Intra-articular Facet Joint Research Articles

Accuracy of Percutaneous Pedicle Screw Placement: Does Training Level Matter?

In vitro human cadaveric surgical technique study. To assess the accuracy of percutaneous pedicle screw placement in a human cadaveric model using standard fluoroscopic guidance technique, compared across varying levels of experience. The current literature varies widely in the reported frequency of facet violation during placement of percutaneous pedicle screws. However, as of yet there are no studies examining the effect that training level has on accuracy of placement. Four surgeons with differing levels of training (PGY-2, PGY-4, fellow, attending) were evaluated on their accuracy of percutaneous placement of screws in a uniform manner. Each of the 10 cadavers was instrumented from L1 to S1 bilaterally, for a total of 120 screws. Specimens were dissected to evaluate for facet and pedicle wall violations. These were then recorded and analyzed to evaluate for correlation among participating surgeons, laterality, spinal level, and cadaver body mass index. Of 120 screws placed, there were 35 total violations [26 superior articular facet violations (21.7%), 5 intra-articular facet joint violations (4.2%), and 4 pedicle breaches (3.3%)]. Among the trainees there was no difference in the likelihood of causing a violation (P=0.8863) but there was a difference when compared with the attending surgeon (P=0.0175). Laterality (P=0.1598), spinal level (P=0.3536), and body mass index (P=0.8547) did not correlate with the likelihood of a violation. Surgeons of differing training levels are able to safely and accurately place lumbar pedicle screws in a percutaneous manner, with a low likelihood of facet and pedicle wall violations.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial.

The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. Five NHS acute trusts in England. Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. Poor recruitment was a limiting factor. This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. Further work is needed to test recruitment from alternative clinical situations. EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Intra-articular facet joint injections for low back pain: a systematic review.

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. 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. 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. 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.

Does therapist's attitude affect clinical outcome of lumbar facet joint injections?

To investigate if the clinical outcome of intra-articular lumbar facet joint injections is affected by the therapist's attitude. A total of 40 patients with facet joint-associated chronic low back pain were randomly divided into two groups. All patients received computed tomography-guided, monosegmental intra-articular facet joint injections. Following the therapeutic procedure, the patients of the experimental group (EG) held a conversation with the radiologist in a comfortable atmosphere. During the dialog, the patients were encouraged to ask questions and were shown four images. The patients of the control group (CG) left the clinic without any further contact with the radiologist. Outcome was assessed using a pain-based Verbal Numeric Scale at baseline, at 1 wk and at 1, 3, and 6 mo after first treatment. The patient demographics showed no differences between the groups. The patients of the EG received 57 interventional procedures in total, while the patients of the CG received 70 interventional procedures. In both groups, the pain scores decreased significantly over the entire observation period. Compared to the CG, the EG showed a statistically significant reduction of pain at 1 wk and 1 mo post-treatment, while at 3 and 6 mo after treatment, there were no significant differences between both groups. Our results show a significant effect on pain relief during the early post-interventional period in the EG as compared to the CG. The basic principle behind the higher efficacy might be the phenomenon of hetero-suggestion.

Management of lumbar zygapophysial (facet) joint pain.

To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain. The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V. Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only. This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Facet-joint injections for people with persistent non-specific low back pain (FIS): study protocol for a randomised controlled feasibility trial.

BackgroundThe role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin.Methods/DesignWe present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses.Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0–10 scale. Questionnaire follow-up will be at 3, 6, and 12 months.Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders.DiscussionWhilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain.Trial registrationEudraCT identifier 2014-000682-50, (registered on 12 February 14). ISRCTN registry number: ISRCTN93184143 DOI 10.1186/ISRCTN93184143 (registered on 27 February 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1117-z) contains supplementary material, which is available to authorized users.

Intraarticular Facet Injections for Low Back Pain: Design Considerations, Consensus Methodology to Develop the Protocol for a Randomized Controlled Trial

Background: Since the publication of guidelines by the UK National Institute for Health and Care Excellence (NICE) and the American Pain Society guidelines for low back pain in 2009 there have been deep divisions in the pain treatment community about the use of therapeutic intraarticular facet joint injections. While evidence for the effectiveness or not of intraarticular facet joint injections remains sparse, uncertainty will remain. The Warwick feasibility study, along with a concurrent study with a different design led by another group, aims to provide a stable platform from which the effectiveness and cost effectiveness of intraarticular facet joint injections added to normal care could be evaluated in randomized controlled trials (RCTs). Objectives: To reach consensus on key design considerations for the Warwick facet feasibility study from which the study protocol and working manuals will be developed. Study Design: A consensus conference involving expert professionals and lay members. Methods: Preliminary work identified 5 key design considerations for deliberation at our consensus conference. Three concerned patient assessment and treatment: diagnosis of possible facet joint pain, interaarticular facet joint injection technique, and best usual care. Two concerned trial analysis: a priori sub-groups and minimally important difference and are reported elsewhere. We did systematic evidence reviews of the design considerations and summarized the evidence. Our design questions and evidence summaries were distributed to all delegates. This formed the basis for discussions on the day. Clinical experts in all aspects of facet joint injection from across the UK along with lay people were invited via relevant organizations. Nominal group technique was used in 15 facilitated initial small group discussions. Further discussion and ranking was undertaken in plenary. All small group and plenary results were recorded and checked and verified post conference. Where necessary participants were contacted via email to resolve outstanding issues. Results: Fifty-two delegates attended the conference with lay people and all relevant professions represented. Consensus was reached on the details of how to assess patients for facet joint pain, undertake the injections, and deliver usual care. Where post conference checking of results revealed errors in calculating ranking results on the day, consensus was reached by email consultation. All but 3 delegates agreed to be associated with the outcome. Limitations: Allocating one day for discussing a wide range of topics imposed time pressure on discussion and calculation of the numerous rankings. Conclusions: Through the use of an evidence-based, systematic, inclusive, and transparent process we have established consensus from expert health professionals in the UK, with lay input, on the clinical assessment of suspected facet joint pain, interaarticular injection for facet joint pain, and best usual care for use in a feasibility study for a proposed pragmatic clinical trial of interaarticular facet joint injections. This provides a strong basis for a clinical trial that will be acceptable to the pain treatment community. Key words: Low back pain, interaarticular facet joint injections, best usual care, consensus, nominal group technique

Pain from intra-articular NGF or joint injury in the rat requires contributions from peptidergic joint afferents

Non-physiological stretch of the cervical facet joint’s capsular ligament induces persistent behavioral hypersensitivity and spinal neuronal hyperexcitability via an intra-articular NGF-dependent mechanism. Although that ligament is innervated by nociceptors, it is unknown if a subpopulation is exclusively responsible for the behavioral and spinal neuronal responses to intra-articular NGF and/or facet joint injury. This study ablated joint afferents using the neurotoxin saporin targeted to neurons involved in either peptidergic ([Sar9,Met (O2)11]-substance P-saporin (SSP-Sap)) or non-peptidergic (isolectin B4-saporin (IB4-Sap)) signaling to investigate the contributions of those neuronal populations to facet-mediated pain. SSP-Sap, but not IB4-Sap, injected into the bilateral C6/C7 facet joints 14 days prior to an intra- articular NGF injection prevents NGF-induced mechanical and thermal hypersensitivity in the forepaws. Similarly, only SSP- Sap prevents the increase in mechanical forepaw stimulation- induced firing of spinal neurons after intra-articular NGF. In addition, intra-articular SSP-Sap prevents both behavioral hypersensitivity and upregulation of NGF in the dorsal root ganglion after a facet joint distraction that normally induces pain. These findings collectively suggest that disruption of peptidergic signaling within the joint may be a potential treatment for facet pain, as well as other painful joint conditions associated with elevated NGF, such as osteoarthritis.

A Systematic Review and Best Evidence Synthesis of Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain

Background: The therapeutic spinal facet joint interventions generally used for the treatment of axial spinal pain of facet joint origin are intraarticular facet joint injections, facet joint nerve blocks, and radiofrequency neurotomy. Despite interventional procedures being common as treatment strategies for facet joint pathology, there is a paucity of literature investigating these therapeutic approaches. Systematic reviews assessing the effectiveness of various therapeutic facet joint interventions have shown there to be variable evidence based on the region and the modality of treatment utilized. Overall, the evidence ranges from limited to moderate. Objective: To evaluate and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain. Study Design: A systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain. Methods: The available literature on lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM – QRB) for randomized trials and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM – QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake consumption. Results: A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement. Limitations: The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections. Conclusion: Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy. Key Words: Spinal pain, chronic low back pain, chronic neck pain, chronic thoracic pain, intraarticular facet joint blocks, facet joint nerve blocks, conventional radiofrequency neurotomy, pulsed radiofrequency neurolysis

Imaging- Guided Facet Joint Injection Technique for Lower Back Pain Management

Objectives: This study aimed to evaluate the role of image-guided lumbar facet joint injection in lower back pain. Background: With the increased lifetime prevalence of spinal pain and the realization by surgeons that not all backache is a ‘disc’ and not all patients with LBP will respond to surgery, there is increasing awareness of the role of percutaneous injection techniques in the nonoperative management of chronic LBP. The use of image-guidance with fluoroscopy or CT scan has increased the precision and safety of these procedures. Methods: Fifty patients with chronic LBP of more than 3 months' duration were selected for facet joint infiltration. Facet joint injections were carried out under fluoroscopic guidance in 38 patients and under CT guidance in 12 cases. Pain relief was assessed using the visual analog scale at 4, 12, and 24 weeks post-procedure. These results were compared to a control group (n=25) which were subjected to medical treatment. Results: A total of 146 facet joints were infiltrated in 50 patients over a 2-year period. There was significant pain relief in 88% after 4 weeks, in 92% after 12 weeks, and in 64% after 24 weeks. No major complications were encountered. The control group which was subjected to medical treatment showed pain relief in 40% after 4 weeks, in 32% after 12 weeks, and in 28% after 24 weeks with less pain relief in comparison to the injected group. Conclusion: With intraarticular facet joint injections, the evidence for short- and medium-term pain relief is successful for lumbar pain in comparison to medical treatment. Facet nerve block was found to be a simple, minimally invasive, and safe procedure. With precise patient selection, we achieved long-term success rates of over 60% after 24 weeks. We conclude that this method represents an important alternative treatment for nonradicular back pain.

Fluoroscopy-Guided Intra-Articular Facet Joint Steroid Injection for the Management of Low Back Pain: Therapeutic Effectiveness and Arthrographic Pattern

Facet joint pain is defined in a functional capacity as pain originating from a facet joint, and is a common cause of low back pain, with a prevalence rate ranging from 15% to 52% (1-4). Clinical symptoms and radiological findings related to facet joint syndrome are unreliable for the diagnosis of facet joint pain, so that the diagnosis “facet joint syndrome” is made clinically and by excluding other causes of low back pain (5, 6). Facet joint pain can be managed by nonsurgical interventions, including intra-articular facet joint steroid injections, medial branch blocks, neurolysis of medial branch nerves, and radiofrequency denervation of medial branch nerves. Of these interventions, intra-articular facet joint steroid injection is helpful Fluoroscopy-Guided Intra-Articular Facet Joint Steroid Injection for the Management of Low Back Pain: Therapeutic Effectiveness and Arthrographic Pattern 요통의 치료를 위한 투시하 척추후관절내 스테로이드 주사: 치료효과와 관절조영술 소견 중심으로

A Comparison of Intraarticular Lumbar Facet Joint Steroid Injections and Lumbar Facet Joint Radiofrequency Denervation in the Treatment of Low Back Pain

Lumbar facet joint degeneration is a source of chronic low back pain, with an incidence of 15% to 45% among patients with low back pain. Various therapeutic techniques in the treatment of facet-related pain have been described in the literature, including intraarticular lumbar facet joint steroid injections and radiofrequency denervation. In this study, we compared the effectiveness of intraarticular facet joint steroid injections and radiofrequency denervation. Our randomized, double-blind, controlled study included patients who received intraarticular steroid infiltrations in the lumbar facet joints (L3/L4-L5/S1) and patients who underwent radiofrequency denervation of L3/L4-L5/S1 segments. The inclusion criteria were based first on magnetic resonance imaging findings showing hypertrophy of the facet joints L3/L4-L5/S1 and a positive response to an intraarticular test infiltration of the facet joints L3/L4-L5/S1 with local anesthetics. The primary end point was the Roland-Morris Questionnaire. Secondary end points were the visual analog scale and the Oswestry Disability Index. All outcome assessments were performed at baseline and at 6 months. Fifty-six patients were randomized; 24 of 29 patients in the steroid injection group and 26 of 27 patients in the denervation group completed the 6-month follow-up. Pain relief and functional improvement were observed in both groups. There were no significant differences between the 2 groups for the primary end point (95% confidence interval [CI], -3 to 4) and for both secondary end points (95% CI for visual analog scale, -2 to 1; 95% CI for Oswestry Disability Index, -18 to 0). Intraarticular steroid infiltration or radiofrequency denervation appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results in terms of pain relief and function improvement, but improvements were similar in both groups.

An Update of the Effectiveness of Therapeutic Lumbar Facet Joint Interventions

Therapeutic lumbar facet joint interventions are implemented to provide long-term pain relief after the facet joint has been identified as the basis for low back pain. The therapeutic lumbar facet joint interventions generally used for the treatment of low back pain of facet joint origin are intraarticular facet joint injections, lumbar facet joint nerve blocks, and radiofrequency neurotomy. To evaluate and update the effect of therapeutic lumbar facet joint interventions in managing chronic low back pain. A systematic review of therapeutic lumbar facet joint interventions for the treatment of chronic low back pain. The available literature on lumbar facet joint interventions in managing chronic low back pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventative Services Task Force. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through June 2012, and manual searches of the bibliographies of known primary and review articles. The primary outcome measure was pain relief with short-term relief defined as up to 6 months and long-term relief as 12 months. Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. For this systematic review, 122 studies were identified. Of these, 11 randomized trials and 14 observational studies met inclusion criteria for methodological quality assessment. The evidence for radiofrequency neurotomy is good and fair to good for lumbar facet joint nerve blocks for short- and long-term improvement; whereas the evidence for intraarticular injections and pulsed radiofrequency neurotomy is limited. The limitations of this systematic review include the continued paucity of evidence, specifically for intraarticular injection therapy. In summary, there is good evidence for the use of conventional radiofrequency neurotomy, and fair to good evidence for lumbar facet joint nerve blocks for the treatment of chronic lumbar facet joint pain resulting in short-term and long-term pain relief and functional improvement. There is limited evidence for intraarticular facet joint injections and pulsed radiofrequency thermoneurolysis.

Systematic Review of the Therapeutic Effectiveness of Cervical Facet Joint Interventions: An Update

Background: The prevalence of chronic, recurrent neck pain is approximately 15% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. Study Design: Systematic review of therapeutic cervical facet joint interventions. Objective: To determine and update the clinical utility of therapeutic cervical facet joint interventions in the management of chronic neck pain. Methods: The available literature for utility of facet joint interventions in therapeutic management of cervical facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: In this systematic review, 32 manuscripts were considered for inclusion. For final analysis, 4 randomized trials and 6 observational studies met the inclusion criteria and were included in the evidence synthesis. Based on one randomized, sham-controlled, double-blind trial and 5 observational studies, the indicated evidence for cervical radiofrequency neurotomy is fair. Based on one randomized, double-blind, active-controlled trial and one prospective evaluation, the indicated evidence for cervical medial branch blocks is fair. Based on 2 randomized controlled trials, the evidence for cervical intraarticular injections is limited. Limitations: Paucity of the overall published literature and specifically lack of literature for intraarticular cervical facet joint injections. Conclusions: The indicated evidence for cervical radiofrequency neurotomy is fair. The indicated evidence for cervical medial branch blocks is fair. The indicated evidence for cervical intraarticular injections with local anesthetic and steroids is limited. Key words: Chronic neck pain, cervical facet or zygapophysial joint pain, cervical medial branch blocks, cervical radiofrequency neurotomy, cervical intraarticular facet joint injections

An Update of Evaluation of Therapeutic Thoracic Facet Joint Interventions

Background: Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of patients based on responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of thoracic medial branches. Study Design: Systematic review of therapeutic thoracic facet joint interventions. Objective: To determine the clinical utility of therapeutic thoracic facet joint interventions in the therapeutic management of chronic upper back and mid back pain. Methods: The available literature for the utility of facet joint interventions in the therapeutic management of thoracic facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 13 studies were identified. Of these, 7 studies were excluded, and a total of 4 studies (after removal of duplicate publication) met inclusion criteria for methodological quality assessment with one randomized trial and 3 non-randomized studies. The evidence is fair for therapeutic thoracic facet joint nerve blocks, limited for thoracic radiofrequency neurotomy, and not available for thoracic intraarticular injections. Limitations: The limitation of this systematic review includes a paucity of literature. The only positive studies were of medial branch blocks performed by the same group of authors. Conclusion: The evidence for therapeutic facet joint interventions is fair for medial branch blocks, whereas it is not available for intraarticular injections, and limited for radiofrequency neurotomy due to lack of literature. Key words: Chronic thoracic pain, mid back or upper back pain, thoracic facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, therapeutic thoracic medial branch blocks, thoracic radiofrequency neurotomy, thoracic intraarticular facet joint injections

Poster 312 Efficacy of Combined Intra-articular Facet Joint and Transforaminal Epidural Steroid Injection in the Management of Symptomatic Lumbosacral Lateral Recess Stenosis: A Retrospective Analysis

Poster 312 Efficacy of Combined Intra-articular Facet Joint and Transforaminal Epidural Steroid Injection in the Management of Symptomatic Lumbosacral Lateral Recess Stenosis: A Retrospective Analysis

Comparative Outcomes of a 2-Year Follow-Up of Cervical Medial Branch Blocks in Management of Chronic Neck Pain: A Randomized, Double-Blind Controlled Trial

Cervical therapeutic intraarticular facet joint injections, therapeutic medial branch blocks, and radiofrequency neurotomy have been applied in managing chronic neck pain of cervical facet joint origin. However, the effectiveness of these modalities continues to be debated. The purpose of this study was to determine the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids. A randomized, double-blind, controlled trial. An interventional pain management practice, a specialty referral center, a private practice setting in the United States. To evaluate the clinical outcomes of therapeutic cervical medial branch blocks with local anesthetic with or without steroids in managing chronic neck pain of facet joint origin. A total of 120 patients meeting inclusion criteria were included. All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, with at least 80% relief. Group I consisted of cervical medial branch blocks with bupivacaine only and Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Therapeutic cervical medial branch blocks with local anesthetic with or without steroids were administered. Main outcome measures included numeric pain scores, Neck Disability Index (NDI), opioid intake, and work status evaluated at baseline, 6, 12, 18, and 24 months. The one-year results of outcomes were published in 2008. This manuscript describes the 2-year results. Significant improvement was defined as at least 50% improvement in pain relief and/or functional status improvement. Patient outcomes were measured at baseline, 3, 6, 12, 18, and 24 months post-treatment with the Numeric Rating Scale (NRS), the Neck Disability Index (NDI), employment status, and opioid intake. Decrease of ≥ 50% of NRS scores and Oswestry scores were considered significant. Eighty-five percent of patients in Group I and 93% of patients in Group II showed significant pain relief (≥ 50%) at 2 years. The average number of treatments for 2 years was 5.7. The duration of average pain relief with each procedure was 17-19 weeks on average in both groups. Significant improvement of pain and function was demonstrated for 83 to 89 weeks over a period of 2 years. The study limitations include the lack of a placebo group. In this study, therapeutic cervical medial branch blocks instituted after the diagnosis, with controlled comparative local anesthetic blocks with 80% concordant pain relief, repeated approximately 6 times over a period of 2 years, provided significant improvement over a period of 2 years. NCT00332722.

Diagnostic Medial Branch Blocks before Lumbar Radiofrequency Zygapophysial (Facet) Joint Denervation

Diagnostic Medial Branch Blocks before Lumbar Radiofrequency Zygapophysial (Facet) Joint Denervation

A Critical Review of the American Pain Society Clinical Practice Guidelines For Interventional Techniques: Part 2. Therapeutic Interventions

Background: Clinical guidelines are a constructive response to the reality that practicing physicians require assistance in assimilating and applying the exponentially expanding, often contradictory, body of medical knowledge. They attempt to define practices that meet the needs of most patients under most circumstances. Ideally, specific clinical recommendations contained within practice guidelines are systematically developed by expert panels who have access to all the available evidence, have an understanding of the clinical problem, and have clinical experience with the procedure being assessed, as well as knowledge of relevant research methods. The recent development of American Pain Society (APS) guidelines has created substantial controversy because of their perceived lack of objective analysis and recommendations perceived to be biased due to conflicts of interest. Objectives: To formally and carefully assess the APS guidelines’ evidence synthesis for low back pain for therapeutic interventions using the same methodology utilized by the APS authors. The interventions examined were therapeutic interventions for managing low back pain, including epidural injections, adhesiolysis, facet joint interventions, and spinal cord stimulation. Methods: A literature search by 2 authors was carried out utilizing appropriate databases from 1966 through July 2008. Articles in which conflicts arose were reviewed and mediated by a third author to arrive at a consensus. Selections of manuscripts and methodologic quality assessment was also performed by at least 2 authors utilizing the same criteria applied in the APS guidelines. The guideline reassessment process included the evaluation of individual studies and systematic reviews and their translation into practice recommendations. Results: The conclusions of APS and our critical assessment based on grading of good, fair, and poor, agreed that there is fair evidence for spinal cord stimulation in post lumbar surgery syndrome, and poor evidence for lumbar intraarticular facet joint injections, lumbar interlaminar epidural injections, caudal epidural steroids for conditions other than disc herniation or radiculitis, sacroiliac joint injections, intradiscal electrothermal therapy, endoscopic adhesiolysis, and intrathecal therapy. However, our assessment of APS guidelines for other interventional techniques, utilizing their own criteria, showed fair evidence for therapeutic lumbar facet joint nerve blocks, caudal epidural injections in disc herniation or radiculitis, percutaneous adhesiolysis in post lumbar surgery syndrome, radiofrequency neurotomy, and transforaminal epidural injections in radiculitis. Also it is illustrated that inclusion of latest literature will change the conclusions, with improved grading – caudal epidural, adhesiolysis, and lumbar facet joint nerve blocks from fair to good or poor to fair. The present critical assessment review illustrates that APS guidelines have utilized multiple studies inappropriately and have excluded appropriate studies. Our integrity assessment shows deep concerns that the APS guidelines illustrating significant methodologic failures which raise concerns about transparency, accountability, consistency, and independence. Conclusion: The current reassessment, using appropriate methodology, shows evidence similar to APS guidelines for several procedures, but differs extensively from published APS guidelines for multiple other procedures including caudal epidural injections, lumbar facet joint nerve blocks, lumbar radiofrequency neurotomy, and percutaneous adhesiolysis. Key words: Guidelines, evidence-based medicine, systematic reviews, American Pain Society, interventional pain management, interventional techniques

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.