch radiofrequency neurotomy for facet joint pain has an intriguing history involving a diverse timeline of medical specialists. This paper aims to chart the pathway that led to its invention and the series of modifications and refinements that have led to modern practice. The story begins with the treatment of World War I soldiers by Nesfield, who used scalpels to cut “trapped” nerves. Inspired by Nesfield’s treatment, Rees developed the “percutaneous rhizolysis” technique in 1960. Shealy was the first to use radiofrequency electrodes for denervation of the facet joints, introducing his technique in 1971. Several radiofrequency electrode developments came about from collaborations with Cosman medical device entrepreneurs during the 1970s, including the Shealy Rhizolysis Kit, the Ray Rhizotomy Electrode, and the Sluijter-Mehta Kit. Subsequent dissections of Rees’ technique and modification of Shealy’s procedure by Bogduk saw the development of “percutaneous lumbar medial branch neurotomy” in 1980 by Bogduk and Long. Bogduk continued to contribute significantly to validation, refinement and acceptance of the technique. In 1998, the technique of pulsed radiofrequency was invented by Sluijter, Cosman, Rittman and van Kleef. Subsequent innovations have consisted of cooled radiofrequency neurotomy, multi-tined cannulae, endoscopic systems, and alternative denervation targets, such as the facet joint capsule. As we pass the first 100 years of the story, we believe there are more chapters to be written on this fascinating subject.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group.

BackgroundThe past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.MethodsIn August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.ResultsTwenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.ConclusionsCervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BackgroundThe past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet...

Facet Joint Injections for the Management of Low Back Pain: A Clinical Review

Introduction: Lumbar facet joints have been implicated in chronic low back pain (LBP) in up to 45% of patients with LBP. Facet joint pain (FJP) diagnosis and management are always challenging for pain physicians. FJP is not diagnosed by specific demographic features, pain characteristics, or physical findings, despite the electrodiagnostic studies and imaging modalities being available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature.&#x0D; Methodology: A randomized, controlled clinical trial was conducted to evaluate the effectiveness of lumbar facet joint injections. A total of 229 participants were enrolled to receive facet injections with bupivacaine and steroid, medial branch blocks, or saline.&#x0D; Result: The results of this study showed that facet joint injections had little long-term therapeutic utility, but had a prognostic value compared to control injections before radiofrequency ablation. Thus, the results of this study emphasized the diagnostic value of facet joint injections.&#x0D; Conclusion: FJP is not diagnosed by demographic features, pain characteristics, physical findings, electrodiagnostic studies, or radiological evaluation as other types of LBP. Diagnostic blocks using comparative local anesthetic blocks or placebo injections are the only reliable diagnostic measures according to the current literature. Their validity, specificity, and sensitivity are considered reliable in the diagnosis of FJP. Facet joint-related anatomical, clinical, and technical knowledge is essential for successful pain management. Pain physicians should embrace all aspects of FJP management, from diagnosis to interventional management.

Clonazepam for pain due to muscle spasm in a patient with vertebral compression fractures caused by multiple myeloma: a case report

BackgroundVertebral compression fractures can cause severe back pain. Although many types of analgesics and interventional treatments are available, they are sometimes ineffective in mitigating the pain. We encountered a case where clonazepam was effective for the management of severe low back pain caused by lumbar vertebral compression fractures.Case presentationA 44-year-old male was diagnosed with multiple myeloma and had vertebral compression fractures of the first and second lumbar vertebrae. He had been suffering from severe low back pain on movement with muscle spasm and pain-associated anxiety. We considered this breakthrough low back pain to be caused by facet joint pain; thus, we prescribed clonazepam as a muscle relaxant and anxiolytic. Following this treatment, the intractable breakthrough pain was dramatically relieved.ConclusionClonazepam, which has both muscle relaxant and anxiolytic effects, might be helpful in mitigating pain, associated anxiety, and muscle spasms due to vertebral compression fractures.

A New Strategy for Rapid Diagnosis of the Source of Low Back Pain in Patients Scheduled to Undergo Treatment with Cooled Radiofrequency Ablation.

Objective: The objective of this study was to develop a new strategy for rapid diagnosis of the source of low back pain (LBP) for treatment with cooled radiofrequency ablation (RFA). Materials: Patients suffering from facet joint (FJ) or sacroiliac joint (SIJ) pain for more than 3 months were included. Two methods, Technetium Tc99m methylene diphosphonate single photon emission tomography/computed tomography (99mTc-MDP SPECT/CT) and a modified Fortin finger test were used to identify the source of LBP for treatment with cooled RFA. The visual analog scale (VAS) and Oswestry disability index (ODI) were used to assess the patients’ pain levels and disabilities respectively. These two measures were recorded at baseline and 1-week, 1-month, 3-month, and 6-month follow-up visits. Results: A total of 40 patients with LBP were included in this study. Our results demonstrated that the patients with LBP identified by our new strategy had significant improvements in VAS or ODI score at 1-week to 6-month follow-up visits (p < 0.001) after receiving cooled RFA. Similar results were also found in patients with FJ pain and those with FJ and SIJ pain respectively. Among all the patients, over 70% had greater than or equal to 50% reduction in VAS and ODI scores. No serious adverse events were observed after treatment. Conclusions: This new strategy could be successfully adopted for rapid diagnosis of the source of comprehensive LBP.

MR-guided lumbar facet radiofrequency denervation for treatment of patients with chronic low back pain in an open 1.0 Tesla MRI system.

BackgroundTo evaluate the feasibility, safety and efficacy of magnetic resonance imaging (MRI)-guided lumbar facet joint radiofrequency denervation (FRD) in patients with chronic low back pain.MethodsThe study consisted of two parts. First, a preclinical analysis using an ex vivo animal model was performed to define optimal technical parameters for ablation. Then, 17 patients with chronic lumbar facet joint pain syndrome were prospectively included and underwent MRI-guided FRD in an open 1.0-Tesla MRI. We analyzed technical feasibility and complications as well as clinical outcome in terms of subjective pain assessed on a numerical visual analogue scale (VAS) before and after 1 week/6 months after FRD. Clinical assessment was complemented by measurement of paravertebral muscle volume and fat content before the intervention and at 6-month follow-up.ResultsAll interventions were technically successful without major complications. Initial VAS scores (median: 8, IQR: 1, range: 6–9, CI: 7.14–8.04) decreased significantly both after one week (median: 4, IQR: 5, range: 0–7, CI: 1.9–4.69, P=0.003) and after 6 months (median: 1, IQR: 6, range: 0–7, CI: 1.06–4.23, P<0.001). Mean multifidus muscle volume increased significantly in the patient population (from 366.8±130.8 cm3 before to 435.4±146.7 cm3 after FRD, P=0.031).ConclusionsThis proof of principle study shows MRI-guided FRD in an open 1.0-Tesla MRI system to be a potential therapy option for patients with chronic low back pain.

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.

Cryoneurolysis\u2019 outcome on pain experience (COPE) in patients with low-back pain: study protocol for a single-blinded randomized controlled trial

BackgroundLow-back pain, including facet joint pain, accounts for up to 20 % of all sick leaves in DenmarkA proposed treatment option is cryoneurolysis. This study aims to investigate the effect of cryoneurolysis in lumbar facet joint pain syndrome.Methods A single-center randomized controlled trial (RCT) is performed including 120 participants with chronic facet joint pain syndrome, referred to the Department of Neurosurgery, Aarhus University Hospital. Eligible patients receive a diagnostic anesthetic block, where a reduction of pain intensity ≥ 50 % on a numerical rating scale (NRS) is required to be enrolled. Participants are randomized into three groups to undergo either one treatment of cryoneurolysis, radiofrequency ablation or placebo. Fluoroscopy and sensory stimulation is used to identify the intended target nerve prior to administrating the above-mentioned treatments. All groups receive physiotherapy for 6 weeks, starting 4 weeks after treatment. The primary outcome is the patients’ impression of change in pain after intervention (Patient Global Impression of Change (PGIC)) at 4 weeks follow-up, prior to physiotherapy. Secondary outcomes are a reduction in low-back pain intensity (numeric rating scale) and quality of life (EQ-5D, SF-36) and level of function (Oswestry Disability Index), psychological perception of pain (Pain Catastrophizing Scale) and depression status (Major Depression Inventory).Data will be assessed at baseline (T0), randomization (T1), day one (T2), 4 weeks (T3), 3 (T4), 6 (T5) and 12 months (T6).DiscussionThis study will provide information on the effectiveness of cryoneurolysis vs. the effectiveness of radiofrequency ablation or placebo for patients with facet joint pain, and help to establish whether cryoneurolysis should be implemented in clinical practice for this patient population.Trial registrationThe trial is approved by the ethical committee of Central Jutland Denmark with registration number 1-10-72-27-19 and the Danish Data Protection Agency with registration number 666,852. The study is registered at Clinicaltrial.gov with the ID number NCT04786145.

The Diagnostic Value of an X-ray-based Scoring System for Degeneration of the Cervical Spine: A Reproducibility and Validation Study.

BackgroundIn interventional pain medicine, cervical facet joint (CFJ) pain is commonly treated with CFJ denervation techniques, almost automatically assuming degeneration of the CFJs as an important cause of CFJ pain. A standard cervical X‐ray is still commonly used in the clinical evaluation of patients suspected for CFJ degeneration. Although degenerative features can be visualized by different radiological imaging techniques, the relation between radiological degenerative features of the cervical spine and pain remains controversial. Paramount in order to estimate the clinical usefulness of a radiological imaging is to establish the reproducibility of the radiological scoring system. A reproducible and clinically feasible diagnostic scoring system was developed to estimate cervical degeneration on standard cervical X‐rays.Materials and MethodsA reproducibility study for the interpretation of degenerative abnormalities on standard cervical X‐rays was performed, using a dichotomous outcome (degenerative abnormalities present Yes/No). The estimation of intervertebral disc height loss on standard cervical X‐rays was validated with computed tomography (CT) scan measurements.ResultsFive radiological degenerative features on standard cervical X‐rays (disc height loss, anterior vertebral osteophytes, posterior vertebral osteophytes, vertebral end plate sclerosis, and uncovertebral osteoarthritis) showed a substantial to excellent reproducibility (kappa value ≥ 0.60). The qualitative definition of disc height loss used in the reproducibility study showed a substantial agreement with the actual measurements of disc height loss on CT scan (kappa value = 0.69).ConclusionSubjective judgment of a cervical standard X‐ray is a reproducible method to demonstrate degenerative abnormalities of the cervical spine.

Development and Description of a New Multifidus-Sparing Radiofrequency Neurotomy Technique for Facet Joint Pain.

The technique of radiofrequency neurotomy (RFN) of the facet joints has been used for decades to treat persistent low back pain to good effect in carefully selected patients. Traditionally, the target is the medial branches of the dorsal root supplying the facet joint. An alternative denervation target is the facet joint capsule. Capsule-targeting techniques may spare the multifidus muscle, a possible unintended target of traditional RFN that is thought to be important in recovering from low back pain, and have shown promising results. A modified RFN technique that targets the capsule and spares the multifidus (multifidus-sparing RFN) is described here, along with a brief report of its application in patients with symptomatic facet joint low back pain as compared to traditional medial branch RFN (MBRF). Over a 2-year period, a total of 401 initial multifidus-sparing RFN and 94 initial MBRF procedures were performed on patients attending a multidisciplinary pain clinic. The proportion of repeat procedures was similar: 28.4% of multifidus-sparing procedures and 23.4% of MBRF procedures. The median repeat interval was 12months for both groups and interquartile range was 10 months (8-18 months) for multifidus-sparing RFN and 4 months (11-15 months) for MBRF. Effectiveness and safety profiles appear to be similar, although limited, retrospective outcome information prevented robust analysis. Multifidus-sparing RFN represents an intriguing technique to denervate the facet joint pain generator while maintaining normal multifidus function. Further study is warranted, particularly in order to identify the appropriate patient criteria and long-term outcomes.

The clinical ability of contrast-enhanced magnetic resonance imaging to predict treatment outcomes for lumbar facet joint pain.

Several radiologic imaging techniques have been used to predict the effects of treatment on lumbar facet joint (LFJ) pain. However, there are no reports on the use of contrast-enhanced magnetic resonance imaging (MRI) in the management of LFJ pain. In the current study, we aimed to evaluate the clinical ability of contrast-enhanced MRI to predict treatment outcomes for LFJ pain. A total of 26 patients with LFJ pain were recruited and intraarticular (IA) corticosteroid injections were administered to each patient. We assessed the treatment outcomes using a numerical rating scale (NRS), and two radiologists independently investigated LFJ enhancement and osteoarthritis grading. No serious complications or adverse events were reported. IA corticosteroid injections were administered to 26 patients (12 women and 14 men; mean age: 65.19±11.05 years) with LFJ pain. Among the 26 patients, 16 patients were included in the facet joints with enhancement group, and the remaining 10 patients were included in the facet joints with non-enhancement group, based on contrast-enhanced MRI scans. In both the enhancement and non-enhancement groups, NRS scores significantly decreased at 1, 2, and 3 months after treatment (P<0.05). However, we saw no significant difference between the groups from pretreatment to three months after treatment (P>0.05). The routine use of contrast-enhanced MRI is not recommended in patients with LFJ pain.

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.