Lumbar Medial Branch Blocks Research Articles

Comparison of the effectiveness of ultrasound-guided versus fluoroscopy-guided medial lumbar bundle branch block on pain related to lumbar facet joints: a multicenter randomized controlled non-inferiority study

BackgroundThe aim of this multicenter randomized interventional prospective study was to compare the ultrasound (US)-guided lumbar medial branch block (LMBB) with the fluoroscopy (FS)-guided LMBB in terms of analgesic efficacy and disability in the setting of the treatment of pain arising from the lumbar facet joints (LFJ).MethodsFifty adults with a “LFJ” syndrome were randomized into two groups: in group FS, fluoroscopic-guidance was used to block the medial branch at three lumbar levels (L3-L4, L4-L5 and L5-S1); in group US, same blocks were performed under ultrasound. Needle transverse approach was used with both techniques. Effects of these procedures were assessed with a Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Duke’s Activity Status Index (DASI) scale, before the treatment, 1 week and 1 month after. Hospital Anxiety and Depression Scale (HADS) score was also collected before the procedure. Analysis of variance, one (for non-inferiority) and two-sided Mann-Whitney tests and Chi-square tests were performed.ResultsLMBB under US-guidance was not inferior to FS-guidance (P = 0.047) in terms of VAPS, ODI and DASI at 1 week and 1 month. Duration of techniques and HADS were similar between groups (=0.34; p = 0.59).ConclusionsThe medial lumbar bundle branch block under ultrasound-guidance is not inferior to the fluoroscopy-guidance procedure in effectively alleviating pain arising from the facet joints. Considering that this ultrasound technique has the benefit of an irradiation-free, real-time procedure, it can be considered as an effective alternative to the fluoroscopy-guided technique.

The Negative Screening Rate of a Second Lumbar Medial Branch Block in Patients With a Positive First Block: A Retrospective Cohort Study

The Negative Screening Rate of a Second Lumbar Medial Branch Block in Patients With a Positive First Block: A Retrospective Cohort Study

Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis.

There is great interest in expanding the use of ultrasound (US), but new challenges exist with its application to lumbar facet-targeted procedures. The primary aim of this systematic review and meta-analysis was to determine the risk of incorrect needle placement associated with US-guided lumbar medial branch blocks (MBB) and facet joint injections (FJI) as confirmed by fluoroscopy or computerized tomography (CT). An a priori protocol was registered, and a database search was conducted. Inclusion criteria included all study types. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the National Heart, Lung, and Blood tool for assessing risk bias for observational cohort studies. Pooled analysis of the risk difference (RD) of incorrect needle placement was calculated. Pooled analysis of 7 studies demonstrated an 11% RD (P < 0.0009) of incorrect needle placement for US-guided MBB confirmed using fluoroscopy with and without contrast. Pooled analysis of 3 studies demonstrated a 13% RD (P < 0.0001) of incorrect needle placement for US-guided FJI confirmed using CT. The time to complete a single-level MBB ranged from 2.6 to 5.0 minutes. The certainty of evidence was low to very low. Ultrasound-guided lumbar MBB and FJI are associated with a significant risk of incorrect needle placement when confirmed by fluoroscopy or CT. The technical limitations of US and individual patient factors could contribute to the risk of incorrect needle placement.

Kümmell’s Disease: An Interventional Pain Approach

BACKGROUND: Kümmell’s disease is a rare diagnosis that involves avascular necrosis of the vertebral body after minor injury. Presentation is subtle and there are pathognomonic findings on imaging. Treatment ranges from symptom management to vertebral augmentation to open surgery depending on patient preference. CASE REPORT: We evaluated the case of an 88-year-old woman with a past medical history of scoliosis who presented to clinic complaining severe low back pain with associated neurologic symptoms 2 weeks after a fall at home. Imaging showed avascular necrosis of T12. CONCLUSIONS: After discussion with the patient, she elected to proceed with a unilateral lumbar medial branch block over vertebral augmentation. Pain scores greatly improved and opioid usage decreased. KEY WORDS: Case report, Kümmell’s disease, avascular necrosis, medial branch block

Lumbar medial branch block progression to radiofrequency neurotomy: A retrospective audit of clinical practice

IntroductionChronic axial low back pain due to zygapophysial joint arthropathy is best diagnosed via lumbar medial branch block (MBB). However, the paradigm by which MBB is used to select patients for lumbar radiofrequency neurotomy (RFN) is contested. Dual diagnostic lumbar MBB with a minimum of ≥80% pain relief to diagnose lumbar zygapophysial joint pain are accepted by some Medicare Local Coverage Determination (LCD) as the method for selecting patients for RFN for the management of lumbar zygapophysial joint pain. However, some argue that dual diagnostic MBB and the ≥80% pain relief threshold lack utility in clinical practice, given that those that progress from MBB1 to MBB2 will then flow from MBB2 to RFN without fail. StudyPragmatic retrospective clinical audit. ObjectiveDoes clinical practice of dual diagnostic lumbar MBBs and an ≥80% pain improvement diagnostic threshold reduce patient eligibility for RFN after both MBB1 and MBB2? ResultsUsing dual diagnostic lumbar MBBs and an ≥80% pain improvement diagnostic threshold, 90/167 (54%, 95% CI 46–61%) patients successfully progressed from MBB1 to MBB2. Of those 90 patients, 66 patients (73%, 95% CI 64–82%) successfully progressed from MBB2 to RFN. Both MBB1 and MBB2 impacted the eligibility of the progression of 77/167 (46%, 95% CI 39–54%) patients and 24/90 patients (27%, 95% CI 18–36%), respectively. An additional sub-cohort analysis which included all the patients from the ≥80% pain relief cohort, and those who progressed at the discretion of the providers with 50–79% relief revealed that 124/167 patients (74%, 95% CI 68–81%) successfully progressed from MBB1 to MBB2. Of those 124 patients, 99 patients (80%, 95% CI 73–87%) progressed from MBB2 to RFN. In this laxer criteria cohort, MBB1 and MBB2 impacted the eligibility of the progression of 43/167 patients (26%, 95% CI 19–32%) and 25/124 patients (20%, 95% CI 13–27%), respectively. ConclusionMBB1 and MBB2 both filtered patients from progression to lumbar RFN using dual MBBs with an ≥80% pain relief criteria. It also held true when using a more relaxed pain relief selection criterion as well. Dual MBB's and ≥80% pain improvement criteria as a selection paradigm led to half as many lumbar RFNs being performed when compared to a single MBB and ≥80% pain improvement criteria. In theory, a more rigid selection paradigm treats less patients but exposes fewer to unnecessary RFNs while a laxer selection paradigm treats more patients but exposes more to unnecessary RFNs.

Uncommon Presentation of Nephrolithiasis Immediately Following Lumbar Medial Branch Block

Uncommon Presentation of Nephrolithiasis Immediately Following Lumbar Medial Branch Block

96. Dual medial branch blocks and progression to radiofrequency neurotomy for zygapophysial arthropathy

96. Dual medial branch blocks and progression to radiofrequency neurotomy for zygapophysial arthropathy

Should a Coexisting or Suspected Diagnosis of Fibromyalgia Affect the Decision to Perform Diagnostic Blocks for Patients with Chronic Noncancer Pain — Results from an Observational Research Study

Diagnostic injections (blocks) are a valuable tool in the management of chronic noncancer pain. By precise blockade of specific neural structures and observation of pain responses, pain mechanisms can be accurately defined. With such information, therapeutic procedures targeting neural structures are possible. Fibromyalgia is a disorder of pain processing with characteristic symptoms. The 2010 American College of Rheumatologists fibromyalgia diagnostic criteria evaluates these symptoms in a scoring system, allowing more objectivity in the diagnosis. We hypothesize that patients with fibromyalgia phenotype fulfilling the 2010 American College of Rheumatologists criteria may respond to diagnostic blocks differently when compared to patients without fibromyalgia phenotype. This study was designed to establish whether diagnosis or suspected diagnosis of fibromyalgia should influence the decision to perform diagnostic blocks for chronic non-cancer pain. A prospective observational research study was performed at our institution. IRAS project ID: 231514. Tertiary pain clinic in the UK. Patients were selected to receive diagnostic block by usual clinical assessment after which they were asked to consent to take part in the study. All participating patients completed the 2010 American College of Rheumatologists fibromyalgia diagnostic questionnaire prior to the diagnostic block. Patients were divided into 2 groups A and B based on the outcome of block - primary outcome. Group A experienced a 70% or greater improvement in pain severity following the block for the anticipated duration of action of the local anesthetic, Group B experienced a less than 70% reduction in pain. Statistical analysis between groups A and B was conducted by comparing categorical data, described as percentages, with the chi squared test. Ordinal variables such as Widespread pain index and Symptom severity score are presented as median and analyzed with Mann-Whitney test. Seventy-seven patients were included in the study. Two patients were lost to follow-up. Of the 75 remaining patients, 44 received lumbar medial branch blocks, 19 genicular nerve blocks, 3 blocks to nerves supplying the sacroiliac joint, one suprascapular nerve block, and 6 cervical and 2 thoracic medial branch blocks. Group A contained 38 patients and group B contained 37 patients. There was no statistically significant difference in the prevalence of fibromyalgia screening questionnaire positive patients between groups A (13 out of 38 patients) and B (13 out of 37 patients), P = 0.93. There was no statistically significant difference in the prevalence of fibromyalgia screening questionnaire positive patients in subgroups undergoing the same type of diagnostic block (spinal pain and knee pain). Selection of patients prior to inclusion in the study may introduce bias. Patients were selected by individual treating clinicians using usual clinical practice; however, the exact selection criteria were not standardized. We conclude that after physician selection, the presence of fibromyalgia phenotype does not influence the outcome from diagnostic block. It is likely therefore that fibromyalgia phenotype should not influence the decision to perform diagnostic blocks if indicated based on assessment by an experienced pain physician.

Impact of Lavender on Pain and Anxiety Levels Associated With Spine Procedures

Background: To reduce pain and anxiety associated with interventional pain procedures, sedation is often used, with benzodiazepines, opioids, and propofol the most commonly used classes of drugs for sedation. However, patient coherence and ability to communicate procedural pain and abnormal sensations help prevent adverse outcomes. Therefore, discovering alternative therapies to mitigate the anxiety and pain associated with these procedures and to minimize risk is important. The aim of our study was to investigate whether lavender has an effect on pain and anxiety associated with lumbar epidural steroid injections and lumbar medial branch blocks.Methods: In this randomized controlled study, 54 subjects were randomly assigned to 1 of 3 intervention groups, and 46 patients were included in the final analysis: experimental lavender group (n=17), control almond oil group (n=15), and placebo sterile water group (n=14). Patients wore a mask infused with either lavender, almond oil, or water for 5 minutes prior to and during their procedure. Patients rated their anxiety using the State-Trait Anxiety Inventory prior to and after the procedure based on how they felt during the procedure. Patients rated their pain according to the numerical rating scale. Outcome measures were a comparison of pain among the 3 groups and a comparison of the change in anxiety before and after the procedure among the 3 groups.Results: The lavender group demonstrated the highest mean change in anxiety scores (9.9) compared to almond oil (5.3) and water (3.6) preprocedurally vs postprocedurally. The lavender group also reported the lowest mean pain level (3.8) compared to almond oil (5.6) and water (5.6). However, none of the differences between groups showed statistical significance at the P<0.05 level.Conclusion: Lavender may have a clinically beneficial effect on anxiety levels and pain reduction.

Diagnostic ultrasound-guided lumbar medial branch block of dorsal ramus in facet joint arthropathy: Technical feasibility and validation by fluoroscopy

Background: Facet joint (FJ)-mediated pain is one of the frequent causes of low back pain. Fluoroscopy and computed tomography guided medial branch blocks (MBBs) are accepted as standard techniques to diagnose FJ arthropathy. Ultrasound-guided (USG) MBB can be an alternative approach for the diagnostic MBB in FJ arthropathy. This study evaluates the feasibility of USG MBB in FJ arthropathy and validates by fluoroscopy. Materials and Methods: Diagnostic USG MBBs were performed in sixty patients. Two medial branches were targeted for each FJ. The needle was inserted in an in-plane technique after identifying the desired site. The needle position was confirmed by fluoroscopy. Pain scores were assessed before and after the nerve block. Results: Out of 161 needle insertions, 139 needles (86.3%) were at the radiologically defined target point as confirmed by fluoroscopy and were labeled as successful. Mean baseline, immediately before, immediately after, and at 24 h, Numeric Rating Scale (NRS) scores were 7.53 (0.93), 7.02 (0.93), 3.03 (1.75), and 2.80 (1.99), respectively (P < 0.05). The mean Modified Oswestry Disability Questionnaire scores before and 24 h after block were 48.77 (8.94) and 32.55 (11.32), respectively. Fifty-three patients had ≥60 points on the 100-point scale given by Helbig, and out of these patients, 44 patients had a ≥50% reduction in the NRS score. Conclusion: Diagnostic USG lumbar MBBs, a minimally invasive procedure without radiation exposure, can be performed with a high success rate in FJ arthropathy.

Predictors of response to medial branch block, radiofrequency ablation or facet joint injections: a retrospective study.

Aim: Low back pain is a leading cause of patient disability in the USA. Our goal was to determine association between patient characteristics and their response to lumbar medial branch block, radiofrequency ablation of medial nerves or lumbar facet joint injections. Materials & methods: Medical records for the first 100 patients who underwent lumbar medial branch block, radiofrequency ablation of lumbar medial nerves or lumbar facet joint injections between 1 September 2019 and 31 March 2020 were reviewed and demographic data were recorded. Results: At the 3-month post-procedure visit, positive responders were significantly more likely to be non obese patients (BMI <30) and those with pain <5-years. Conclusion: Obesity and chronicity of pain certainly are found to be predictors of response to the above mentioned procedures.

Anticoagulants and Antiplatelets for Lumbar Medial Branch Blocks.

Anticoagulants and Antiplatelets for Lumbar Medial Branch Blocks.

Interventional Pain Medicine Practice in the UK and the USA: A Survey of 242 Pain Physicians

Pain medicine practices vary across different regions within a country and between countries. The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before medial branch blocks at all the spinal levels. Around 50% of pain physicians in the UK and US are stopping anticoagulants before lumbar and cervical RFD. Over 95% of UK and US respondents stopped antithrombotic agents for interlaminar and transforaminal epidural injections along the spine. At the lumbar level, 51% of pain physicians in the UK and 47% in the US use a particulate steroid for the initial lumbar transforaminal epidural injection (TFESI); and 4% and 14% in the UK and US, respectively, use a particulate steroid for initial cervical TFESI. Eight percent of pain physicians in the UK and 20% from the US would switch to a particulate steroid if the initial TFESI with a nonparticulate steroid did not provide satisfactory pain relief. Ten percent of pain physicians from the United Kingdom and 20% from the US believed that this switch provides better pain relief. Interventional pain physicians from the UK and the US were invited to respond. This may not reflect global practice. Our survey has highlighted the wide variation in interventional pain medicine practices both in the UK and the US. The relevant governing bodies in the UK and in the US should encourage clinicians to use at least an 18-gauge radiofrequency needle for RFD at the lumbar level. Discontinuing antithrombotic agents for the lumbar medial branch block is not justifiable. Pain physicians must discuss the advantages and disadvantages of using a nonparticulate over a particulate steroid preparation with the patient before performing TFESI as a standard procedure during the consenting process. Antithrombotic agents, epidural steroid, medial branch blocks, pain practice variations, particulate and nonparticulate steroids, radiofrequency denervation, spinal interventions.

Ultrasound-guided L5 dorsal ramus block: validation of a novel technique

BackgroundAlthough the value of ultrasound-guided (USG) lumbar medial branch blocks (MBB) has previously been examined in several clinical trials, blocking the L5 dorsal ramus (DR) remains a technical challenge and...

Using Music During Lumbar Medial Branch Block Procedure

Using Music During Lumbar Medial Branch Block Procedure

Measuring Needle Angle and Depth for Lumbar Medial Branch Block Using Ultrasonography: An Evaluation of Efficiency Compared with Magnetic Resonance Imaging

Measuring Needle Angle and Depth for Lumbar Medial Branch Block Using Ultrasonography: An Evaluation of Efficiency Compared with Magnetic Resonance Imaging

Lumbar Medial Branch Block Volume-Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

BackgroundLumbar facet arthropathy is a common cause of low back pain. Literature supports treatment with radiofrequency ablation (RFA) of associated nerves that innervate lumbar facets when alternative conservative therapies have failed. Diagnostic local anesthetic blocks precede therapeutic ablation, but have a false-positive rate of 27%-63%, and some authors have questioned their utility in predicting therapeutic response to RFA. The authors of the current study believe that injectate volume may be a contributing factor to false positivity. ObjectiveTo evaluate the difference in volume dispersion between 0.25 mL and 0.5 mL of injectate when performing lumbar medial branch blocks. We hypothesized that injection volumes greater than 0.25 mL during lumbar medial branch blocks would affect the distal branches of the adjacent medial branches, thus decreasing the specificity of the procedure. Thus, we attempted to demonstrate that injection volumes greater than 0.25 mL during lumbar medial branch blocks would affect the distal branches of the adjacent medial branches, which might increase false positivity of the blocks. Study DesignCadaveric investigation. SettingTertiary care center. ParticipantsNot applicable. Outcome MeasurementsTo demonstrate that the spread of lumbar medial branch blocks using commonly injected volume coats adjacent structures that are not affected by radiofrequency ablation. MethodsSix cadavers were chosen with nondissected lumbar spines. Fluoroscopically guided medial branch injections were performed bilaterally using the posterior oblique approach. A volume of 0.25 mL or 0.50 mL of a 9:1 solution of Omnipaque 240 and 1% medical grade methylene blue were delivered to the left and right sides, respectively. Postinjection computed tomographic imaging was performed, followed by dissection. ResultsBoth volumes adequately coated the medial branches, but in the 0.5-mL injectate cohort there was consistent spread dorsally to the superficial muscles and distal segments of the dorsal branches distant to the target nerves, whereas in the 0.25-mL injectate cohort the spread was contained in the deep and intermediate muscular lumbar layers, close to the intended target. ConclusionWe suggest that a 0.5-mL injectate volume in clinical practice may produce an adjacent-level nerve block in addition to the intended injection level, thus decreasing the specificity of a targeted lumbar medial branch block. A 0.25-mL quantity of injectate reliably contacted the lumbar medial branches without extensive extravasation. Presumably, this means that 0.25 mL total volume for a lumbar medial branch block may provide greater specificity for RFA planning. Level of EvidenceNA

The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures.

Guidelines have been published that recommend discontinuing anticoagulants in patients undergoing interventional pain procedures. The safety and effectiveness of these guidelines have not been tested. The present study was performed to determine if continuing or discontinuing anticoagulants for pain procedures is associated with a detectable risk of complications. An observational study was conducted in a private practice in which some partners continued anticoagulants while other partners routinely discontinued anticoagulants. No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths. Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.

Technique for CT Fluoroscopy–Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation

The purpose of this study is to describe the procedure for CT fluoroscopy-guided lumbar medial branch blocks and facet radiofrequency ablation. CT fluoroscopic guidance allows more-precise needle tip positioning and is an alternative method for performing medial branch blocks and facet radiofrequency ablation.

Detection of Intravascular Injection During Lumbar Medial Branch Blocks: A Comparison of Aspiration, Live Fluoroscopy, and Digital Subtraction Technology.

Medial branch blocks may have unrecognized vascular uptake potentially resulting in false- negative results. To determine the rate of unintended vascular injection of contrast medium during medial branch blocks (MBB) with digital subtraction (DS) technology in the context of negative vascular uptake as determined by live fluoroscopy. Prospective Study in an academic medical center. 344 consecutive MBBs in 80 subjects. The presence of vascular flow as determined by live fluoroscopy and DS technology. Unintended vascular injection of contrast medium was determined on 344 consecutive MBBs in 84 subjects, first using live fluoroscopy followed by DS. If live fluoroscopy initially detected vascular uptake, the needle was repositioned until no vascular flow was detected. Once no vascular uptake was confirmed by live fluoroscopy, a contrast medium was then injected while being visualized with DS to again assess the presence or absence of vascular flow undetected by live fluoroscopy. Live fluoroscopy revealed inadvertent vascular uptake in 38 of the 344 blocks [11% (95% CI 8.0-15%)]. DS uncovered an additional 27 of the 344 blocks [7.8% (95% CI 5.3-11.4%)] with evidence of vascular uptake that were not detected with conventional live fluoroscopy. DS enhances the ability to detect inadvertent vascular flow during medial branch blocks. This study demonstrates that standard live fluoroscopy can miss a small percentage of cases with unintentional vascular uptake during MBB when compared with DS and may contribute to occasional false-negative responses.